Background: Heart failure (HF) with preserved ejection fraction (HFpEF) is a common yet complex condition managed by primary care providers (PCPs) and requires a multidisciplinary approach to treatment. Prior research showed that, compared to patients with heart failure with reduced ejection fraction (HFrEF), patients with HFpEF are less likely to be recognized and referred by PCPs to cardiology and HF specialty services. We explored PCP-reported challenges and opportunities for HFpEF referrals to cardiology and ancillary services. Methods: A mixed methods analysis included semi-structured interviews and online surveys of PCPs recruited from academic and community practices in the US Southeast. During interviews, participants were asked how they manage HFpEF, refer patients to cardiology, cardiac rehabilitation (CR), and collaborate with other specialty and ancillary services. Surveys collected data on the number of years in practice, practice setting, and factors affecting referral of HFpEF patients to specialty services. Qualitative data were analyzed using thematic analysis in NVivo15 and quantitative data were analyzed using Chi-square tests in SAS. Results: Forty-six PCPs completed the online survey, and another 14 PCPs completed interviews. Of the survey participants, 65% (30) were in academic practice and 35% (16) were in community practice. Of the interviewees, 85.7% (12) were in an urban area and 14.3% (2) practiced in a rural area. Among survey respondents, 50% believed that cardiology should primarily manage HFpEF, while the other half believed that PCPs should do so. Most of the study sample (80.8%) were unlikely to refer patients to cardiology when a HFpEF diagnosis was suspected but not confirmed. 82.6% of PCPs did not refer HFpEF patients to cardiac rehabilitation. Consistent with survey data, thematic analysis identified 3 themes: inconsistency in referrals for HFpEF to cardiology, underutilization of CR and supervised exercise for HFpEF and variable use of ancillary services (i.e. nutrition education, clinical pharmacy) (Figure). Conclusions: Variability in HFpEF management by PCPs suggests that it is not yet standardized, and referrals to cardiology and other services are largely dependent on regional and financial availability. The subjectivity in patient management and structural barriers are the primary drivers of under-utilization of specialty and ancillary services for patients with HFpEF.
Hantouche et al. (Tue,) studied this question.