Towards a disease management plan for heart failure patients in general practice

Introduction Heart failure (HF) is a prevalent health problem with an important economic impact particularly due to frequent (re) hospitalizations. Comprehensive disease management programs (DMPs) integrate all aspects of HF management in a seamless, multidisciplinary system of care. They showed potential to decrease HF readmissions up to 30% but not all DMPs were equally effective. Additionally, from a community perspective the majority of HF DMPs target a minority of the HF population in general practice. The current HF DMPs lack a pro-active chronic care approach. Therefore, the role of general practitioners (GPs) in HF DMPs should be expanded. In order to do that, more knowledge is needed about the identification of HF patients in general practice, the current quality of HF treatment and how to evolve to multidisciplinary HF care in Belgium. This PhD thesis aimed to answer these questions and set steps towards the development of a successful DMP for HF patients in general practice.

Methods Chapter 1.1 was dedicated to the identification of HF patients in general practice. We used data from the INTEGO database to study the burden of HF in Flemish general practice. We performed a systematic review of all studies identifying HF patients in general practice to provide an overview of all possible identification methods.  We studied the BELFRAIL cohort with 567 patients aged 80 years and older to report on the correlation between objective cardiac abnormalities and GPs’ judgement on HF and to validate and compare four diagnostic algorithms for HF. Think-aloud interviews with 14 GPs were used to gain insight in GPs’ diagnostic reasoning in real-world HF patients. Chapter 1.2 focused on stakeholders’ views. We made a systematic overview of all qualitative studies about GPs experiences with HF management and performed semi-structured interviews with 13 GPs about their perspectives on HF management in Belgium. In Chapter 1.3 we used a modified Delphi method to identify quality indicators for HF in general practice. In Chapter 2, a multifaceted intervention consisting of a clinical audit in the GPs’ electronic health record (EHR), an N-terminal pro-brain natriuretic peptide (NT-proBNP) point-of-care (POC) test and support by a specialized HF nurse, was piloted in eight general practices.

Results First, an extended clinical audit in the GPs’ EHR led to a 40% increase in the identification of HF patients, highlighting the need for case-finding in general practice. Second, we found that GPs are in need of measures to reduce uncertainty in the HF diagnosis. Natriuretic peptides (NPs) proved to be the most important diagnostic clue to decide upon referral, even in elderly, however currently they are hardly used since they are not reimbursed in Belgium. Access to NPs is indispensable to improve the HF diagnosis. Third, standardized specialist communication with respect to diagnostic and echocardiographic terminology is warranted. Fourth, treatment rates of HFrEF patients with renine-angiotensin-aldosteron-system (RAAS) blockers and B-blockers were high but target doses were seldom reached. GPs expressed the need to evolve to a multidisciplinary chronic care model for HF, envisioning as a fifth measure more protocol-driven HF care and as a sixth measure task delegation to nurses.

Conclusion This PhD thesis added to the existing literature targets and interventions to extend HF DMPs to general practice and optimize care for a broader group of HF patients.