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Hub 1 Final Report
Adherence to Heart Failure Practice Guidelines in Primary and
Secondary Care: A Mixed-Methods Study



TECHNICAL DATA TITLE: Recap – Hub 1 Final Report EDITOR: Prof. dr. H.P. Brunner-La Rocca Drs. S. Bektas FHML, opleiding Geneeskunde Universiteit Maastricht. TEXTS: Belgium: Thomas More University College University Hospital Maastricht Maastricht University The contents of this report reflect the authors' views and do not necessarily reflect the opinion of the European Communities. The European Commission is not liable for any use that may be made of the information contained therein. EDITION DATE: December 2014 INFORMATION ABOUT RECAP PROJECT:



Abstract
Aim:
Explore the adherence to heart failure clinical practice guidelines by general practitioners (GP's)
and cardiologist and identifying the barriers in adherence to these guidelines. Methods: A mixed-methods study design was used, containing a qualitative part and a quantitative
part. The qualitative study was conducted using semi-structured interviews with six cardiologist and 19 GP's. These caregivers were identified from thirty-two secondary care patients with heart failure (HF), randomly selected from Maastricht University Medical Centre (MUMC) in the Netherlands. Nine primary care patients with HF were also interviewed, selected at random from the included GP's. The quantitative study was conducted using medical charts from MUMC for the secondary care patients and from medical charts provided by the GP's for primary care patients. Results: A major variability is found in the management of HF between primary care and secondary
care. Knowledge of medication for HF and adherence to evidence-based guidelines differs between GP's. The cardiologist is the main caregiver in secondary care patients. GP's merely have a small role, altering medications if needed. Prescription of HF medication by GP's such as ARBs/ACE inhibitors and beta-blockers are considerably less (55.5%, 66.7%, respectively) in comparison with cardiologist (88.7%, 85.5%, respectively). GP's have a preference for treating elderly patients in primary care, using diuretics for symptom relief and as a sort of diagnostics method. Conclusion: Our qualitative and quantitative results support one another, identifying the barriers for
the suboptimal treatment of HF in the primary care. Treatment in secondary care is close to ideal. Adherence to evidence-based guidelines in primary care is poor. More research needs to be done in primary care to identify this population to improve the management of HF in primary care, since ACE inhibitors and beta-blockers are still being underutilized. Introduction
Heart failure (HF) is a common chronic disease that is associated with a poor prognosis. The 5-year
survival rate is less than 50%, which is worse than many forms of cancer.1-5 It is estimated that approximately 1 to 2% of the adult population in developed countries has HF. Even though a decline in prevalence of other cardiovascular diseases has been seen, the prevalence of HF continues to rise. Among persons 70 years of age or older it is up to >10%.6 This is due to the ageing population in the developed countries and better survival from cardiovascular diseases earlier in life.2,5,7 This has resulted in heart failure being a serious cause of hospital admissions among the geriatric group.8 Hospital admissions are often of long duration, leading to considerably high health care expenditures.9 In the Netherlands, the total costs of heart failure care was approximately 940 million euros in 2011, which was 11,4% of the total costs of cardiovascular diseases and 1,1% of the total healthcare costs.10 This has led to HF becoming one of the main health care issues in developed Since heart failure is a complex disease with a high morbidity and mortality, many controlled clinical trials have been done over two decades to improve the treatment of HF. This has resulted in significant developments in both drug and device treatment of HF. Several international guidelines have been made on how to practice these evidence-based treatments.11-14 Even though these guidelines have been available in Europe for over a decade, management of HF still seems to be suboptimal.11,12,15-17 With the mortality of HF still being high, and the high costs HF health care has, adherence to practice guidelines is critical, because evidence-based literature has shown that these medications recommended in these guidelines, such as ACE inhibitors, angiotensin receptor blockers (ARBs) and beta-blockers will help in delaying progression and improve the survival and quality of life for patients with HF.13,14,18-19 In practice more advantages can be obtained when adherence to the evidence-based guidelines. Therefore changes need to be made in the clinical management of HF. For this purpose it is important to know what barriers there are in the management of HF. Therefore, the aim of this study is to identify the pharmacological treatment for heart failure in patients in primary and secondary care (i.e. GP's and cardiologists), comparing this to the guidelines available in the Netherlands (i.e. Nederlands Huisartsen Genootschap (NHG) guideline Heart failure and ESC Guideline.14,19) and identifying the barriers healthcare givers experience for not fully following the guidelines. Study design
In this study a mixed methods design was used, containing a combination of qualitative and
quantitative research methods. Through this mixed design a comprehensive understanding will be obtained of current heart failure care. The qualitative and quantitative parts were done concurrently. Study population
The intention of this study is to get the best possible overview of current HF pharmacological
treatment. Therefor patients diagnosed with symptomatic heart failure were recruited from both primary and secondary care. A total of 38 patients were recruited for an interview. Six primary care patients were selected at random from different GP's in the region of Limburg in the Netherlands, and 32 secondary care patients were randomly selected from the outpatient clinic of various cardiologists in Maastricht University Medical Centre. Patients were included when diagnosed with heart failure and with a minimum age of 18 years. Additionally, included patients were to be able to understand and follow the instructions of the research personnel (i.e. speaking and understanding Dutch language, were able to hear and speak, were able to have a conversation with a duration of approximately an hour). Furthermore, all participants in this study had to sign an informed consent form. Patients were excluded when they have had heart transplantation. One of the aims of this study was to identify the caregivers, therefor caregivers were also considered to be subjects, since they were interviewed themselves. Thus after patients were interviewed, the main treating physician as depicted by the patient (e.g. GP, cardiologist, other specialist) was invited for an interview to describe the processes in HF care form another perspective. Interviewed caregivers consisted of 19 GP's from the region of Limburg and six cardiologists from Maastricht University Medical Centre. In addition, 29 patients were included for retrospective quantitative data collection from medical charts, 3 patients were randomly selected from primary care and 26 patients were randomly selected from secondary care. Qualitative part
In this part of the study, patients and their health care providers participated in semi-structured,
individual interviews. The participants were contacted to supply them with full and sufficient verbal and written information concerning the nature, goal, possible risks and advantages of the study. When they agreed to participate in the study, an appointment was made either at the outpatient clinic or at their home to conduct the interview. Interviews were conducted between September 2012 and June 2014. These interviews were performed by trained research assistants who had no part in de standard care patients received, nor were they medical experts. This is an important feature to prevent the interviews from being biased. Questions in the interviews with caregivers were based on their management of HF in general and their management of HF in specific patients (i.e. the secondary care patients included in this study, treated by both GP and cardiologist). One of the questions for GP's was their knowledge on the guideline specially made for GP's in the Netherlands, based on evidence-based literature: the NHG- guideline Heart Failure.19 All selected stakeholders were asked permission and participants had to sign an informed consent form before the interview could take place or medical data was recorded. Interviews were audio taped (Smartpen, Livescribe) and transcribed verbatim for analysis. Transcripts were coded using inductive, conventional content analysis by two independent researchers who frequently debated their codes and reflections in order to achieve consensus. Codes were sorted on major topics generated directly from the interviews. After all interviews were coded, one researcher clustered single codes on recurrent themes. From each cluster, phrases from different original sources were compared. This across-case analysis was used to uncover both analogies and remarkable divergence from the prevailing opinions. Quantitative part
This part of the study contains medical information of the patients that were interviewed. Since
qualitative analysis with interviews is very time-consuming, it does not allow a large sample size, thus may introduce some bias. Therefore, we expanded the sample size for the quantitative part beyond the number of interviewed patients. As stated above, a total of 29 patients were additionally included for the quantitative data collection. Data was collected retrospectively, using patients' computerized medical charts. These medical charts were provided by the Maastricht University Medical Centre and by the included GP's. Collected data contained: demographic and clinical characteristics and pharmacological treatment of HF. All data was processed anonymously. This study conforms to the Declaration of Helsinki and has been approved by the Ethics Committee of the Maastricht University Medical Centre. Data analysis
The data from the interviews was analysed using NVivo 10 (QSR International, Cambridge, MA).
Quantitative data was entered into a specially designed Access-database (Microsoft Office). Analysis of the quantitative data was done using SPSS v 20.0 (IBM). Results are presented as frequencies (%), mean (± SD), or median [interquartile range]. Kolmogorov- Smirnov test was used to indicate normal distribution. Results
In this study we focused on the following groups of participants: the patients from primary and
secondary care, the GP's and the cardiologist. The included 32 secondary care patients had 25 GP's. Of these GP's five refused to participate and one GP was interviewed, however did not want to be recorded. These remaining 19 GP's were asked to provide a list of their patients with HF. Six patients were randomly selected from these lists and interviewed. Of the cardiologists invited, one refused to participate. In this analysis only caregivers who completed a recorded interview were included, which were 19 GP's and six cardiologist. Interviews
General practitioners' knowledge and adherence of the NHG guideline for HF management

Knowledge of the GP's on the existence of a NHG guideline about heart failure is variable. Most GP's mentioned using a guideline for the management of heart failure. Of those GP's the majority mentioned to know the ‘NHG Guideline Heart Failure'. Some GP's stated to not know this guideline. One GP mentioned he has knowledge of various NHG guidelines, but does not know if there is a NHG guideline particularly for HF management. GP 12: "In general, I use NHG-guidelines. But according to me there is no NHG guideline for heart failure." On practicing the ‘NHG guideline Heart Failure', one GP stated that he uses a guideline for the treatment of HF, though he was not sure what kind of guideline that was that he uses. GP 8: "I partly use the general guideline], but I do not know which guidelines, but they are a bit of general, these guidelines." A few GP's mention using the ‘NHG guideline Heart Failure', though not in every case. In some cases the GP said to need this guideline to make sure not to forget anything. In other cases the GP did not need to take a look in the guideline to make a treatment plan. GP 6: "Yes, but not always, because often I know what to do. But if all of a sudden someone new will come, I will sometimes look in the NHG guideline to make sure I am not forgetting anything." GP 15: "There is the NHG guideline for heart failure of course, so yes that is one to follow. And I also use my individual assessment of what is the most important." The majority reported to use this guideline in every case involving management of HF. GP 11: "Yes of course, you automatically end up using the NHG guideline for heart failure." Some GP's noted that even though they know there is a guideline for HF specially made for GP's, they choose not to use them. Instead, they obtain their information from other sources, by reading articles or by going to refresher courses. GP 2: "I do not use it, but I do read some articles, which I use." GP 3: "Well, I use what I hear at training of the cardiologist." GP 18: "No, no guideline." General practitioners' knowledge on and prescription of HF medication in general
As well as practice of the ‘NHG guideline Heart Failure', knowledge on HF medication is also diverse between the GP's. When asked about the HF medication that GP's would prescribe in general for a HF patient, most stated they would begin their treatment with a diuretic. Reason for a diuretic to be the first treatment was stated to be symptom relieving. GP 3: "To start, if someone is really short of breath, I start with furosemide." GP 13: "Usually, they do have complaints of excessive fluid. So, first you will look at dewatering. So first, the first step is actually a diuretic." GP 14: "Well, that depends on the severity of the symptoms. So usually it is fluid in the lungs and fluid in the legs. [in that case] it is often first adding diuretics as fast symptoms relief." One GP mentioned he would start a diuretic to get confirmation for his diagnosis of HF. GP 6: "You often start with a diuretic to see if there is heart failure, look if there is improvement. It's partly diagnostic." As for prescribing other medication in the treatment of HF medication, statements are highly variable. From prescribing a diuretics with an ACE inhibitor, with occasionally a beta-blocker or an aldosterone antagonist, to prescribing Plavix, an anticoagulant. GP 2: "When someone is a little decompensated I think: well, maybe I will just give a little more Plavix or something and things will be good again." An ACE inhibitor and beta-blocker were frequently mentioned, though several GP's noted that they do not prescribe an ACE inhibitor or a beta-blocker as easily and quick as a diuretic. When GP's do prescribing an ACE inhibitor or beta-blocker, the dosage is carefully considered, usually starting with a low dosage. Some GP's stated to prefer to leave the prescription of these medications to a cardiologist if their patient is already in secondary care. GP 15: "depending on whether there is a fast heartbeat,[I will prescribe] a beta-blocker or no. [other medication] an ACE inhibitor but not always an ACE inhibitor, which [the dosage] I build up slowly." GP 11: "The moment you have got a serious suspicion [of HF], you will start with diuretics, sometimes low doses of beta-blockers and ACE inhibitors." A few GP's mentioned a prescription of an ARB or digoxin, and one GP mentioned a aldosterone antagonist and one GP a calcium antagonist. Reasons for prescribing these medication differ between GP's. One GP explained the importance of an ACE inhibitor for a patient with HF and noted that apart from the diuretic, an ACE inhibitor and beta-blocker are the most important to prescribe. Another GP noted prescribing certain medication due to following the ‘NHG guideline GP 7: "Yes [I follow] the NHG guideline. So I will give a diuretic and ACE inhibitor and sometimes add a beta blocker or a aldosterone antagonist." Others reported that the prescription of an ACE inhibitor or beta-blocker depends on the situation and on the symptoms the patients presents itself. A few GP's mentioned that it is important to identify the cause of HF for a better treatment. When knowing the cause of HF the GP can treat the GP 8: "It depends on why he got decompensated. Is there atrial fibrillation involved or other causes? That is something you need to look at first." GP 13: "You have to treat the cause, otherwise it is just a waste of time." Some GP's stated that prescribing HF medication is sometimes out of their hands. In these cases patients will already have received their HF medication from a cardiologist. GP 16: " Well, most of the time all the steps are already taken, if they come [to me." GP 18: "diuretics usually first and then they also receive an ACE inhibitor. As for further steps, they will have been to the cardiologist who then will set them up further." A visual illustration is given in figure 1 on what GP's mention a patient with HF need for treatment. Numbers are in percentages, though need not be interpreted that way. This figure shows that most mentioned medications for the treatment of HF by a GP are diuretics, followed by an ACE inhibitors and beta-blockers, respectively. Figure 1 Knowledge medical treatment GP
General practitioners' role in HF management
Though many GP's enumerate the medication they would prescribe for HF patients, many GP's respond with not having actually been prescribing these HF medications for the secondary care patients included in this study. Several GP's mention that in practice the cardiologist will prescribe the HF medication. GP 17: "No, not in this case. I did not do anything. That's all done in hospital." Moreover, some GP's noted that this happens frequently if he refers his patients to the cardiologist for diagnostics to confirm the diagnosis of HF. Once the patient is registered in hospital, the patient seems often to be lost to follow up by the GP, which is found to be unfortunate by GP's. GP 16: "No. This happens very often. The patient comes with dyspnea, and is then diagnosed as pulmonary or cardiac. If it is cardiac, additional research will be done, and if there is something found, the patient will be referred to the outpatient clinic. And then she's gone [out of my side]." Other reasons for not prescribing any HF medication for these patients were mostly complex patients, which are described as patients with complex pathology. A few GP's did have a small role in prescribing HF medication; they started the treatment of HF with a diuretic. Pharmacological therapy other than a diuretic was prescribed by a cardiologist. GP 19: "Only furosemide. It took one week before he [the patient] got everything from a specialist." Various GP's said that though they did not initiate the HF medication in the secondary care patients who were discussed, they do are involved in the HF management by adjusting these medications. Of those GP's, the majority do these adjustments by themselves. A few indicated to only adjust the medication in consultation of a cardiologist, with main reason to be the complexity of the patients' disease. If possible, GP's usually prefer to adjust the medication themselves, but they will refer their patient to a cardiologist if their adjustment of the treatment does not work or does not suffice. GP 14: "at that moment when they have some symptoms, they will report it to their general practitioner first. And it is often up to us to determine whether the diuretics must be increased [in dosages]. (…) If it is easily to handle, I'll do it myself. If it is difficult or complicated, or it does not work, I will of course consult with the cardiologist or I will refer the patient to the cardiologist. But often I do it myself." Furthermore, GP's prefer to keep the geriatric population in primary care instead of referring them to a cardiologist. They rather treat the elderly patients themselves, focusing on quality of life. GP 9: "that is difficult in my opinion, but I think you should aim to optimize these people's home situation and arrange care and supervision." Cardiologists' adherence of guideline for HF
Each cardiologist has an action plan for the treatment of HF, using either the European society guideline on HF or the HF management protocol provided by Maastricht University Medical Centre. Cardiologists stated that they know most of the steps in the guideline. Occasionally they look in the guideline to be sure not to forget anything. Though trying to adhere to the guidelines that are provided, once in a while there are certain cases were cardiologist diverge from the guideline. CAR 5: "Well the guideline is treatment of heart failure and analysing the cause of heart failure. It is important to do both, not just analysing, but also treating the patients." CAR 6: "I will check the protocol in particularly when all the diagnostics I have used have excluded the most common causes, and I need to look into the more exotic things." Cardiologists' knowledge and prescription of HF medication in general
The cardiologists noted to follow the guideline and usually start with the treatment of HF parallel with the diagnostics. For them it is important to start the treatment with an ACE-inhibitor and beta- blocker. If these medications do not suffice, an aldosterone antagonist will be added in their pharmacological treatment. Prescribing a diuretic or an ARB is also mentioned, however an ACE inhibitor and a beta-blocker are described as the key medications for a HF patient. Furthermore, cardiologists stated the importance of finding the cause of HF. When a patient has coronary artery disease a statin and anticoagulation is also necessary. CAR 1: "Usually a patient needs to recompensate, so this needs to be treated first, parallel with the diagnostics that is done. After that the important medication needs to be started, such as an ACE inhibitor, a beta blocker and an aldosterone antagonist, the latter depending how things go." Cardiologists' role in HF management
The role of the cardiologist is mainly to diagnose a patients' disease by using diagnostics, such as ordering blood tests or perform an echocardiography. If heart failure is diagnosed, the cause of HF needs to be investigated by the cardiologist. Parallel with diagnostics the cardiologist stated to be treating the patient with medication as stated above. Cardiologists stated to be treating these patients in the outpatient clinic, having these patients come to have check ups every few months or so. In addition it is also stated that if a patients' HF condition is stable, cardiologist will be referring the patient back to their general practitioner. CAR 2: "The cardiologist examines the cause of heart failure, he treats the cause and takes measures in the lifestyle, medication and other things, such as electrical therapy and surgical therapy. Demographic and clinical characteristics
Sixty-two patients from secondary care were included. Nine patients were included from primary
care (i.e. only treated by their GP). Clinical and demographic characteristics are summarized in Table 1. Participants from secondary care were aged between 28 and 93 (mean age 71), the majority were men (58,1%). At moment of diagnosis of HF 50% had a cardiac history. Participants from primary were aged between 65 and 88 (mean age 81); 5 (55,6%) were men and 4 (44,4%) women. Echocardiography was done in merely two patients (22%) at the moment of diagnosis of HF. None of these patients had an implanted electronic device, nor did they undergo cardiovascular interventions. 33,3% had a cardiac history when diagnosed with HF. Patients characteristic
Secondary care (N=62)
Primary care (N=9)
Age, mean (SD)
84.9 [77.9-87.5]* Deceased
EF ≥ 50%
EF < 50%
Risk factors
BMI, mean (SD)
31,2 [24.5-33.9]* Diabetes mellitus
Nicotine abuses
Ethanol abuses
Renal dysfunction
Cardiac history
Positive family history
History – cardiac
Coronary artery disease
Rhythm disorder (total)
Valve disease
Valve surgery
Ablation
History – non-cardiac
Peripheral artery disease
History of TIA
History of Stroke
Sleep apnea
Thyroid dysfunction
Connective tissue disease
* median and interquartile range Abbreviations: BMI, body mass index; PCI, percutaneous coronary intervention; CABG, coronary artery bypass surgery; ICD, implantable cardioverter-defibrillator; PM, pacemaker; CRT, cardiac resynchronization therapy; EP, electrophysiological; TIA, transient ischemic attack); COPD, chronic obstructive pulmonary disease; SD, standard deviation. Therapy in first 3 months after diagnosis
As seen in Table 2, when diagnosed with HF 62,9% of the patients in secondary care received an ACE
inhibitor in the first three months, 77,4% received a beta-blocker and 75,8% received a diuretic. The cardiologists prescribed most of these medications. For secondary care patients, GP's had only prescribed a diuretic, which was the case in 8,5%. The prescription of diuretics for primary care patients was lower than for patients in secondary care. In primary care 66,7% of the patients received a diuretic, with the GP prescribing the diuretic in most of the cases. In primary care 55,6% used a beta-blocker, with patients receiving prescription from various caregivers. ACE inhibitors in primary care were used by 33,3%, all prescribed by a GP. An ARB was used in 27,4% in secondary care, with the cardiologist being the main prescriber. In primary care 33,3% used an ARB, the majority being prescribed by a GP. Aldosterone antagonists were not used by patients in primary care, 19,4% in secondary care received one prescribed by a cardiologist. Therapy first 3 months after diagnosis
Secondary Care (N=62)
Primary Care (N=9)
Emergency department
Other caregiver
Emergency department
Other caregiver
Emergency department
Other caregiver
ARB
Emergency department
Other caregiver
Aldosterone antagonist
Emergency department
Other caregiver
Emergency department
Other caregiver
Emergency department
Other caregiver
Emergency department
Other caregiver
Abbreviations: GP, general practitioner; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers Current medication
Table 3 gives an overview of the current medication used by patients in primary and secondary care.
Beta-blockers are used the most in secondary care (85,5%), followed by diuretics (75,8%). Furthermore, an ACE inhibitor is used more often (54,8%) by secondary care patients than an ARB (33,9%). An aldosterone antagonist is used by as much patients in secondary care, as ARB. In primary care the prescription of diuretics is the most, being 77,8%. This is followed by beta- blockers (66,7%). In primary care patients an ARB is more used (44,4%) than an ACE inhibitor (11.1%). No aldosterone antagonist was prescribed in the primary care. Current medication
Secondary Care (N=62)
Primary Care (N=9)
Diuretics
Aldosterone antagonist
Calcium antagonist
Lung medication
Gout medication
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; PPI, Proton-pump inhibitor. Discussion
This study shows there is a major difference between the population of HF patients treated in the
primary and secondary care. Patients treated in primary care are often elderly patients. This can be explained with our qualitative results, where GP's stated they preference to keep elderly patients in primary care treating these patients themselves, rather than referring these patients to a cardiologist. Secondary care patients more often have a history of coronary artery disease, while atrial fibrillation was slightly more present in primary care patients. The first can be explained by the interventions these patients may need after an ischemic event, such as a PCI or a CABG. The percentage of atrial fibrillation in primary care can be explained with the age of the primary care being more older.20 Differences are also seen in the use of echocardiography. There were some missing values of left ventricular ejection fractions (LVEF) in secondary care patients. The reason for this is that we collected data of echocardiography done from the moment of diagnosis till a year later. All secondary patients had an echocardiography at some point, however in some cases these echocardiograms were done some time before the actual diagnosis was stated in their medical chart, therefore for a small number of patients no LVEF was registered in our study. In this study we found results from the qualitative part to demonstrate a variety in views on knowledge and adherence to guidelines, knowledge of medication for HF and the role in HF management between the interviewed GP's. This is in contrast to the interviewed cardiologists, who seem to have a same idea on these topics. Our quantitative results supports the outcome of the medication prescriptions by the GP's and role in prescriptions described by the caregivers in the interviews, with GP's having a small role in the prescription of medication in secondary care patients, having only prescribed a diuretic in 8,5% of the cases. Furthermore, it was seen in the quantitative results that GPs' prescription of diuretics is more frequent than any other medication for HF for patients in primary care. This is consistent with previous studies, where it is shown that diuretics were the preferred single agent for initiation of treatment by GP's and the most prescribed in comparison with other medications for HF.11,21-24 This study gives an explanation for the reason why GP's tend to prescribe a diuretic more often. GP's stated that their treatment is based on the symptoms patients present themselves with. Their intention is to make sure patients experience a quick improvement with the treatment they receive. In perspective of the GP quick improvements are seen when prescribing a diuretic. These results suggest that GP's do not seem to base their treatment on the cause of HF. This is also confirmed in the interviews by GP's, stating they often use a diuretic as a sort of diagnostics method to confirm their suspicion of HF in their patients. This is retrievable in the quantitative results, with echocardiography been done in only 22% of the primary care patients. With this, it can be concluded that GP's tend to omit echocardiography as a diagnostics in their confirmation of the diagnosis of HF. This bring us to the conclusion that GP's evidently do not know what kind of patients they treat in primary care, due to not knowing what cause of HF their patients have. This seems also to be the case in a previous study by Remme et al. where echocardiography was also rarely done or requested by the GP for the diagnosis of HF.11 Diagnosis of HF by GP's seem to be almost purely on symptoms and sign. This was also shown by Remme et al. with 80% of the GP's stating to often base their diagnosis of HF on symptoms and signs and that less than 30% of the GP's considered the need for further investigation before coming to a conclusion of the diagnosis HF.11 This poor quality of diagnosis of HF in primary care has to be taken in consideration when looking at our results in the primary care. As echocardiography has not been done to confirm diagnosis of HF, patients coded to have HF in primary care may not actually have HF and could be treated faulty, due to receiving medications for the management of HF with not actually having heart failure. Even though the cause of HF is unknown in patients in primary care. It is evidence-based and stated in the guidelines that an ACE inhibitor and a beta-blocker is beneficial for every patient with HF, for both patients with HF with a reduced ejection fraction (HFrEF), as for patients with HF with a preserved ejection fraction (HFpEF).12,13,15-17,19 Thus, assuming in this study all primary care patients' diagnosis of HF is correct, every patient in this study should have had an ACE inhibitor and a beta- blocker. This is however not the case. Previous studies concluded that GP's prescribe less potentially beneficial medication for their patients compared to cardiologist.25,26 This is also seen in our study. Results from our study on the current treatment of HF received by the patients, indicate that diuretics are more prescribed for patients in primary care, whereas ACE inhibitors and beta-blockers is more received by patients in secondary care. ARB's seem to be more prescribed in primary care, as a substitution for ACE inhibitors, indicating GP's prefer the prescription of an ARB over an ACE inhibitor. Looking at the overall percentage of prescription of an ARB or ACE inhibitor, cardiologists do a much better (88,7%) in prescribing these medications to their patients in contrast to the GP's (55,5%). With these results, conclusion can be drawn that GP's still do not follow the clinical practice guidelines as how they should do, leading to suboptimal treatment by the GP's. 12,13,15-17,19 As seen in the quantitative results GP's have a small role in the management of HF in secondary care patients. Results from the interview explain reasons and barriers in this matter. The majority of GP's has sufficient knowledge of the medications available for HF. However most of the GP's do not prescribe them. As stated above this is part due to their purpose of treatment, which is based on reducing symptoms quickly. For patients in secondary care, GP's explain they withhold treatment because these patients are also treated by a cardiologist. As stated by GP's, the cardiologist is the specialist with more knowledge on HF. GP's therefore tends to rely on the cardiologist, assuming cardiologists will start the medication that is needed. This is also confirmed by Steinman et al. stating that GP's are more reluctant to prescribe medications when their patient is also treated by other doctors.27 Though co-management is seen as a barrier for GP's for not prescribing an ARB/ACE inhibitor and beta-blocker in secondary care, poor prescription rates of these medications in primary care cannot be explained with this, since the responsibility in this population is of the GP. Results from our qualitative analysis may explain what barriers are encountered here by the GP's. One is the lack of knowledge. As previously mentioned knowledge of GP's on the available guidelines and on medications for HF are highly variable. Moreover, lack of courage to start these medications is also a perceived barrier. GP's mentioned in this study their prescription of an ARB/ACE inhibitor and beta- blocker is carefully considered if it is prescribed. Fuat et al. stated that fear of side effects plays a key role in prescribing medication, such as an ACE inhibitor.28 This could also explain why the majority of the primary care patients is using an ARB instead of an ACE inhibitor. Apart from fear of side effects, a recent study showed that GP's also perceived a barrier with the burden of monitoring, due to having concerns surrounding the initiation and titration of ACE inhibitors and beta-blockers.29 As for the secondary care, treatment by cardiologists seems adequate regarding the percentages of prescribed medication of ARBs/ACE inhibitors and beta-blockers. The next step would be identifying the dosages these patients receive. Although the prescriptions of ARBs/ACE inhibitors and beta- blockers by cardiologists are over 80%, dosages of these medications have not been analyzed. Therefor it is not yet clear if the secondary care patients have the treatment they should have. Maggioni et al. noted that though the percentage of HF medication prescribed in secondary care is rising to a adequate percentage, target doses have only reached in one-third to one-fourth of the cases.30 Therefor further research needs to be done in identifying prescription dosages Though analysis on this matter have not been done. It is expected that our secondary care patients are receiving more their target doses than is seen in previous studies, since cardiologists in our study stated to follow the recommended treatment in guidelines, and saying to only deviate in some cases. However, it can be concluded that the adherence of cardiologist to guideline-recommended treatment is much more closer to ideal than the adherence of GP's.25 Strengths and limitations of the study
A limitation of this study is the number of included primary care patients. This is due such data
saturation has not been reached. We encountered the difficulty in recruiting primary care patients. GP's were often reluctant in providing lists of their patients due to protecting the privacy of their patients. Furthermore, when recruiting patients from primary care who were diagnosed with HF, patients often did not think or know they were diagnosed with HF. With this reasons, patients refused participation in this study. Though the number of primary care patients was limited, we believe that this did not bias our results. Our study is a mixed-methods study, which is considered as strength. To our knowledge no mixed- methods study has been done on the management of heart failure. With a mixed-methods study results of the quantitative analysis were explained and supported by the qualitative analysis and vice versa. Furthermore, our study included the view of both the GP as the cardiologist, giving us a better illustration on how management of HF is in both primary care as secondary care. Conclusions
A number of barriers have been identified in the management of heart failure in primary care. There
is a variety in knowledge and adherence to guidelines and medication prescription among general practitioners. Different approaches have been found in the management of heart failure between GP's and cardiologists. Treatment of heart failure is close to ideal in secondary care, however still suboptimal in primary care. For better management in primary care adherence of guidelines by GP's needs to be improved. It is of concern GP's rarely use diagnostics for their diagnosis of HF. There is still underutilization of ACE inhibitors and beta-blockers. To optimize treatment in primary care, a better understanding of patients in primary care is needed; therefore more diagnostics need to be References
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Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002. 23;360(9346):1631-9. 22. Bongers FJ, Schellevis FG, Bakx C, et al. Treatment of heart failure in Dutch general practice. BMC Family Practice. 2006. 5;7:40. 23. Hobbs FD, Jones MI, Allan TF, et al. European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). European Heart Journal. 2000. 21(22):1877-87. 24. Bosch M, Wensing M, Bakx C, et al. Current treatment of chronic heart failure in primary care; still room for improvement. Journal of Evaluation in Clinical Practice. 2010. 16(3):644-50. 25. Rutten FH, Grobbee DE, Hoes AW. Differences between general practitioners and cardiologist in diagnosis and management of heart failure: a survey in ever-day practice. European Journal of Heart Failure. 2003; 5 (3):337-344. 26. Khunti K, Hearnshaw H, Baker R, et al. Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. European Journal of Heart Failure. 2002. 4(6):771-7. 27. Steinman MA, Dimaano L, Peterson CA, et al. Reason for Not Prescribing Guideline- recommended Medications to Adults With Heart Failure. Medical Care. 2013. 51(10):901-7. 28. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. British Medical Journal. 2003. 326(7382):196. 29. Hancock HC, Close H, Fuat A, et al. Barriers to accurate diagnosis and effective management of heart failure have not changed in the past 10 years: a qualitative study and national survey. BMJ Open. 2014. 4(3):e003866. 30. Maggioni AP, Dahlström U, Filippatos G, et al. EURObservational Research Programme: the Heart Failure Pilot Survey (ESC-HF Pilot). European Journal of Heart Failure. 2010;12(10):1076-84.

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