Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study
Open accessAbstract
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, β 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 strategies—for example, the provision of guidelines—are 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
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Patients can resist being referred and can resist offers of medication.
“Referral implies that a GP has identified particular features of candidacy and is seeking to match those to a service that deals with that form of candidacy, but patients can resist being referred [42,63] and can resist offers of medication [64,65].”
From Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups (2006) · cites this paper as [63]
Crucial to the local production of candidacy is the perceived or actual availability and suitability of resources to address that candidacy.
“Crucial to the local production of candidacy is the perceived or actual availability and suitability of resources to address that candidacy [60,63].”
From Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups (2006) · cites this paper as [63]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Wagner, H. R., Glaser, B. G., & Strauss, A. L. (1968) · Social Forces · doi:10.2307/2575405 · Cited by 46,470 · see citing works
The Discovery of Grounded Theory; Strategies for Qualitative Research
Glaser, B. G., Strauss, A. L., & Strutzel, E. (1968) · Nursing Research · doi:10.1097/00006199-196807000-00014 · Cited by 39,449 · see citing works
Handbook of Qualitative Research
Crozier, G., Denzin, N., & Lincoln, Y. (1994) · British Journal of Educational Studies · doi:10.2307/3121684 · Cited by 26,636 · see citing works
(1990) · Cited by 24,217 · see citing works
Qualitative evaluation and research methods
Ellis, D. J. (1990) · International Journal of Information Management · doi:10.1016/0268-4012(90)90041-p · Cited by 17,942 · see citing works
(1994) · Cited by 13,126 · see citing works
(1990) · Cited by 8,425 · see citing works
National service framework for coronary heart disease
Lloyd‐Mostyn, R. H. (2000) · BMJ · doi:10.1136/bmj.321.7261.634 · Cited by 833 · see citing works
Epidemiology, aetiology, and prognosis of heart failure
McMurray, J. J. V., & Stewart, S. (2000) · Heart · doi:10.1136/heart.83.5.596 · Cited by 799 · see citing works
The Discovery of Grounded Theory: Strategies for Qualitative Research
Wakeford, J. (1969) · Sociology · doi:10.1177/003803856900300233 · Cited by 734 · see citing works
Validity of clinical diagnosis of heart failure in primary health care
Remes, J., MlETTINEN, H., Reunanen, A., & Pyörälà, K. (1991) · European Heart Journal · doi:10.1093/oxfordjournals.eurheartj.a059896 · Cited by 536 · see citing works
Why general practitioners do not implement evidence: qualitative study
Freeman, A., & Sweeney, K. (2001) · BMJ · doi:10.1136/bmj.323.7321.1100 · Cited by 398 · see citing works
Remme, W. J., Cleland, J. G. F., Dargie, H. J., Erdmann, E., Ferrari, R., Kjekshus, J., Komajda, M., Poole-Wilson, P., Riegger, G. A. J., Soler-Soler, J., et al. (1997) · European Heart Journal · doi:10.1093/oxfordjournals.eurheartj.a015339 · Cited by 361 · see citing works
Techniques of Validation in Qualitative Research: a Critical Commentary
Bloor, M. (1997) · SAGE Publications Ltd eBooks · doi:10.4135/9781849208758.n3 · Cited by 317 · see citing works
The treatment of heart failure
Remme, W. J., Cleland, J. G. F., Dargie, H. J., Erdmann, E., Ferrari, R., Kjekshus, J., Michel Komajda, N., Poole-Wilson, P. A., Riegger, G. A. J., Soler‐Soler, J., et al. (1997) · European Heart Journal · Cited by 293 · see citing works
Context and Method in Qualitative Research
Charmaz, K. C., Miller, G. E., & Dingwall, R. W. J. (1999) · Contemporary Sociology A Journal of Reviews · doi:10.2307/2654919 · Cited by 276 · see citing works
Echocardiography in chronic heart failure in the community
WHEELDON, N. M., MacDonald, T. M., FLUCKER, C. J., McKendrick, A. D., McDevitt, D. G., & Struthers, A. D. (1993) · QJM · doi:10.1093/oxfordjournals.qjmed.a068731 · Cited by 269 · see citing works
Fortnightly Review: Diagnosis and management of heart failure
Dargie, H. J., & McMurray, J. J. V. (1994) · BMJ · doi:10.1136/bmj.308.6924.321 · Cited by 197 · see citing works
Evidence of inadequate investigation and treatment of patients with heart failure.
Clarke, K., Gray, D. P., & Hampton, J. R. (1994) · Heart · doi:10.1136/hrt.71.6.584 · Cited by 196 · see citing works
Hobbs, R. F. (2000) · European Heart Journal · doi:10.1053/euhj.2000.2170 · Cited by 149 · see citing works
The evidence for beta blockers in heart failure
Cleland, J. G. F., McGowan, J., Clark, A. L., & Freemantle, N. (1999) · BMJ · doi:10.1136/bmj.318.7187.824 · Cited by 107 · see citing works
Houghton, A. R., & Cowley, A. J. (1997) · International Journal of Cardiology · doi:10.1016/s0167-5273(96)02904-x · Cited by 95 · see citing works
Producing ‘Plausible Stories’: Interviewing Student Nurses
Melia, K. M. (1997) · SAGE Publications Ltd eBooks · doi:10.4135/9781849208758.n2 · Cited by 72 · see citing works
Diagnosis and management of heart failure
Lakasing, E., & Francis, H. (2006) · Primary Health Care · doi:10.7748/phc2006.06.16.5.36.c611 · Cited by 55 · see citing works
Barriers to optimum management of heart failure by general practitioners.
Horne, R., Coombes, I., Davies, G., Hankins, M. C., & Vincent, R. (1999) · Europe PMC (PubMed Central) · Cited by 42 · see citing works
Khunti, K. K., Baker, R., & Grimshaw, G. (2000) · Europe PMC (PubMed Central) · Cited by 37 · see citing works
Hobbs, R. F. (2000) · Europe PMC (PubMed Central) · Cited by 30 · see citing works
Open-access echocardiography to general practitioners for suspected heart failure.
Murphy, J. J., Frain, J. P., Ramesh, P., et al. (1996) · PubMed · Cited by 26 · see citing works
Self-citationRimington, H. M., Adam, G., & Chambers, J. B. (1996) · The Lancet · doi:10.1016/s0140-6736(05)64722-8 · Cited by 20 · see citing works
Toal, M., & Walker, R. (2000) · European Journal of Heart Failure · doi:10.1016/s1388-9842(00)00071-4 · Cited by 11 · see citing works
The implications of the National Service Framework for coronary heart disease.
Wierzbicki, A. S. (2000) · PubMed · Cited by 8 · see citing works
Rimington, H. M., Adam, G., & Chambers, J. B. (1996) · The Lancet · doi:10.1016/s0140-6736(05)65457-8 · Cited by 8 · see citing works
Corbella, E. C., Alonso, J. J. R., Luzon, C. Q., et al. (1995) · BMJ · doi:10.1136/bmj.311.7002.453b · Cited by 5 · see citing works
Caring for the Fourth Age: A Practical Guide to Medical Problems in Old Age
MACLENNAN, W. J. (1997) · BMJ · doi:10.1136/bmj.315.7115.1103a · Cited by 2 · see citing works
Anderson, P. (1998) · Physiotherapy · doi:10.1016/s0031-9406(05)65567-8 · Cited by 1 · see citing works
Flagged first, then by citations
Research works printed but not linked: 2
- McMurray J, Hart W, Rhodes G. An evaluation of the economic cost of heart failure to the National Health Service in the United Kingdom. Br J Med Econ 1993;6:99-110.
- Toal M, Walker R. ACE inhibitors in the treatment of heart failure in gen- eral practice in north Cumbria. Eur J Heart Fail 2000;2:201-7.
Cited by
Sorted by citations
Dixon-Woods, M., Cavers, D., Agarwal, S., Annandale, E., Arthur, A., Harvey, J., Hsu, R., Katbamna, S., Olsen, R., Smith, L., et al. (2006) · BMC Medical Research Methodology · doi:10.1186/1471-2288-6-35 · Cited by 2,053 · see citing works
Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care
Cochrane, L. J., Olson, C. A., Murray, S., Dupuis, M., Tooman, T., & Hayes, S. (2007) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.106 · Cited by 500 · see citing works
Hayes, J., Ford, T., Rafeeque, H., & Russell, G. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1800-1 · Cited by 83 · see citing works
- Authors
- Fuat, A., Hungin, A. P. S., & Murphy, J. J.
- Affiliations
- Durham University (GB)
- Corresponding author
- Fuat, Ahmet
- ORCID
- Hungin, A Pali S
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2003-01-25
- Volume
- 326
- Issue
- 7382
- Pages
- 196
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC140276
- OpenAlex
- W2161111685
- Cited by
- 284
- References
- 35
- Citations by year
- 2025: 3 · 2024: 6 · 2023: 3 · 2022: 9 · 2021: 6 · 2020: 7 · 2019: 16 · 2018: 12 · 2017: 12 · 2016: 19 · 2015: 15 · 2014: 17 · 2013: 10 · 2012: 15
- FWCI
- 13.19
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- BMJ (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Durham Research Online (Durham University) (acceptedVersion)
- Durham Research Online (Durham University) (submittedVersion, cc-by)
- Funders
- Bristol-Myers Squibb
- Pfizer
- Servier
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- heart failure, general practitioners, primary care, barriers to diagnosis, guideline uptake, left ventricular systolic dysfunction, ACE inhibitors, beta-blockers, spironolactone, polypharmacy, frail elderly patients, implementation strategies, professional culture, National Service Framework for Coronary Heart Disease, quality of care
- MeSH terms
- Adult, Attitude of Health Personnel, Cardiac Output, Low, Decision Making, Echocardiography, England, Female, Health Services Accessibility, Humans, Male, Middle Aged, Practice Patterns, Physicians', Primary Health Care, Sensitivity and Specificity, Focus Groups
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
