Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7382.196 (Published 25 January 2003) Cite this as: BMJ 2003;326:196
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Dear Editor
Fuat and colleagues (BMJ 2003, 326:196) draw attention to the
problems of piecemeal healthcare in relation to the management of heart
disease.
In the rush to ‘modernise’ the NHS the patient has been overlooked.
The patient is reduced to a consumer of ever narrowing specialties that
address a single organ, tissue or system. The service provider reduces
waiting times with rapid access clinics, and directors of ‘innovation’,
‘modernisation’ and ‘user involvement’ ensure that government targets are
met. Meanwhile the cardiology consumer (angina patient) is seen in
secondary care in record time but depression and anxiety are overlooked
and the symptoms seem to get worse. How has this situation arisen and
what is the remedy?
The health profession is to blame for subscribing to a mechanistic
model that ignores the role of the mind in medicine, whilst the government
is to blame for creating structures that promote piecemeal healthcare. The
patient is thus poorly served by medical overspecialisation and arbitrary
political outcome measures that fail to see the patient as a whole. This
fundamental failure in healthcare is probably best illustrated with
reference to depression and comorbid medical conditions.
Depression increases the risk of heart disease by as much as four-
fold; it is a risk factor for stroke; may be associated with bone mineral
density (BMD) loss and impacts significantly on diabetes and arthritis1.
Regrettably depression remains grossly under-diagnosed in medical settings
yet there is growing empirical research (as if this were needed) that
improving depression improves physical outcome2. Moreover, the use of
SSRIs in non-depressed cardiovascular and diabetic patients is associated
with improved physical outcome. For example a recent randomised trial
showed that sertraline reduced cardiac morbidity and mortality following
acute MI3 and other studies have demonstrated the value of SSRIs in
diabetes and stroke4,5.
There is clearly a need for education to raise awareness of the
prevalence of depression in co-morbid conditions and scope for promotion
of a ‘whole system approach’ in medicine. If patients are to benefit from
a modernised NHS it is imperative that doctors recognise the interplay
between mind and body, and capitalise on the growing evidence that a
‘systems approach’ really works.
Yours faithfully
Bruce J Moore
Consultant Psychiatrist
REFERENCES
1. Krishnan KRR. Delong M, Kraemer H et al (2002) Comorbidity of
Depression with other medical diseases. Biological Psychiatry, 52:559-588
2. Wells KB, Stuart A, Hays RD et al (1989) The functioning and well-being
of depressed patients: results from the medical outcomes study. JAMA,
262:914-9
3. Glassman MD, et al. Sertraline Treatment of Major Depression in
Patients with Acute MI or Unstable Angina. JAMA, 288(6):701-9
4. Goodnick PJ, Kumar A, Henry JH, et al. Sertraline in Coexisting Major
Depression and Diabetes Mellitus. Psychopharmacology Bulletin1997;
33(2):261-264
5. K Ranga Rama Krishnan (2000) Depression as a contributing factor in
cerebrovascular disease. American Heart Journal. 140(4) 70-76
Competing interests:
None declared
Competing interests: No competing interests
Fuat et al describe an important problem. We investigated this same
issue by semi-structured interviews with individual GPs. This
investigation [1] undertaken in 1998 identified many common themes to this
more recent work using focus groups of GPs.
However, two important themes we identified are absent in this later
study. The first is that discussion of patients with 'suspected heart
failure' was very difficult, that GPs more readily identified with symptom
-based scenarios, such as managing the breathless patient.
The second, related issue was of 'therapeutic trials'. Most described
difficulties in the differential diagnosis between chronic obstructive
pulmonary disease and heart failure. Several GPs described using
bronchodilators or diuretics to determine which could alleviate symptoms,
arriving at a symptomatic rather than pathophysiological diagnosis.
The GPs we interviewed were aware of the benefits of ACE inhibitors, but
symptom control appeared to be the focus of management in many cases.
These additional factors, which featured highly in the thinking of some
practitioners, should be taken account of in the design of any future
interventions to improve management of heart failure in primary care.
[1] The need for a diagnostic approach in the development of
guideline implementation strategies - a qualitative study
Lambert MF, Watt IS, Woodhouse AM, Balmer S, Robinson MR. British Journal
of Clincal Governance 2002;7:255-60
Competing interests:
None declared
Competing interests: No competing interests
Editor- I read the recent article, diagnosis and management of heart
failure in primary care, with interest (1). Inability of clinicians to
diagnose heart failure accurately, using clinical symptoms alone is well
established. Echocardiography, the ‘Gold Standard’ for diagnosis of heart
failure, may not always be accessible to primary care, is time consuming,
costly and general practitioners may not understand results.
One possible answer to these problems, given that diagnosis is
inaccurate in 60-70% of cases, could be blood tests for cardiac
natriuretic peptides, released from the heart into the circulation (2).
ANP (Atrial Natriuretic Peptide) and BNP (Brain Natriuretic Peptide) are
released predominantly from atria and ventricles respectively, and
increase in the blood according to NYHA classification. Furthermore, BNP
and N-terminal BNP, or N-terminal ANP (pro-hormones of these peptides)
could be important in detecting left ventricular systolic dysfunction.
These peptides could be used to exclude the possibility of heart failure
in patients with clinical symptoms, but without genuine heart failure (3),
since in the majority of cases, only patients with heart failure will have
raised cardiac peptide levels. Other factors, which can sometimes elevate
cardiac peptides, such as hypertension, or renal impairment could be
excluded by measuring blood pressure and creatinine. Patients with
elevated blood cardiac peptides could then be referred for further
investigation for heart failure. Patients with clinical symptoms of heart
failure, but cardiac peptides within the healthy range could be
investigated for other reasons for their clinical signs and symptoms of
heart failure.
Blood could be taken in general practice and posted, or delivered to
a reference laboratory for peptide measurement (2). Furthermore, blood
tests for these peptides could be used to titrate effective drug treatment
for heart failure, by adjusting drug dose accordingly, until these
peptide(s) are returned to within, or near the healthy range (4). A third
member of this peptide family (CNP) could also be a potential marker for
cardiac vascular disease and/ or coronary artery disease (5).
Blood tests of this type, using BNP and/ or N-terminal BNP could
provide general practitioners with a helpful, less complicated and cost
effective way of diagnosing and treating heart failure in general
practice.
1. Fuat A, Hungin APS, Murphy JJ. Barriers to accurate diagnosis and
effective management of heart failure in primary care: qualitative study.
BMJ 2003; 326: 196-200.
2. Buckley MG, Marcus NJ, Yacoub MH. Cardiac peptide stability,
aprotinin and room temperature: importance for assessing cardiac function
in clinical practice. Clin Sci 1999; 97: 689-695.
3. Hobbs FDR, Davis RC, Roalfe AK, Hare R, Davies MK, Kenkre JE.
Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis
of heart failure: cohort study in representative and high risk community
populations. BMJ 2002; 324: 1498-1500.
4. Richards AM, Lainchbury JG, Nicholls MG, Troughton RW, Yandle TG.
BNP in hormone-guided treatment of heart failure. Trends Endocrinol Metab
2002; 13(4): 151-155.
5. Buckley MG, Jenkins GH, Mitchell AG, Yacoub MH, Singer DRJ.
Circulating C-type natriuretic peptide is increased in orthotopic cardiac
transplant recipients and associated with cardiac allograft vasculopathy.
Clin Sci 2000; 99: 467-472.
Competing interests:
None declared
Competing interests: No competing interests
Sir--
Fuat et al recently conducted a survey of attitudes toward the management
of heart failure in general practice. [1] Through group discussion, the
authors were able to identify areas of concern among general
practitioners. Points of particular note included difficulties in the
assessment of subtle early signs of heart failure, difficulties in the
interpretation of echocardiography reports, and concerns about the number
of drugs recommended for patients with heart failure.
We feel that the issues arising from this study further strengthen
the case for the establishment of specialist heart failure clinics, as
outlined in the National Service framework (NSF) for Coronary Heart
Disease. [2] Such clinics employ a multi-disciplinary team consisting of
physicians (specialist and primary care), specialist nurses and cardiac
technicians, and facilitate a co-ordinated approach to the diagnosis,
assessment and management of heart failure. Objective evidence of cardiac
dysfunction may be obtained (e.g. by echocardiography) and interpreted by
a cardiologist, with the subsequent formulation of a treatment strategy.
We believe this is preferable to open access echo services, with the
difficulties in interpretation highlighted by Fuat. [1] Specialist
dedicated heart failure nursing provides a vital bridge between hospital
and community-care, and allows for continued clinical assessment and
appropriate titration of medication, as well as continued patient
education. Such nursing has been associated with a significant reduction
in hospital re-admission due to heart failure. [3] Widespread awareness of
current treatment guidelines appeared to be lacking in the primary care
setting; the dedicated nursing services can be instrumental in
implementing guidelines.
One particular comment reproduced in the article by Fuat et al. [1]
was that heart failure invariably affects the elderly. This is simply not
true. Clearly the disease becomes more prevalent with age, but there are
many young patients with dilated cardiomyopathy who suffer delayed
diagnosis precisely because of this perception.
Heart failure has a high prevalence and is associated with a terrible
prognosis, despite availability of evidence based treatments. GP’s are at
the sharp end of an escalating problem, and specialist clinics provide
invaluable support for the growing burden of chronic heart failure.
Gurbir Bhatia
Research Fellow
Michael Sosin
Research Fellow
Jane Stubley
Senior Heart Failure Specialist Nurse
Russell Davis
Consultant Cardiologist
Sandwell & West Birmingham NHS Trust,
Lyndon,
West Bromwich
B71 4HJ
[1] Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and
effective management of heart failure in primary care: qualitative study.
BMJ 2003;326:196-201.
[2] Department of Health. The national service framework for coronary
heart disease. London: Stationery Office, 2000.
[3] Blue L, Lang E, McMurray JV et al. Randomised control trial of
specialist nurse intervention in heart failure. BMJ 2001;323:715-8.
Competing interests:
None declared
Competing interests: No competing interests
I read with interest the article by Fuat,et al (1) and agree very
much with their views that improvement on local organisational factors
around NHS provision of diagnostic services, resource, and interaction
between primary and secondary care may influence how primary care doctors
manage heart failure cases.
Heart failure is poorly managed in the United Kingdom due to variety
of reasons, mainly because of lack of facilities to make an accurate bed-
side diagnosis of heart failure in the primary care, which may lead to
inappropriate treatment for a section of the general population. The issue
on diagnosis in the primary care, was recenty discussed in this journal by
Davis, et al (2) and their proposal for 'targated echocardiographic
screening' could be well heeded.
I can see the problems faced in the primary care mainly in the
diagnostics, as well as other problem, such as variability in
echocardiography reporting, lack of guidance for using the procedure and
the technicality of echo-reporting. These problems are further compounded
by the fact that only 37% of UK family doctors have direct access to
echocardiography equipment (3,4). A recent audit had shown that 36%
requests for routine echocardiography were unnecessary (5). Therefore, a
clear guideline, along with 'targated echocardiography' approach, will
enable the primary care physicians to utilise the open access
echocardiography service to its fullest potential.
This, along with, closer interaction between primary and secondary
cares on reporting of echocardiography, will boost the morale and the
confidence of the primary care doctors to take decesions on diagnosis and
management of heart failure cases.
References:
1.Fuat A, Hungin AP,Murphy JJ. Barriers to accurate diagnosis and
effective management of heart failure in primary care: qualitative study.
BMJ 2002; 326: 196-209
2.Davis RC, Hobbs FDR, Kenkre JE, Roalfe AK, Hare R, Lancashire RJ,
Davies MK. Prevalence of left ventricular systolic dysfunction and heart
failure in high risk patients: community based epidemiological study. BMJ
2002; 325: 1156-65
3.Struthers AD, Morris AD. Screening for and treating left-
ventricular abnormalities in diabetes mellitus: a new way of reducing
cardiac deaths. Lancet 2002; 359: 1430-32.
4.Sinharay R. Echocardiography in heart failure.
BMJ.com/cgi/eletters/325 (7373) 3 december 2002
5.Sinharay R. Five thpusand echocardiograms: what have we done ? Br J
Cardiol 2002; 9: 516
2.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
I partly agree with Fuat. A. et al. (1). Surely, general practitioners
experience difficulties in diagnosing, and only then, in my opinion,
managing heart failure, although technical progresses (labotatory, ECG,
a.s.o.) they usually utilize. GPs, who mainly show “uncertainty about
clinical practice”, need a reliable “physical” semeiotics, which can help
them in bed-side decision making, providing reliable information, e.g., on
B-Natriuretic Peptides blood concentration (See HONCode site 233736,
http://digilander.libero.it/semeioticabiofisica), not to speak about bed-
side recognizing quantitatively even the “real” risk of CAD (See in
Medscape Forum
Discussion:http://boards.medscape.com/forums?10@21.vI21azPRbg5^1@.ee82234).
As a matter of fact, mainly those individuals, affected by genetically-
determined “real” risk of CAD, can suffer in the future from heart failure
(2). In order to avoid, firstly, uncertainty about diagnosis, including
that of “real” risk of CAD, GPs have to be fortunately told that a new
physical semeiotics exists, a part from the necessity of identifying
“barriers to be overcome across primary and secondary care in
implementation strategies that are specific to the locality and
multifaceted” (1).
1) Fuat A., Hungin APS., Murphy JJ. Barriers to accurate diagnosis
and effective management of heart failure in primary care: qualitative
study. BMJ 2003;326:196 ( 25 January ).
2) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and
Myocardial Oxygenation evaluated clinically with the aid of Biophysical
Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta
Med. Medit. 13, 109, 1997.
Competing interests:
None declared
Competing interests: No competing interests
Echocardiography: A Diagnostic tool for Heart Failure in Primary care.
Chronic heart failure is becoming increasingly common and affects up
to 5,00,000 people in the United Kingdom. Recent studies have confirmed
the poor prognosis of heart failure. Half of those with heart failure die
within 5 years of diagnosis despite conventional treatment and mortality
is directly proportionate to the severity of the symptoms. According to
NICE guidelines and audit recommendations, the basis of historical
diagnosis of heart failure should be reviewed and only patients whose
diagnosis is confirmed should be managed for heart failure. A Study using
echocardiography in the community, found the true prevalence of heart
failure to be 8 per 1000 although 16 per 1000 patient receiving diuretics
for this indication.
Heart Failure At Guilsborough Surgery, Northampton
Guilsborough surgery is highly computerized practice using EMIS
system with all patient notes recorded on the computer. There are
templates for many chronic diseases including heart failure but heart
failure template not been used so far. The purpose of audit was to help
practice team audit the management in primary care of patients who are
diagnosed as having heart failure.
Criterion:
The records show that the clinical diagnosis of suspected heart
failure is confirmed by trans-thoracic echocardiography with exception in
following conditions:
1) Patient declining further investigations or not willing to have
echocardiography.
2) Where this would be inappropriate e.g. terminal illness, debilitating
disease.
3) Patient not able to attend hospital due to disability or immobility.
Standard
90% of the patients, newly diagnosed as heart failure in a period of last
16 months (01/04/03 - 31/07/04), should have echocardiogram to confirm
their diagnosis.
First Data Collection and Summery of Results
The criteria and standard identified, discussed and agreed.
Instructions for auditing heart failure from ELI LILLY National clinical
audit centre studied and agreed for procedures of audit .10 patients were
identified as newly diagnosed heart failure in a last 16 months .70% of
the newly diagnosed patient with heart failure had echocardiogram and 30%
did not have their diagnosis confirmed by echocardiography. Among those
patients whose diagnosis was not confirmed by echocardiogram none had
terminal illness or disability that could limit their mobility.
Recommendations
After analysis of results and reviewing system of entering diagnosis
and investigations in computer records following recommendations are
suggested to Guilsborough practice:
1) Accurate coding of diagnosis: Patients who are suspected of heart
failure on the basis of their symptoms should be coded as their symptoms
and only those patients whose diagnosis is confirmed by echocardiogram
should be coded as heart failure.
2) Template for heart failure should be used for all newly diagnosed
patients with heart failure and entry of echocardiogram should be made in
each template.
3) Hospital investigations need to be entered on the template to improve
the effectiveness of data collection. This can be done when clinic
letters, discharge letters and investigations are summarised on practice
computer.
4) To achieve better diagnostic standards it is necessary to have open
access to Echocardiography.
5) Another audit (Second Data Collection) on “use of echocardiography for
diagnosis of heart failure” needs to be performed in one-year time. The
accurate use of template for heart failure would make re-audit easier.
Competing interests:
None declared
Competing interests: No competing interests