BMJ 2003;326:196 ( 25 January )

Primary care

Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study

Ahmet Fuat, Northern and Yorkshire Regional Health Authority research training fellow, ^a A Pali S Hungin, professor of primary care and general practice, ^a Jeremy James Murphy, consultant cardiologist. ^b

^a Centre for Integrated Health Care Research, Wolfson Research Institute, University of Durham, Stockton-on-Tees TS17 6BH, ^b Darlington Memorial Hospital, Darlington, County Durham DL3 6HX

Correspondence to: A Fuat ahmet{at}fuat.freeserve.co.uk

Objective: To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care.
Design: A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory.
Setting: North east England.
Results: Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors,  blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care.
Conclusions: The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategiesfor example, the provision of guidelinesare unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.

What is already known on this topic Heart failure is a common condition with a high morbidity and mortality and is largely managed in primary care Although modern management with accurate diagnosis and treatment improves prognosis considerably, unacceptable variations exist in the clinical application of current guidelines for heart failure What this study adds General practitioners expressed a lack of confidence in establishing an accurate diagnosis of left ventricular systolic dysfunction, even if open access echocardiography was available Uncertainty about diagnosis led to poor uptake of evidence based treatment strategies for heart failure patients, and, despite awareness, reluctance to initiate modern treatment Local organisational factors around NHS provision of diagnostic services, resources, and interaction between primary and secondary care influence how general practitioners manage heart failure Implementation strategies for heart failure management across primary and secondary care are needed that are specific to their locality and multifaceted

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© 2003 BMJ Publishing Group Ltd
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