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Aims: The diagnosis of heart failure (HF) is an important problem in primary care. We previously demonstrated a 74% increase in registered HF diagnoses in primary care electronic health records (EHRs) following an extended audit procedure. What remains unclear is the accuracy of registered HF pre-audit and which EHR variables are most important in the extended audit strategy. This study aims to describe the diagnostic HF classification sequence at different stages, assess general practitioner (GP) HF misclassification, and test the predictive performance of an optimized audit., Methods and Results: This is a secondary analysis of the OSCAR-HF study, a prospective observational trial including 51 participating GPs. OSCAR used an extended audit based on typical HF risk factors, signs, symptoms, and medications in GPs' EHR. This resulted in a list of possible HF patients, which participating GPs had to classify as HF or non-HF. We compared registered HF diagnoses before and after GPs' assessment. For our analysis of audit performance, we used GPs' assessment of HF as primary outcome and audit queries as dichotomous predictor variables for a gradient boosted machine (GBM) decision tree algorithm and logistic regression model. Of the 18 011 patients eligible for the audit intervention, 4678 (26.0%) were identified as possible HF patients and submitted for GPs' assessment in the audit stage. There were 310 patients with registered HF before GP assessment, of whom 146 (47.1%) were judged not to have HF by their GP (over-registration). There were 538 patients with registered HF after GP assessment, of whom 374 (69.5%) did not have registered HF before GP assessment (under-registration). The GBM and logistic regression model had a comparable predictive performance (area under the curve of 0.70 [95% confidence interval 0.65-0.77] and 0.69 [95% confidence interval 0.64-0.75], respectively). This was not significantly impacted by reducing the set of predictor variables to the 10 most important variables identified in the GBM model (free-text and coded cardiomyopathy, ischaemic heart disease and atrial fibrillation, digoxin, mineralocorticoid receptor antagonists, and combinations of renin-angiotensin system inhibitors and beta-blockers with diuretics). This optimized query set was enough to identify 86% (n = 461/538) of GPs' self-assessed HF population with a 33% reduction (n = 1537/4678) in screening caseload., Conclusions: Diagnostic coding of HF in primary care health records is inaccurate with a high degree of under-registration and over-registration. An optimized query set enabled identification of more than 80% of GPs' self-assessed HF population., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Heart failure (HF) is an important health problem. Most chronic HF management occurs in primary care. Although guidelines exist, there is an important implementation gap in current HF care in Belgium., Methods: We will conduct a non-randomised, non-controlled prospective observational trial to implement guideline-recommended disease management interventions in primary care in Leuven, a region of ±100.000 inhabitants. These interventions include education of general practitioners, reimbursement of the analysis of circulating natriuretic peptides and audits in the electronic health record (EHR), training and implementation of HF educators in primary care, and a protocol to structure transition to primary care after discharge. The main objective is to study and implement interventions in an iterative implementation process., Conclusions: We will evaluate the implementation of several guideline-recommended disease management interventions to optimise the diagnosis and treatment of heart failure in a real-world primary care setting., Trial Registration: NCT04334447 (clinicaltrials.gov).

Background: The electronic health record (EHR) of the general physician (GP) is an important tool that can be used to assess and improve the quality of healthcare. However, there are some problems when (re) using the data gathered in the EHR for quality assessments. One problem is the lack of data completeness in the EHR. Audit and feedback (A&F) is a well-known quality intervention that can improve the quality of healthcare. We hypothesize that an automated A&F intervention can be adapted to improve the data completeness of the EHR of the GP, more specifically, the number of correctly registered diagnoses of type 2 diabetes and chronic kidney disease., Methods: This study is a pragmatic cluster randomized controlled trial with an intervention at the level of GP practice. The intervention consists of an audit and extended electronically delivered feedback with multiple components that will be delivered 4 times electronically to general practices over 12 months. The data will be analyzed on an aggregated level (per GP practice). The primary outcome is the percentage of correctly registered diagnoses of type 2 diabetes. The key secondary outcome is the registration of chronic kidney disease. Exploratory secondary outcomes are the registration of heart failure, biometric data and lifestyle habits, and the evolution of 4 different EHR-extractable quality indicators., Discussion: This cluster randomized controlled trial intends to primarily improve the registration of type 2 diabetes in the EHR of the GP and to secondarily improve the registration of chronic kidney disease. In addition, the registration of heart failure, lifestyle parameters, and biometric data in the EHR of the GP are explored together with 4 EHR-extractable quality indicators. By doing so, this study aims to improve the data completeness of the EHR, paving the way for future quality assessments., Trial Registration: ClinicalTrials.gov NCT04388228 . Registered on May 14, 2020.

Background: Heart failure (HF) imposes a burden for patients and health economics. General practitioners (GPs) are confronted with the broadest range of HF management. Although guidelines exist, they are not fully implemented in the Belgian health care system. Methods: We will conduct a non-randomised, non-controlled prospective observational trial (six months follow-up) to implement a multifaceted intervention in Belgian general practice to support GPs in the implementation of evidence-based HF guidelines. The multifaceted intervention consists of an audit and feedback method to detect previously unrecognised patients with HF and to increase awareness for proactive HF management, an NT-proBNP point-of-care test to improve detection and adequate diagnosis of patients with HF and a specialist HF nurse to assist GPs in the education of patients, optimisation of treatment and follow-up after hospitalisation. All patients aged 40 years and older with a confirmed diagnosis of HF by their GP based on the clinical audit are eligible for participation. The main objective of this pilot study is to evaluate the feasibility of this multifaceted intervention and the evolution of predefined quality indicators. We will measure the impact on HF diagnosis, medication optimisation, multidisciplinary follow-up and patients' quality of life after six months. Additionally, the experiences of GPs and investigators will be studied. Conclusions: Heart failure is an important health problem in which GPs play a key role. Therefore, we will evaluate the feasibility of a multifaceted intervention to optimise diagnosis as well as implement the guideline recommended therapies in patients with HF in general practice.

Background: Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients., Objective: To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients., Design: We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment., Main Measures: Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (OR adj ) were calculated for GPs' advice to stop., Key Results: Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (OR adj 13.8, 95%CI 12.6-15.1), with side effects compared to without OR adj 1.62 (95%CI 1.5-1.7) and with frailty (OR adj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (OR adj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99)., Conclusions: The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Background: A comprehensive disease management programme (DMP) with a central role for general practitioners (GPs) is needed to improve heart failure (HF) care. However, previous research has shown that GPs have mixed experiences with multidisciplinary HF care. Therefore, in this study, we explore the perceptions that GPs have regarding their role in current and future HF care, prior to the design of an HF disease management programme., Methods: This was a qualitative semi-structured interview study with Belgian GPs until data saturation was reached. The QUAGOL method was used for data analysis., Results: In general, GPs wanted to assume a central role in HF care. Current interdisciplinary collaboration with cardiologists was perceived as smooth, partly because of the ease of access. In contrast, due to less well-established communication and the variable knowledge of nurses regarding HF care, collaboration with home care nurses was perceived as suboptimal. With regard to the future organization of HF care, all GPs confirmed the need for a structured chronic care approach and envisioned this as a multidisciplinary care pathway: flexible, patient-centred, without additional administration and with appropriate delegation of some critical tasks, including education and monitoring. GPs considered all-round general practice nurses as the preferred partner to delegate tasks to in HF care and reported limited experience in collaborating with specialist HF nurses., Conclusion: GPs expressed the need for a protocol-driven care pathway in chronic HF care. However, in contrast to the existing care trajectories, this pathway should be flexible, without additional administrative burdens and with a central role for GPs.

Objectives: General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs' perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement., Design: Qualitative evidence synthesis., Methods: Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programme's checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis., Results: Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs' uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration., Conclusions: The main challenges identified in this synthesis were how to deal with GPs' uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs' HF care were identified., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Objectives: Conflicting evidence exists about the value of general practitioners' (GPs') diagnoses of chronic heart failure (CHF), especially in older persons. Therefore, the relationship between GPs' judgement of CHF and objective cardiac abnormalities and their respective prognostic value for 5-year mortality in patients aged 80 and older was studied., Methods and Results: These analyses were embedded within the prospective, population-based BELFRAIL study. At baseline, 525 patients (mean age 85 ± 3.7 years, 37% men) were clinically assessed by their GPs, had NT-proBNP levels determined and received a detailed echocardiography at home. GPs were asked to judge the presence of CHF and to list their arguments in favour or against CHF. Cause-specific mortality was collected until 5.2 ± 0.25 years after baseline. GPs suspected CHF in 154 patients (29%). The prevalence of objective cardiac abnormalities was 35% (n=183). GPs' judgement predicted objective cardiac abnormalities inaccurately (sensitivity 45% (95% CI 38-53), specificity 79% (95% CI 75-83)). However, both objective cardiac abnormalities and GPs' diagnoses of CHF were good predictors of 5-year mortality (HR 2.1 (95% CI 1.6-2.7) vs 1.7 (95% CI 1.3-2.3), respectively). Furthermore, the presence of objective cardiac abnormalities was not significantly better than GPs' judgement in identifying patients at risk for mortality, although a trend for better cardiovascular mortality risk classification was noted (NRI 10% (95% CI -2 to 21%), P=0.13)., Conclusions: Although GPs' judgement of CHF and objective cardiac abnormalities correlated poorly, the validity of GPs' clinical judgement for mortality risk stratification was demonstrated., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)