Barriers to diagnosing and managing heart failure in primary care

OBJECTIVE: To explore potential barriers to the optimal diagnosis and management of heart failure in primary care. DESIGN AND SETTING: Qualitative study involving semi-structured focus groups or telephone interviews with general practitioners, in three urban and one rural Division of General Practice with above-average elderly resident populations, conducted between 1 April and 31 July 2002. PARTICIPANTS: 31 self-selected GPs who responded to a general invitation and four GPs who were personally invited to participate in the study. MAIN OUTCOME MEASURES: Issues identified by GPs as barriers and GPs' ratings of their importance. RESULTS: GPs reported that most of the difficulties in accurately diagnosing heart failure were associated with masking of the disease by other conditions and the lack of specificity of the symptoms, particularly in the early stages. They felt that echocardiograms can be difficult to access, were of unclear benefit and may not be warranted in obvious cases. Concerns about possible side effects and reliance on other forms of therapy were common reasons for the suboptimal use of angiotensin-converting enzyme inhibitors. Underuse of beta-blockers was associated mainly with concerns about side effects, contraindications and comorbidities, and a lack of experience with initiating therapy, particularly in community settings. CONCLUSIONS: This study identified specific barriers to GPs implementing evidence-based recommendations in managing heart failure. Tailored strategies that address the practical concerns of GPs about applying research evidence in the primary care setting and that facilitate better linkages between GPs and specialists are needed.