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Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis.

ABSTRACT: OBJECTIVES:General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs' perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement. DESIGN:Qualitative evidence synthesis. METHODS:Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programme's checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis. RESULTS:Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs' uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration. CONCLUSIONS:The main challenges identified in this synthesis were how to deal with GPs' uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs' HF care were identified.

SUBMITTER: Smeets M

PROVIDER: S-EPMC5168518 | biostudies-other | 2016 Nov

REPOSITORIES: biostudies-other

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Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis.

Smeets Miek M Van Roy Sara S Aertgeerts Bert B Vermandere Mieke M Vaes Bert B

BMJ open 20161130 11

<h4>Objectives</h4>General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs' perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement.<h4>Design</h4>Qualitative evidence synthesis.<h4>Methods</h4>Searches of MEDLINE, EMBASE, Web of Science and C ...[more]

PMID: 27903565

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Project description:ObjectiveClinical Cancer Decision Tools (CCDTs) aim to alert general practitioners (GPs) to signs and symptoms of cancer, supporting prompt investigation and onward referral. CCDTs are available in primary care in the UK but are not widely utilised. Qualitative research has highlighted the complexities and mechanisms surrounding their implementation and use; this has focused on specific cancer types, formats, systems or settings. This study aims to synthesise qualitative data of GPs' attitudes to and experience with a range of CCDTs to gain better understanding of the factors shaping their implementation and use.DesignA systematic search of the published (MEDLINE, CINAHL, Web of Science and EMBASE) and grey literature (July 2020). Following screening, selection and assessment of suitability, the data were analysed and synthesised using normalisation process theory.ResultsSix studies (2011 to 2019), exploring the views of GPs were included for analysis. Studies focused on the use of several different types of CCDTs (Risk Assessment Tools (RAT) or electronic version of RAT (eRAT), QCancer and the 7-point checklist). GPs agreed CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. They had concerns about the impact on trust in their own clinical acumen, whether secondary care clinicians would consider referrals generated by CCDT as valid and whether integration of the CCDTs within existing systems was achievable.ConclusionsCCDTs might be a helpful adjunct to clinical work in primary care, but without careful development to legitimise their use GPs are likely to give precedence to clinical acumen and gut instinct. Stakeholder consultation with secondary care clinicians and consideration of how the CCDTs fit into a GP consultation are crucial to successful uptake. The role and responsibilities of a GP as a clinician, gatekeeper, health promoter and resource manager affect the interaction with and implementation of innovations such as CCDTs.

Project description:Importance:Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. Objective:To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. Design, Setting, and Participants:Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. Main Outcomes and Measures:Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. Results:Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. Conclusions and Relevance:While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.

Project description:BACKGROUND:Noninvasive telemonitoring (TM) can be used in heart failure (HF) patients to perform early detection of decompensation at home, prevent unnecessary health care utilization, and decrease health care costs. However, the evidence is not sufficient to be part of HF guidelines for follow-up care, and we have no knowledge of how TM is used in the Nordic Baltic region. OBJECTIVE:The aim of this study was to describe health care professionals' (HCPs) perception of and presumed experience with noninvasive TM in daily HF patient care, perspectives of the relevance of and reasons for applying noninvasive TM, and barriers to the use of noninvasive TM. METHODS:A cross-sectional survey was performed between September and December 2016 in Norway and Lithuania with physicians and nurses treating HF patients at either a hospital ward or an outpatient clinic. A total of 784 questionnaires were sent nationwide by postal mail to 107 hospitals. The questionnaire consisted of 43 items with close- and open-ended questions. In Norway, the response rate was 68.7% (226/329), with 57 of 60 hospitals participating, whereas the response rate was 68.1% (310/455) in Lithuania, with 41 of 47 hospitals participating. Responses to the closed questions were analyzed using descriptive statistics, and the open-ended questions were analyzed using summative content analysis. RESULTS:This study showed that noninvasive TM is not part of the current daily clinical practice in Norway or Lithuania. A minority of HCPs responded to be familiar with noninvasive TM in HF care in Norway (48/226, 21.2%) and Lithuania (64/310, 20.6%). Approximately half of the HCPs in both countries perceived noninvasive TM to be relevant in follow-up of HF patients in Norway (131/226, 58.0%) and Lithuania (172/310, 55.5%). For physicians in both countries and nurses in Norway, the 3 most mentioned reasons for introducing noninvasive TM were to improve self-care, to reduce hospitalizations, and to provide high-quality care, whereas the Lithuanian nurses described ability to treat more patients and to reduce their workload as reasons for introducing noninvasive TM. The main barriers to implement noninvasive TM were lack of funding from health care authorities or the Territorial Patient Fund. Moreover, HCPs perceive that HF patients themselves could represent barriers because of their physical or mental condition in addition to a lack of internet access. CONCLUSIONS:HCPs in Norway and Lithuania are currently nonusers of TM in daily HF care. However, they perceive a future with TM to improve the quality of care for HF patients. Financial barriers and HF patients' condition may have an impact on the use of TM, whereas sufficient funding from health care authorities and improved knowledge may encourage the more widespread use of TM in the Nordic Baltic region and beyond.

Dataset Information

Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis.

Publications

Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis.

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