Dataset Information

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study.

ABSTRACT:

Aims

Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care.

Methods and results

This study describes the baseline results of the OSCAR-HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N-terminal pro-B-type natriuretic peptide point-of-care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR-HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ? 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin-angiotensin-aldosterone system blockers (84%, n = 92) and beta-blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively).

Conclusions

This study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease-modifying drugs in HFrEF patients.

SUBMITTER: Smeets M

PROVIDER: S-EPMC7754725 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Publications

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study.

Smeets Miek M Vaes Bert B Aertgeerts Bert B Raat Willem W Penders Joris J Vercammen Jan J Droogne Walter W Mullens Wilfried W Janssens Stefan S

ESC heart failure 20200924 6

<h4>Aims</h4>Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care.<h4>Methods and results</h4>This study describes the baseline results of the OSCAR-HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prosp ...[more]

PMID: 32969599

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Project description:AimsHeart failure (HF) is an important health problem for which multidisciplinary care is recommended, yet few studies involve primary care practitioners in the multidisciplinary management of HF. We set up a multifaceted prospective observational trial, OSCAR-HF, piloting audit and feedback, natriuretic peptide testing at the point of care, and the assistance of a specialist HF nurse in primary care. The aim was to optimize HF care in general practice.Methods and resultsThis is an analysis at 6 month follow-up of the study interventions of the OSCAR-HF pilot study, a nonrandomized, noncontrolled prospective observational trial conducted in eight Belgian general practices [51 general practitioners (GPs)]. Patients who were assessed by their GP to have HF constituted the OSCAR-HF study population. We used descriptive statistics and mixed-effects modelling for the quantitative analysis and thematic analysis of the focus group interviews. There was a 10.2% increase in the registered HF population after 6 months of follow-up (n = 593) compared with baseline (n = 538) and a 27% increase in objectified HF diagnoses (baseline n = 359 to 456 at T6 M). Natriuretic peptide testing (with or without referral) accounted for 54% (n = 60/111) of the newly registered HF diagnoses. There was no difference in the proportion of patients with HF with reduced ejection fraction who received their target dosage of renin-angiotensin-aldosterone system inhibitors or beta-blockers at 6 months compared with baseline (P = 0.9). Patients who received an HF nurse intervention (n = 53) had significantly worse quality of life at baseline [difference in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score 9.2 points; 95% confidence interval (CI) 4.0, 14] and had a significantly greater improvement in quality-of-life scores at the 6 month follow-up [change in MLHFQ score -9.8 points; 95% CI -15, -4.5] than patients without an HF nurse intervention. GPs found audit and feedback valuable but time intensive. Natriuretic peptides were useful, but the point-of-care test was impractical, and the assistance of an HF nurse was a useful addition to routine HF care.ConclusionsThe use of audit and feedback combined with natriuretic peptide testing was a successful strategy to increase the number of registered and objectified HF diagnoses at 6 months. GPs and HF nurses selected patients with worse quality-of-life scores at baseline for the HF nurse intervention, which led to a significantly greater improvement in quality-of-life scores at the 6 month follow-up compared with patients without an HF nurse intervention. The interventions were deemed feasible and useful by the participating GPs with some specific remarks that can be used for optimization.Trial registrationClinicalTrials.gov (NCT02905786), registered on 14 September 2016 at https://clinicaltrials.gov/.

Project description:Depression is more prevalent in patients with heart failure (HF) than in those without, but its detection is complicated by the symptom overlap between the two diseases. General practitioners (GPs) are the first point of contact for patients with HF. Therefore, this study aims to investigate GPs' awareness of depression in their HF patients and factors associated with this awareness.In this cross-sectional, observational study 3224 primary care patients with HF were screened for depressive symptomatology using an algorithm based on the Hospital Anxiety and Depression Scale, the 9-item subscale on Depression of the Patient Health Questionnaire, and selected items from the PROMIS Depression and Anxiety scales. The 272 GPs of all patients involved in the study were interviewed by telephone regarding their patients' somatic and psychological comorbidities. The awareness rates of depressive symptomatology by the patients' GPs are analyzed using descriptive statistics. Logistic regression analyses are applied to investigate the patient- and GP-based factors associated with the GPs' awareness of depressive symptomatology.GPs were aware of their patients' depressive symptomatology in 35% of all cases. Factors associated with the awareness of depressive symptomatology were: higher patient education levels, a history of depression known to the GP, GP-consultations due to emotional distress within the last 6 months, a higher frequency of GP-contacts within the last 6 months, a higher New York Heart Association (NYHA) classification and more severe depressive symptomatology. The GPs' characteristics, including further education in psychology/psychiatry, were not associated with GP awareness.Many aspects, including the definition of awareness and the practical issues in primary care, may contribute to the unexpectedly low awareness rates of depressive symptomatology in HF patients in primary care. Awareness rates might increase, if GPs encouraged their patients to talk about emotional distress, held detailed medical interviews including a patient's history of depression and payed special attention to HF patients with low education levels. However, it remains to be investigated whether GPs' judgement of depressive symptomatology is a better or worse indicator for the future prognosis and quality of life of HF patients than psychiatry based diagnostic criteria.

Project description:BackgroundAccessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.MethodsMixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.ResultsReflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.ConclusionsGeneral practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Project description:ObjectiveWe conducted a scoping review with the aim of comprehensively investigating what tools or methods have been examined in general practice research that capture a wide range of psychosocial problems (PSPs) and serve to identify patients and highlight their characteristics.MethodsWe followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and the Joanna Briggs Institute Reviewer's Manual on scoping reviews. A systematic search was conducted in four electronic databases (Medline [Ovid], Web of Science Core Collection, PsycInfo, Cochrane Library) for quantitative and qualitative studies in English, Spanish, French, and German with no time limit. The protocol was registered with Open Science Framework and published in BMJ Open.ResultsOf the 839 articles identified, 66 met the criteria for study eligibility, from which 61 instruments were identified. The publications were from 18 different countries, with most studies employing an observational design and including mostly adult patients. Among all instruments, 22 were reported as validated, which we present in this paper. Overall, quality criteria were reported differently, with studies generally providing little detail. Most of the instruments were used as paper and pencil questionnaires. We found considerable heterogeneity in the theoretical conceptualisation, definition, and measurement of PSPs, ranging from psychiatric case findings to specific social problems.Discussion and conclusionThis review presents a number of tools and methods that have been studied and used in general practice research. Adapted and tailored to local circumstances, practice populations, and needs, they could be useful for identifying patients with PSPs in daily GP practice; however, this requires further research. Given the heterogeneity of studies and instruments, future research efforts should include both a more structured evaluation of instruments and the incorporation of consensus methods to move forward from instrument research to actual use in daily practice.

Dataset Information

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study.

Aims

Methods and results

Conclusions

Publications

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study.

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