Introduction and background
Literature review
Methods
Participants and recruitment
Study location
Data collection
Data analysis
Results
GP number | GP or GP trainee | Years of practice | General demographic profile of all patients seen | CHF patient loada
| Profile of CHF patients |
---|---|---|---|---|---|
1 | GP | Newly registered | ∙ Low socioeconomic status (SES) ∙ Retirees ∙ Young families | Medium | – |
2 | GP | 4 | ∙ Farming families ∙ Retirees ∙ Young families | High | ∙ Elderly (> 65 years old) ∙ Male ∙ Farmers |
3 | GP | 20 | ∙ Young families ∙ Elderly (> 65 years old) ∙ Indigenous | Medium | ∙ Multi-morbidity |
4 | GP | 6 | ∙ Indigenous | Medium | – |
5 | Trainee | 0.5 | ∙ Women ∙ Children ∙ Elderly | Low | ∙ Elderly (> 65 years old) ∙ Young ∙ Pre-existing cardiac conditions |
6 | GP | 45 | ∙ Indigenous ∙ Young families | Medium | ∙ Elderly (> 65 years old) |
7 | GP | 30 | ∙ Indigenous | Medium | ∙ Patients with risk factors for cardiac disease (smoking, obese, sedentary) |
8 | GP | 13 | ∙ Lower SES ∙ Indigenous ∙ Substance use disorders | Low | ∙ Low SES ∙ Indigenous ∙ Substance use disorders ∙ Young ∙ Pre-existing cardiac conditions |
9 | Trainee | 1 | ∙ Indigenous | Low | ∙ Indigenous |
10 | GP | 20 | ∙ Indigenous | High | ∙ Indigenous ∙ Multi-morbidity ∙ Low SES |
11 | GP | 30 | ∙ Young ∙ Elderly | Medium | – |
12 | GP | 14 | ∙ Indigenous ∙ Tourists ∙ High SES | Medium | ∙ Elderly (> 65 years old) |
13 | GP | 6 | ∙ Varied | N/A | ∙ Elderly (> 65 years old) |
14 | GP | 9 | ∙ Tourists ∙ High SES | Medium | ∙ Elderly (> 65 years old) |
15 | GP | 15 | ∙ Young | High | ∙ Elderly (> 65 years old) ∙ Pre-existing cardiac conditions |
Main findings
Theme | Subtheme |
---|---|
Resources | Distance to services |
Inadequate consultation time and remuneration | |
Inadequate service availability | |
Complexity of heart failure | Patients’ understanding of disease |
Comorbidities | |
Coordinated multidisciplinary care | |
Relationships | Relationships between GPs and cardiologists |
Relationships between GPs and their patients | |
Patient demographics, priorities and views | Socio-economic disadvantage and patients’ personal priorities |
Patients’ family-level barriers | |
Patients’ views |
Theme 1 - resources
Distance to services
Inadequate consultation time and remuneration
One GP explained why a majority of their colleagues in the Northern Rivers elected to charge their patients beyond the rate of Medicare subsidies, rather than reduce their fees such that consultations were entirely compensated by Medicare subsidies (known as bulk billing), as choosing to do so would lead to an unsustainable workload.“We can't necessarily spend the time …we’ve actually got to generate an income in a relatively insufficient time frame …it frustrates me … I think a lot of that care should be done in general practice… you just feel a bit pressured with time.”- GP 008
Significant patient loads minimised the time that GPs could spend developing ongoing therapeutic relationships with their patients and limited the opportunities for patient education.“Very few doctors bulk bill or advertise that they bulk bill. I think a lot of them actually do but they don't advertise they do so they're not gonna sort of end up with a huge, they basically manage their work load by access blocking.”- GP 008
Inadequate service availability
Theme 2 – complexity of heart failure
Patients’ understanding of disease
One GP postulated that lower levels of health literacy in the area may be contributing to their patients’ limited understanding of CHF.“Most of the problems tend to be around the education. Getting the patients onboard, understanding what their early warning signs are, getting them to understand that they're in control….to keep their weight and fluid levels down, and then being able to monitor for other warning signs. Whether it be irregular heartbeats, tolerance, distance, ability to lie flat, how many pillows they're using.”- GP 004
Comorbidities
“Another sort of main challenge is just that these people obviously often are quite a bit older and they’ve had these various different sorts of chronic conditions quite some time and ultimately becomes that sort of balance… what are their goals, what are their lives… trying to kind of tailor the treatment appropriately.”- GP 003
Coordinated multidisciplinary care
Cardiac rehabilitation was stressed to be particularly pivotal in improving outcomes in both early and ongoing management. Moreover, chronic disease nurses were commonly described to play an essential role in the effective planning and coordination of continuous care for CHF patients.“[It’s] pretty useful where you have ... not just a cardiologist but you've got allied health and it's kind of like a multidisciplinary approach, …that can be helpful for patients in terms of being educated about the disease …, getting different advice from different perspectives and I think that can be quite encouraging for patients as well.”- GP 005
They were also noted to be invaluable when reinforcing education regarding non-pharmacological management and monitoring for disease progression.“Having a cardiac nurse in primary care whose job was to manage that cohort of people in primary care ..., is really beneficial. I just think having someone to manage their complex care from a health background, whether it be a hospital or in primary care, is undoubtedly very helpful.”- GP 008
Some GPs anticipated that provision of more co-located multidisciplinary healthcare providers within culturally sensitive systems such as Aboriginal Medical Services (AMSs) would foster more positive therapeutic relationships and facilitate the ongoing delivery of non-pharmacological CHF management to Indigenous communities.“It just comes back to having nurses who are always around… who can just run a really good preventive health service and work together with the GPs... if they know that the nurse is going to give them the same information the doctor's going to give them and that service is always there and they can come in when things aren't going well to plan or... when we're trying to educate them, I think it's so much more beneficial”- GP 009
On the other hand, fragmented care due to poor communication between providers at different levels of healthcare was commonly reported. Many GPs emphasised the discordance between primary and tertiary health care systems, particularly regarding delayed discharge summaries which disrupted continuity of care. This issue was interpreted by one GP to be due to the sole focus on acute care over promoting primary prevention in tertiary settings.“Having [allied health practitioners] on site especially in an Aboriginal medical service would just be so helpful. We do lots of little other things so, to explore that a bit more would be so beneficial and keeping it in-house I think in an [Indigenous] population would make them I guess, comes back to that relationship with your care providers, and I think that would be really really helpful for them.”- GP 009
“It's a bit of a pet peeve how bad communication can be sometimes and even how hard it can sometimes be for some specialists... to be able to get them on the phone to be like ‘I'm having troubles with managing this person you see’... discharge summaries come back late... patient care then and there is probably top priority. I just think if we all communicated a lot better and the service is linked in a bit better... I think that would really help people manage chronic disease better.”- GP 003
Theme 3 – relationships
Relationships between GPs and cardiologists
However, ambiguity in relationships between GPs and cardiologists was described as a barrier to CHF management, as some GPs felt it resulted in a lack of clear professional role in their patient’s ongoing management."Having worked locally in the local base hospitals, I've worked with all the local cardiologists and so I know them well... a quick 2-minute conversation can save three months and an avoidable admission to hospital. So that's really valuable and that is a great enabler."- GP 001
Relationships between GPs and their patients
On the other hand, one GP expressed how inadequately explaining the rationale for non-pharmacological management often meant that patients would struggle to identify its personal relevance and therefore tended to be less adherent.“It’s about having conversations and really trying to understand... the relationships I think are key to that, they need to know you, you need to know them, and then you’re more likely to get a bit of traction.”- GP 003
Many GPs noted that patient-centred care and goal-oriented management were important principles to consider when implementing non-pharmacological interventions. One GP described how collaboratively setting measurable and achievable goals with their patients, based on compromise, individual circumstances and shared accountability encouraged and motivated their patients to improve adherence with non-pharmacological self-management."Clinicians don't explain the reasons for their care well enough... The importance of certain things is not demonstrated or discussed in the right context with the patient to identify why it's important to them personally."- GP 008
“My little template, is “okay between now and when I see you again, what are our goals? And I’m going to hold them to you, and they can be one or two”; and if it was related to their heart disease, it’ll be like “okay, well, this is what you need to fluid restrict to this much and how we’re going to do that. That’s our goal” and just break it down in chunks, then we revisit it in two to three months time, or earlier if I need to”- GP 008
Theme 4 – patient demographics, priorities and views
Socio-economic disadvantage and patients’ personal priorities
“The AMS [patients] are quite lucky because if they have chronic health conditions … you can develop a management plan … and [government subsidies] will pay for a private visit to a cardiologist.”- GP 008
Patients’ family-level barriers
There’s a distinct inability to understand the way people make decisions in the [Indigenous] community and the need for allowing whoever needs to be in the room to make the decision and having that process…. [Indigenous people] need to understand why it’s important, how it impacts, who it impacts, you know, they need to ask the important people in their life about whether that’s a good thing for them or not.- GP 008
Patients’ views
Another view was the expectation that management came in the form of a ‘magic pill’, in that patients had preconceived expectations of an instant cure-all solution to manage their CHF. Several GPs described that this expectation detracted from their patients’ desire to implement non-pharmacological management focused on long-term incremental gains, as they quickly became disheartened when tangible gains were not immediately evident. Furthermore, this led to patients dismissing non-pharmacological interventions such as exercise, fluid restriction or dietary changes as they believed a far easier ‘Quick Fix’ alternative existed.“There’s a different attitude to empowerment, to being able to be a master of your health destiny... a lot of the people that we see here as patients historically have been disempowered and chronic racism and ...socio-political history. They are not empowered to feel like they’re going to be able to be masters of [lifestyle changes] in their life.”- GP 007
Finally, many GPs described their patients’ views towards their lifestyle were often cemented by long-standing patterns of behaviour. As a result, lifestyle modifications for older patients were often regarded as inherently difficult.“Poor patient adherence to non-pharmacological management, like I think it’s the key stone of everything and I think this is why we have so much or not all chronic diseases attributed to this but a lot of it is the fact that we just don’t look after ourselves. We’re kind of waiting for the magic pill to fix everything and it’s not there and then patients get distressed because they’re not seeing results and yeah, you know, they take the easiest path to their treatment.”- GP 009
“If you’re 70 or 75 …, then it’s hard to change the way you live because you’ve lived like that for 50 years.”- GP 012