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Barriers to accurate diagnosis and effective management of heart failure have not changed in the past 10 years: a qualitative study and national survey

Objectives To explore changes in healthcare professionals’ views about the diagnosis and management of heart failure since a study in 2003. Design Focus groups and a national online cross-sectional survey. Setting and participants Focus groups (n=8 with a total of 56 participants) were conducted in the North East of England using a phenomenological framework and purposive sampling, informing a UK online survey (n=514). Results 4 categories were identified as contributing to variations in the diagnosis and management of heart failure. Three previously known categories included: uncertainty about clinical practice, the value of clinical guidelines and tensions between individual and organisational practice. A new category concerned uncertainty about end-of-life care. Survey responses found that confidence varied among professional groups in diagnosing left ventricular systolic dysfunction (LVSD): 95% of cardiologists, 93% of general physicians, 66% of general practitioners (GPs) and 32% of heart failure nurses. For heart failure with preserved ejection fraction (HFpEF), confidence levels were much lower: 58% of cardiologists, 43% of general physicians, 7% of GPs and 6% of heart failure nurses. Only 5–35% of respondents used natriuretic peptides for LVSD or HFpEF. Confidence in interpreting test findings was fundamental to the use of all diagnostic tests. Clinical guidelines were reported to be helpful when diagnosing LVSD by 33% of nurses and 50–56% of other groups, but fell to 5–28% for HFpEF. Some GPs did not routinely initiate diuretics (23%), ACE-inhibitors (22%) or β-blockers (38%) for LVSD for reasons including historical teaching, perceived side effects and burden of monitoring. For end-of-life care, there was no consensus about responsibility for heart failure management. Conclusions Reported differences in the way heart failure is diagnosed and managed have changed little in the past decade. Variable access to diagnostic tests, modes of care delivery and non-uniform management approaches persist. The current National Health Service (NHS) context may not be conducive to addressing these issues.


Introduction
Heart failure (HF) is a major health problem in industrialised countries with ageing populations. 1 HF diagnosis and management are complex with variable care provision. 2 Some variability may relate to access to services, 3 regardless of public or private provision. 2,4 The key to reducing mortality, morbidity and costs associated with HF is early, accurate diagnosis and appropriate management. [5][6][7] Traditionally, heart failure has been attributed to left ventricular systolic dysfunction (LVSD), generally measured as reduced ejection fraction. The evidence base for treatment with medication and device therapy relates to LVSD, 8 but over 50% of heart failure hospitalisations occur in patients with preserved ejection fraction (HFpEF). [9][10][11][12] HFpEF has sometimes been equated with diastolic heart failure although the existence of HFpEF per se has been questioned and an evidence base for treatment is lacking. 13,14 Heart failure is difficult to diagnose accurately as symptoms are often nonspecific and physical signs can be difficult to elicit; 15,16 there is evidence to suggest that diagnosis is missed in up to two thirds of cases. 17 In 2003, we reported reasons why GPs had not implemented best evidence in the diagnosis and management of HF. 2 Key barriers included a lack of confidence in diagnosis and management, a lack of awareness of the relevant evidence-base for care, and variation in GPs' personal preferences and organisational care pathways. Since then there have been major NHS re-organisations including dedicated HF services 18 and the introduction of technologies such as cardiac resynchronization therapy (CRT). 19 Despite, or perhaps because of, on-going developments, there is variability in the diagnosis and management of HF 20 including service access 3,4 , which includes both the availability and use of services. This two-phase study evaluated the key barriers and facilitators to the appropriate management of HF in the UK, comparing findings with those reported in 2003, 2 and extending the previous evaluation to include cardiologists, general physicians and heart failure nurses as well as GPs in a national survey.

Methods
Focus group participants were recruited from health authority registers for the North East of England, including salaried GPs and GP partners, cardiologists, general physicians and HF nurses.
Purposive sampling 21 allowed diverse representation of gender, role, seniority, ethnicity, geographical distribution, employment status (part or full time) and practice size (group or single handed) and avoided over-representation of individual practices. Specific numbers were guided by data saturation across groups. 22 A qualitative (hermeneutic phenomenological) approach 23,24 was used to explore clinicians' decision-making, as well as experiences of barriers and facilitators to Medicine, 319 for Specialist Nurses and 13,504 for Salaried GPs and GP Partners). Aiming for a 5% sample, the survey was sent to all staff within these groups.

Data analysis
Thematic data analysis 23,24 conducted by two phenomenologists (HH and HC) produced a textural description of experiences of diagnostic and care provision for heart failure from the focus groups; 25 neither analyst was involved in the 2003 study. Preliminary codes were identified by each analyst, refined as coding progressed, and grouped into categories. From these, a set of themes emerged which were tested using diverse accounts within and between cases to challenge and define the integrity of the theme boundaries. Findings were subsequently discussed by the whole team.
Descriptive data analysis, using SPSS version 19, was used to summarise survey findings and explore subgroup patterns. The key subgroups were salaried (permanent, locum, and out-of-hours) GPs, GP partners, Cardiologists, General Physicians and HF Nurses.

Study population
Eight focus groups with salaried and partner GPs, cardiologists, general physicians, and HF nurses participants (39 GPs, 4 cardiologists, 6 general physicians, and 7 HF nurses) were conducted between December 2010 and March 2011 in affluent and deprived locations in the North East of England.
For the national survey, of eligible staff from the professional groups included, 514 (3.1%) responses were received from staff working in 40 Strategic Health Authorities across the UK. Of these, ten were duplicate responses and a further ten declined to indicate their occupational group; thus a total of 494 unique responses were included in the analysis. Reasons for non-participation are unknown. Not all respondents answered all questions, thus denominators for each group and question are tabulated.
The majority of survey participants (69.4%) were aged between 41 and 60 years of age, were male (54.5%) and worked within an English SHA (85.3%). Baseline characteristics of participants are shown in Table 1. Similar demographic trends were apparent in each professional group with the exception of salaried GPs and nurses who were predominantly female. Focus group themes and survey responses are reported together.

Study findings
From the focus groups, four categories were identified which contribute to variations in the diagnosis and management of HF: uncertainty about clinical practice, the value of clinical guidelines, tensions between individual and organisational practice, and, uncertainty about end-of-life care. The first three categories virtually replicated 2003 2 findings, the fourth was new.

The diagnostic process
The majority of survey respondents had responsibility for diagnosing HF due to LVSD with the exception of nurses of whom 23% reported doing so. Co-morbidities and non-specific symptoms and signs were the most challenging aspect of making a diagnosis. Cardiologists, general physicians and nurses rated co-morbidities highest while GPs rated non-specific signs and symptoms as most highly challenging. A lower proportion of HF nurses (32%) were confident in their ability to diagnose LVSD than any other group, followed by GPs (66%) when compared with 95% and 92% of cardiologists and general physicians. "I'd leave it to specialists" (Out-of-hours GP) The majority of cardiologists (87%) identified that they had responsibility for diagnosing HFpEF, followed by general physicians (59%). Of the 13 cardiologists who did not diagnose HFpEF, 9 were not convinced that HFpEF exists. Most GPs (84%) and nurses (87%) did not diagnose HFpEF. A lower proportion of GPs (7%) were confident in their ability to diagnose HFpEF than any other group. One cardiologist commented that they would like access to "A crystal ball" to inform HFpEF diagnosis, while a GP partner asked "What is HFpEF?".
A cardiologist highlighted the complex nature of diagnosis: "I've rescued a few people with heart failure from asthma clinics … But we all know it's very hard to do sometimes, isn't it, in someone who's breathless and they've got crackles and they've got a funny looking x-ray, and distinguishing between fibrosis and chronic lung disease and heart failure, just on that first visit isn't always very easy." (Cardiologist)

Diagnostic tests
The majority of survey respondents who diagnosed LVSD used ECGs, chest x-rays and clinical assessment, the exception being nurses. Around a quarter of nurses (23%) and half of GPs (49%) were confident in interpreting the results of an ECG while most cardiologists and general physicians (both: 87%) were confident. One third of nurses (33%) and two thirds of GPs (65%) were confident in interpreting the results of an echocardiogram while the majority of cardiologists and general physicians (98% and 85% respectively) were confident. Cardiologists were more likely to use ECGs and chest x-rays (64% and 63% respectively) to diagnose HFpEF than other groups; clinical assessment was almost never used by any group. This was reflected in confidence levels interpreting these results (see Table 2).

Availability and use of echocardiography services
For LVSD, echocardiographic findings were used by 97% of cardiologists, 91% of general physicians, 52% of salaried GPs, 35% of GP partners and 31% of nurses. Even though generally availability was high, some GPs and general physicians were reluctant to use open access echocardiography because of a lack of knowledge about interpreting results; many preferred to refer the patient to a cardiologist or to a specialist HF clinic.

"… I don't understand a lot of the [echocardiograms]…" (GP partner)
Cardiologists and nurses were more confident in using and interpreting echocardiography reports than GPs, but expressed frustration about patients not routinely referred for echocardiography testing, and the poor quality of referral information: "… we go onto the ward, we read the notes, and it's screaming heart failure at you, screaming it. And nobody's considered doing an echo. And …you want to just say, will you please echo this patient!" (HF nurse) To diagnose HFpEF, most cardiologists used echocardiography (91%) followed by physicians (67%), salaried GPs (30%), nurses (21%), and GP partners (17%). Again confidence in using results reflected this pattern of usage (Table 2).

Availability and use of BNP and NT-pro BNP
GPs were more likely to use BNP (28%) than other groups; NT-pro BNP was used in similarly low proportions. Between 10% and 50% of all respondents expressed a need for access to natriuretic peptides. However, a general physician commented: "We have tried BNP and found that it added no value." Between 10% and 61% of all respondents expressed confidence in interpreting the results of natriuretic peptides in LVSD diagnosis ( Table 2). Few practitioners use natriuretic peptides to diagnose HFpEF.

Communicating a diagnosis
All cardiologists (100%), and most physicians (94%) and nurses (95%) took responsibility for informing patients of a heart failure diagnosis; a minority of GPs felt that this was not their responsibility (16%) but a cardiologist's. One cardiologist commented: "In some patients it is very easy and in some very difficult. Communicating difficult information well requires training and experience." And another: "I think it's something we haven't been trained to do." (Cardiologist) Most participants felt it was important to educate patients about their illness but some expressed concerns about informing patients of their diagnosis as this might lead to anxiety.
"I don't tend to tell them that their prognosis is pretty lousy if they've got a bad heart, which it is, isn't it." (Cardiologist) Of those who managed LVSD, all groups cited co-morbidities as the most challenging aspect of management. GPs and general physicians cited poly-pharmacy as being the second most challenging aspect, while cardiologists and nurses cited unpredictable disease progression. Some GPs felt that the organisation of care, with an emphasis on specialist HF services, led to deskilling in primary care.
"The thing that concerns me most is being deskilled because as I'm doing much less management of heart failure than, the heart failure nurses are probably doing a lot more." (GP Partner) A particular concern among GPs, regardless of level of experience, was anxiety about the delicate risk-benefit balance where management required investigations, initiation and titration of evidence Cardiologists most commonly initiated medication for the treatment of LVSD, although the majority of all groups reported initiating medication. Some GPs did not routinely initiate diuretics (23%), ACEi (22%) or β blockers (38%). All respondents reported titrating medication for the treatment of LVSD.
Concerns surrounding the initiation and titration of angiotensin converting enzyme (ACE) inhibitors and beta-blockers (β-blockers) seemed to arise as a result of previous teaching, a fear of side effects, and the burden of monitoring. "The danger of impaired renal function with high doses of not only the diuretics but the ACE inhibitors as well juggling doses of ACE inhibitors against diuretics, up and down, checking potassium. I do find some of those conflicts difficult to resolve." (GP partner) There was a reluctance to prescribe additional medications to a group characterised by polypharmacy and comorbidities; this was seen as a particular problem in the elderly: "Particularly in more frail/elderly people for example, particularly if the blood pressure is hovering around 100-110 anyway, because of their age and you crank their ACE inhibitor as far as it can go, maybe a little bit dry as well, I think a beta blocker on top of that is always a bit of a concern. Relatively easy to do, maybe, when the patient's already in hospital, and is going to be in for another day or so and they can see probably what's going to happen but it's more difficult out in the community." (GP partner) All professional groups shared a reluctance to increase dosage if the patient was asymptomatic or stable: "I must say I'm inclined to do it when the patient's struggling a wee bit rather than when they're well. You know if you've got a perfectly, someone who's feeling great, and you put them on an ACE inhibitor and their kidney goes pear shaped, I tend to just not do anything I must admit." (Cardiologist) Most GPs admitted to being unaware of the place for other agents including spironolactone and angiotensin II antagonists in treating heart failure: "What I'm not clear about is spironolactone is do we adjust the dose of that? It seems 25mg is the recommended dose and yet when we used to use it 30 odd years ago it was always 100mg of spironolactone. Is it more dangerous to use a higher dose, is there a titration schedule? I don't know." (GP partner) Several respondents reflected upon the lack of effective symptomatic treatment for HFpEF, leading to "an inability to do anything useful" (GP partner), while another GP partner stated: "I remember Non-pharmaceutical management of heart failure Around half of respondents in all groups reported that they had access to rehabilitation for heart failure. Heart failure nurses and cardiologists highlighted the importance of rehabilitation and frustration at the limitations on service provision in this area. "We had a support group running for our patients for about 4 years successfully, and now the commissioners have just pulled it because they won't fund it anymore. It was an exercise support group, rehab, and they won't fund it now, so we can't run it." (HF Nurse). "It's patients who've had heart failure and previous coronary disease ..patients with heart failure secondary to cardiomyopathy. Then it's sometimes difficult to find a rehab program for them." (Cardiologist).
Few GPs (18%) understood the indications for electrical therapies in the management of heart failure compared with nearly all cardiologists (98%). "… you think 'crikey', particularly with the younger heart failure patients maybe they ought to go and talk to somebody who knows a bit more than me. Because maybe there are things that can be done for them that I wouldn '

Priorities for care in HF management
Views varied about priorities for investment to improve heart failure services. Cardiologists, general physicians, salaried GPs and nurses emphasised improved access to heart failure clinics and heart failure nursing teams; salaried GPs cited education for GPs. "If you look at heart failure admissions since we introduced specialist heart failure nurses and the heart failure clinic in 2002

Tensions between individual and organisational practice
In addition to specialist medical training (or lack thereof) and clinical experience, another important theme influencing clinicians' diagnosing behaviour arose from the provisions made by outside organisations (health authorities, secondary care trusts and primary care trusts). For example, cardiologists and general physicians expressed concern about the organisation of specialist care by

Uncertainty about end-of-life care
Most respondents stated that their patients had access to an end-of-life pathway for heart failure, although these were used only occasionally by any group other than nurses, 45% of whom stated that they used care pathways frequently. Most cardiologists and general physicians did not see themselves as being responsible for end-of-life care for heart failure, while around 80% of GPs and nurses felt that they had responsibility within a team. There was a lack of consensus about who held final responsibility for end-of-life care, with most respondents identifying some or all members of the multidisciplinary team as being responsible.
Within most professional groups studied 'defining end-of-life' was the most challenging aspect of end-of-life care; 'co-ordination of care' was the second most challenging aspect. A cardiologist stated that the most challenging aspect was "persuading overzealous colleagues that palliation is appropriate." Another cardiologist highlighted the "sometimes false expectations of patients and their families -sometimes fuelled by other health care professionals -sometimes fuelled by success of previous treatment for heart failure." The majority of participants, regardless of role, identified doubts about their ability to identify the

Discussion
Among the five health professional groups studied, variable opinions and practices persist in the diagnosis and management of heart failure. Uncertainty about appropriate clinical practice (including the diagnostic process and medical management), utility of clinical guidelines and individual practice preferences with local organisational influences were similar to themes identified a decade ago. 2 Uncertainties around end of life care emerged as a new theme.
The difficulty of achieving an accurate diagnosis of heart failure has changed little in the last ten years despite improved access to diagnostics including natriuretic peptides and echocardiography.
Non-specific symptoms and signs, and significant co-morbidities in increasingly elderly patients, continue to contribute to the complexity of diagnosis. Despite NICE guidance recommending natriuretic peptide testing when diagnosing heart failure, availability and use remains variable.  guidelines now discourage this and suggest referral for specialist assessment for diagnosis and management. 26 A lack of knowledge about diagnosis and management of HFpEF was evident across all professional groups, including many cardiologists. Issues around communicating the diagnosis of heart failure to patients and carers, was highlighted. Generally the lack of evidence base for diagnosis and management of HFpEF meant the guidelines for this condition were deemed to be less useful than those for LVSD.
Despite a decade of availability, and clear guidance, clinicians still vocalise concerns about initiating beta-blockers or digoxin, although survey findings suggest that most clinicians initiate and titrate evidence-based drugs for heart failure. The previous study identified ageism as a potential source of variability although in this study ageism per se was not seen as a problem, rather the comorbidities associated with age.
Availability of diagnostics (including natriuretic peptides), access to heart failure specialist services and rehabilitation were variable and thus subject to geographical locality. Cardiologists felt that lack of continuity of care and service availability at weekends increased hospital admissions and delayed hospital discharge. Lack of integrated disease registers and joined up computer systems across primary and secondary care were seen as a barrier to communication in heart failure care.
Many participants felt that the main barrier to a coordinated end of life management plan was the inability to predict when the palliative phase should commence in heart failure patients. There was a difficult balance to strike between increasingly invasive technologies (including CRT and ICD) and palliative care planning underpinned by quality of life considerations. All groups highlighted the difficulty in communicating the end of life phase to patients and carers, especially if high expectations for survival had been raised by colleagues.
There appeared to be a lack of consensus about who is responsible for heart failure care, from diagnosis, through management to palliative care. This is despite the fact that NICE guidelines recommend specialist care by multidisciplinary heart failure teams for patients with suspected heart failure, and in-patients with heart failure.

Strengths and Limitations of the Study
The mixed methods approach used in this study permitted the key themes and issues experienced by clinicians to be identified and a questionnaire to be developed to quantify current beliefs and behaviours. Focus groups were conducted to the point of data saturation and can be validated to some extent against historical work although it would be useful for independent research to confirm these themes. The response rate to the questionnaire appears low at 3.1%, however this was an electronic survey with a substantial total number of responses. Electronic surveys, as unsolicited emails, typically feature low responses. This style of technology has been commonly used in both market surveys and in clinical and epidemiological research. Despite their relative popularity and ease they frequently do not reach all subjects. Qualitative and survey research, by necessity, reports what respondents wish to say which may differ in some circumstances from their actual behaviour. 27,28 Nonetheless this study provides further understanding of the reasons behind the evidencepractice mismatch for heart failure in the UK.

Conclusions
Reported reasons for variability in heart failure diagnosis and management have changed little in the last decade. Issues of service availability, access, delivery of care and a lack of co-ordination persist.
The current working environment appears not to be conducive to promoting ownership or engagement with such difficulties. Rather than interventions targeted at clinicians to improve care, the primary need may be for a health service, which enables coordinated care, responsibility and training.  This article presents independent research and all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Data sharing:
There is no additional data available. located; and, vi) licence any third party to do any or all of the above. All research articles will be made available on an Open Access basis (with authors being asked to pay an open access fee-see http://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/copyright-openaccess-and-permission-reuse). The terms of such Open Access shall be governed by a Creative Commons licence-details as to which Creative Commons licence will apply to the research article are set out in our worldwide licence referred to above.

Contributorship statement:
HH: I declare that co-designed the study, led data collection, participated in data analysis, interpretation and writing this report, and that I have seen and approved the final version.
HC: I declare that I participated in data collection, data analysis, interpretation and writing this report, and that I have seen and approved the final version.
AF: I declare that I devised the research question, participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
JJM: I declare that I participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
APSH: I declare that I participated in data interpretation and writing this report, and that I have seen and approved the final version.

Abstract
Objective To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care. Design A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory. Setting North east England.
Results Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care. Conclusions The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies-for example, the provision of guidelines-are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.

Introduction
Heart failure is difficult to define and diagnose. 1 It is common, increasing in prevalence, and has high morbidity and mortality akin to common cancers. 2 It is managed largely in primary care, imposing a heavy burden on the NHS, and accounts for 5% of admissions to medical wards, with high readmission rates. 3 4 Diagnosis by clinical assessment is difficult and is correct in less than half of cases confirmed by echocardiography. 5 6 Heart failure is poorly managed in general practice for many reasons. [7][8][9][10][11] Uncertainty about diagnosis 8 11 ; lack of access to diagnostic services 10 ; lack of awareness of research evidence and guidelines 7 9 ; worries about adverse effects, cost, and inconvenience of angiotensin converting enzyme inhibitors 7 ; and poor communication between professionals in primary and secondary care 11 lead to variable practice, and the reasons for this variability need to be elucidated further.
Much of the current evidence on how to diagnose and manage heart failure comes from a secondary care perspective, where the difficulties of primary care, including differences in patient populations, are not necessarily appreciated. Studies have usually relied on quantitative methods, with little exploration of the complexity of general practice and its relations with patients and secondary care. 7 10 This study aimed to ascertain the beliefs, current practices, and decision making of general practitioners around the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to optimal care.

Methods
Focus groups with general practitioners were our chosen format for the study, which was set in north east England, an area with a population of 617 532 and with 316 general practitioners in 88 practices. We used a mixed purposive sampling strategy to select participants. 12 Stratification of general practitioners allowed proportionate representation of sex, ethnic group, geographical distribution, employment status (part time or full time), and practice size (group or singlehanded) and avoided selecting general practitioners from the same practice. We contacted 41 general practitioners and organised four focus groups.  Eleven doctors did not attend; their demographic and professional characteristics did not differ from the remaining 30. The four focus groups consisted of six to eight participants, and a co-moderator was used in three of them.
The 30 participants (25 men, overall age range 33-64 years, years since graduation 10-42) represented a wide range of practice size and length of experience, including three singlehanded practices. Twenty seven doctors worked full time and three part time; 20 (66%) had open access echocardiography. The ratio of male to female general practitioners in the locality was 3:1; in the focus groups it was 5:1.
To help the discussion the principal investigator (AF) used a list of points to be considered, compiled from a literature review. The sessions were audiotaped, transcribed, and then corrected and verified by AF.

Analysis
We analysed the contents of the interviews following the principles of the theory of "pragmatic variant" grounded theory. 13 14 We read transcripts and identified broad themes as the groups progressed. This iterative process allowed ideas and thoughts that were emerging to be brought back to subsequent groups. We analysed deviant cases to question widely accepted practice. 14 No new major themes arose by the end of the fourth focus group, implying that saturation was being reached. 14 The transcripts were read several times, data organised into codes from which categories were identified, and major themes were constructed by AF and APSH. All three investigators contributed to multiple coding and agreed final themes. Analysis was enhanced by constant comparison with the transcripts and available research in this field from the initial literature review. 14

Respondent validation
To validate the findings we sent all 30 participants a report summarising the study results and conclusions. 15 Of 28 respondents 27 "strongly agreed" or "agreed" and one "neither agreed, nor disagreed" that the report was an accurate representation of their opinions and the group outcomes.

Results
We identified three themes that contributed to reasons for the variation in medical practice and why general practitioners experienced difficulties in diagnosing and managing heart failure: firstly, uncertainty about clinical practice, including the availability and use of echocardiographic services; secondly, lack of awareness of relevant research evidence; and thirdly, influences of individual references and local organisational factors.

Uncertainty about clinical practice
Most participants expressed a lack of confidence in establishing the diagnosis of heart failure. This affected the management of individual patients. Three main categories were identified: the diagnostic process, availability and use of echocardiography services, and treatment issues.

The diagnostic process
Heart failure was perceived to be a difficult diagnosis to make in general practice because of: x Problems with subtlety of clinical symptoms and signs: "Some of the clinical signs, if you have a raised JVP or third heart sound, hepatomegaly, are often difficult in the obese to detect, and ankle oedema is common anyway." x Difficulty in differential diagnosis, especially in elderly patients with comorbidity such as chronic obstructive airways disease and obesity: "I think heart failure would be not too difficult a subject if it occurred in young fit people but the biggest problem is that it's always inevitably older people who get it. It's a co-pathology intermingled with other things, and that makes it often quite difficult to disentangle." x Time constraints and generally increasing clinical and administrative workload for general practitioners: "20 plus patient surgeries, and having to try and stick to close to 10 minutes, it can be quite difficult to do a really full assessment." x Lack of availability of diagnostic tests, including electrocardiography, chest radiography, and echocardiography, and lack of confidence in interpreting the results of these: "You get a kind of slightly reduced ejection fraction, and you know an iffy tricuspid valve or two, and you know you're not really that much further forward." x Inertia or fear of initiating action because of anxieties about committing to an intensive course of action, including investigations, initiation, titration, and monitoring of treatment: "I think it's the milder degrees of heart failure . . . that is the difficulty. But once you've diagnosed it you're committed to a course of action, and I suppose it seems quite a drastic course of action, you've obviously got the diuretics, ACE inhibitors, and possibly other medication as well, full investigations, and I suppose that could lead to a bit of inertia, couldn't it." x Patients' choices, including reluctance to be investigated or treated further: "Some patients obviously don't want to be hospitalised or don't want a second opinion, and sometimes don't want to go to hospital, so you end up treating them yourself."

Availability and use of echocardiography services
Perceived handicaps included the variability of open access echocardiography in the same locality; two thirds of the participants had this facility. Some of the inequity resulted from the continuation of access acquired previously by general practice fundholders.
Several of the open access services had been funded through pharmaceutical sponsorship but disappeared as "monies dried up." A further perceived problem was variability in echocardiography reporting, some by technicians and some by clinicians, and a lack of guidance for using the procedure or for standardising request forms.
Difficulties for general practitioners concerning echocardiography Some general practitioners did not use open access echocardiography even when it was available, chiefly because of not being able to understand it and the inconvenience caused to patients who were often very ill. The reasons given included: x Uncertainty about the importance of results and interpretation of technical reports: "The problem with echocardiograms is that I really just don't understand  them. I don't think of myself as being really that old, I mean I'm 43 . . . and when I went through my postregistration years echocardiograms just weren't around . . . I just don't know where I am with them. When does an ejection fraction of such and such per cent stop being reasonable and start being a problem?" x Not being able to cope with echocardiography, many preferred to refer the patient to a consultant: "I would rather refer than do an echocardiogram, the interpretation of which I am not confident with." "I'm not confident in diagnosis of heart failure. I think I just like to have it rubber stamped." x Distance to nearest echocardiography clinic may inconvenience patients: "It takes a whole day to go to hospital, and for an elderly person with breathlessness that's a long day, ambulance there and back, sit in a waiting room, and patients do it once and they won't do it again, and they don't all have relatives to take them in." General practitioners were less likely to use open access echocardiography when reports were technical and lacked a clinical opinion than when a clinician guided report was available. In these circumstances they either treated their patients' symptoms or referred them to hospital; a lack of open access was cited as a reason for increased referrals. Apprehension was expressed about overloading cardiology services, especially with patients who seemed well: "I think there is also a feeling that it's almost an inappropriate cardiac referral . . . the cardiologists are so busy and when you first make the diagnosis they [the patients] are often actually not that poorly."

Treatment issues
Uncertainty about diagnosis cast doubts on the development of strategies for individual treatment of patients. The treatment process was an area that entailed further barriers to evidence based practice.
Doctors had good awareness of nonpharmacological advice and interventions (such as weight reduction, tailored exercise, restriction of salt intake) for patients with heart failure. 16 Most participants agreed the importance of educating patients, but some expressed concerns at informing patients about the diagnosis as this might lead to anxiety. This was countered by those who believed that openness with and involvement of patients improved compliance.

Concerns about using ACE inhibitors in general practice
Although attitudes were felt to be changing, worries still surrounded the use of angiotensin converting enzyme (ACE) inhibitors, especially about starting treatment in primary care as opposed to in hospital, partly because of previous teaching and a fear of side effects, mainly hypotension, in the community setting: x Concerns about the use of angiotensin converting enzyme inhibitors in elderly patients and those with renal impairment and worries about side effects including cough, postural hypotension, and renal failure: "I'm not too sure exactly at what degree of renal impairment one should worry too much." x Polypharmacy and drug interactions was considered a barrier, especially in elderly patients: "The other thing that raises its head is polypharmacy here, where you have got your people who have been chewing their aspirin for years, that a lot of these will be on statins and antiarthritic drugs. You've got your ACE inhibitors and diuretics. Well that's five or six [drugs], and I think you're going to have rebellion on your hands from people who say they are on far too many tablets . . ." x Ageism was flagged up as a consideration in all four groups: "I think there is an ageist agenda with it as well because you know somebody of 60 who has got heart failure you're going to be much more aggressive with than someone who is 78, not just in terms of making the diagnosis but the investigations and treatment." x A few general practitioners were happy to keep patients taking diuretics and "spare them the ACE inhibitor unless they are getting worse." x A minority's perception was that diuretics alone are "OK in mild heart failure."

Barriers to achieving optimal doses of ACE inhibitors in general practice
Even if treatment with angiotensin converting enzyme inhibitors was initiated in primary care, a further barrier was the inability to attain the recommended doses as in major studies and guidelines 16 : x Worry that the diagnosis of heart failure was incorrect: "But it worries me that if you are pushing the ACE inhibitors up to the maximum dose, which you are recommended to do, that you've got your diagnosis right in the first place." x Although some awareness of the benefits of high dose existed, a lack of knowledge of target doses used in major trials became apparent.
x Worries were expressed about "huge doses" leading to side effects and intolerance.
x Reluctance to increase dosage if patient was asymptomatic or stable: "If you've got someone who is stable, you're sometimes a bit reluctant to increase the dosage of any medication if the condition is well controlled." x It was assumed that it may be more difficult to increase dosage "if already been on a low dose for a while." Awareness of the use of blockers in heart failure was widespread, but a unanimous feeling was that it should be a "hospital initiated thing," because of a fear that patients might collapse in the community setting. 17 Most doctors were apprehensive about the use of blockers, and one, voicing fears, indicated that it was "common sense for general practitioners to be a little bit reticent." Most general practitioners mentioned medical school teaching that emphasised that blockers were contraindicated in heart failure: "It still seems a contradiction when we were taught blockers precipitate cardiac failure. I'm sure we've all seen that happen and to turn round and prescribe them; it goes against the grain a bit." Most general practitioners indicated that they were unaware of the place for other agents including spironolactone and angiotensin II antagonists in treating heart failure 16 ; and in spite of its previous use over many centuries digoxin posed a problem: "I'm not (even) up to speed with spironolactone or blockers yet." A common response was: "Digoxin: I wouldn't use it in sinus rhythm."

Lack of awareness of relevant research evidence
All focus groups discussed their views on the dissemination of research evidence, guidelines, and applicability of evidence in primary care. Overload with information was seen as a common cause of stress. Many worried about the "rapidity of change in all fields" and "keeping up to date with changes" but believed that "[we] owe it to our patients" to be in touch.
Existing guidelines about the diagnosis and management of heart failure and treatment with angiotensin converting enzyme inhibitors were not familiar to most participants. To some extent this was due to "guideline fatigue"; one general practitioner felt "bombarded and bamboozled by guidelines." Specific to heart failure was the lack of awareness of the importance of confirming left ventricular systolic dysfunction, differences between systolic and diastolic heart failure, and the importance of the NYHA (New York Heart Association) classification-a system of grading the severity of heart failure-in categorising heart failure. A lack of knowledge became obvious as to how this classification could be used to provide a prognosis and guide management.
Some general practitioners were happy to keep patients taking diuretics alone, possibly unaware of potential benefits of angiotensin converting enzyme inhibitors, blockers, and spironolactone. 16 17 Most had little knowledge of the place for agents other than diuretics and angiotensin converting enzyme inhibitors, and a feeling predominated in some quarters that heart failure should be managed in secondary care: "Can we adequately manage heart failure in general practice, given the modern advances that we are all unsure about?"

Influences of personal preference and local organisational factors
Medical training, anecdotal experiences, and outside agencies (health authorities, primary care trusts, and the pharmaceutical industry) emerged as influences on individual clinicians' behaviour and professional culture. In some instances this was deeply entrenched and perversely affected newer influences. An example of this was a participant from a large teaching practice who justified his reluctance to refer all patients for echocardiography; the factors behind this are likely to be complex and to do with coming to terms with a rapidly changing medical environment: "I got through the whole of hospital training, and we didn't use echocardiograms. In cardiology we managed everyone with heart failure without an echocardiogram." Local organisational factors around the provision of diagnostic services, such as open access echocardiography, resources, lack of cardiologists, and professional interactions between primary and secondary care shaped practice and decision making processes among general practitioners. A locality based, contextualised approach was found acceptable: x "A locally drawn up set of guidelines which are pertinent to the local situation, that is primary and secondary care situations, drawn up by representatives from both primary and secondary care and other interested stakeholders that is owned by everyone who is going to use them." x "We are in an imperfect health service, and we are resource starved, and if like every other medical problem we deal with, if we wanted to manage heart failure as we would like to, it's going to have significant resource implications." Waiting lists and the local availability of consultants influenced the general practitioner's decision in relation to the referral to cardiologists of patients with suspected heart failure: "Being pragmatic you look at waiting lists, we've got some very good geriatricians who have excellent clinical skills, and certainly, if the patient has got multiple pathologies, I would have no hesitation in referring to them."

Discussion
Heart failure is poorly managed in the United Kingdom, mainly because of inaccurate diagnosis and inappropriate treatment, including the use of treatment for heart failure in a large group of patients who do not actually have heart failure. 8 18 A major reason for failing to make an accurate diagnosis is that the symptoms and signs are not highly specific. 19 This study provides information about the difficulties perceived by general practitioners in achieving accurate diagnosis and instituting modern treatment. 16 The most accurate method of diagnosis entails the use of echocardiography, but this study confirmed a variation in its availability and discovered that practitioners were not confident about interpreting results. 20 At the same time a reluctance to refer to a consultant for a definitive diagnosis prevailed because of a fear of overloading services and a continuing perception that heart failure remains a problem to be dealt with in primary care.

Perceived advantages and disadvantages of modern management
Diagnosis and management of heart failure have evolved dramatically, such that they rely on specialised investigations and drug regimens that often require specialist input. Clinicians who trained in the distant past have essentially not come to terms with the more modern approach. In turn, services to capitalise on modern management have been insufficiently developed.
Paradoxically, the general practitioners appreciated the benefits of modern treatment shown in large scale trials, particularly those of angiotensin converting enzyme inhibitors. 16 Although confidence in the use of angiotensin converting enzyme inhibitors has increased in the past 10 years, a substantial minority of general practitioners were reluctant to use them, especially in elderly patients. This was related to fears about side effects, especially hypotension and collapse in the community setting, and the lack of monitoring guidelines in the context of primary care.
Polypharmacy was viewed particularly negatively. If between one and five drugs are prescribed, the likelihood of adverse drug reactions is 3.4%, rising to 24% with six or more. 21 The increased numbers of tablets likely to be required by elderly patients with concurrent conditions, such as diabetes and its associated problems, was considered daunting and detracting from compliance. In such situations decisions about the most appropriate regimens were likely to be weighted by the requirements of the different conditions and perceived returns from intervention. Although chronic heart failure is serious and progressive and appropriate drug intervention proved to be beneficial, many clinicians do not find it easy to judge the extent of worthwhile returns in older patients with underlying problems such as ischaemic heart disease. Patients whose heart failure has already been diagnosed, who seem stable having conventional treatment but who might benefit from newer interventions, 17 also posed a dilemma; many clinicians were reluctant to initiate newer treatments that may have been around for decades, such as digoxin and spironolactone. 16 Suboptimal care often results from factors outside the immediate control of the general practitioner. 9 Local circumstances such as resource allocation, priorities, and attitudes of consultants are crucial. This study confirms that general practitioners perceived this to be the case for heart failure. The increasing involvement of primary care in planning local services through primary care trusts may alleviate this problem, providing the trusts can work effectively with secondary care providers.

Methodological aspects
The qualitative method for this research lent itself well to discovering the barriers to optimal care. Rigour was enhanced by multiple coding and validation of respondent validation. 15 The personal and intellectual bias of the principal investigator was minimised by using a co-moderator in three groups, by allowing discussions to develop naturally, and by reporting the wide range of perspectives. Analysis of deviant cases enhanced the validity of the findings by bringing widely accepted practice into question. 14 Generalisability from qualitative research remains an issue with some doctors. Guba and Lincoln have introduced the concept of transferability as an alternative to generalisability. 22 This implies that the onus is on the reader to evaluate the methods, setting, and results and decide if these are transferable to their own situation. We believe that the findings of this study can be transferred to most settings in the United Kingdom.

Barriers and overcoming them
A dilemma is inherent in the management of heart failure. Advances in science have outstripped the ability and capacity of NHS delivery systems; rapidly changing therapeutic paradigms have confused clinicians, sometimes because drugs previously regarded as dangerous, such as blockers, are new cornerstones, and others expelled from the arena, such as spironolactone, are back in vogue. Previous work has explored general reasons why general practitioners do not always implement best evidence. 23 This study identified specific barriers that need to be overcome if aiming for state of the art management. Particular factors needing attention are better and clearer information, improved availability of tests and a useful translation of results from diagnostic methods, and expedient access to specialist advice in case of doubt. Strategies to achieve these objectives might include the development of heart failure clinics and involving general practitioners and nurses with a specialist interest in an integrated care pathway. The national service framework emphasises that substandard care for heart failure is unacceptable, and such new, conjoint strategies are needed urgently. 24 We thank the general practitioners who participated in the study and Jane Pryzborski for transcribing the tapes. AF thanks his practice colleagues for their tolerance in covering his practice workload. Contributors: AF conceived the study. AF and APSH designed the study. AF conducted the focus groups. All authors contributed to the analysis and interpretation of the data. AF wrote the paper, and all authors contributed to revising the paper and approving the final draft. APSH is the guarantor. Funding: Northern and Yorkshire Regional Health Authority, through a research training fellowship awarded to AF.

What is already known on this topic
Heart failure is a common condition with a high morbidity and mortality and is largely managed in primary care Although modern management with accurate diagnosis and treatment improves prognosis considerably, unacceptable variations exist in the clinical application of current guidelines for heart failure

What this study adds
General practitioners expressed a lack of confidence in establishing an accurate diagnosis of left ventricular systolic dysfunction, even if open access echocardiography was available Uncertainty about diagnosis led to poor uptake of evidence based treatment strategies for heart failure patients, and, despite awareness, reluctance to initiate modern treatment Local organisational factors around NHS provision of diagnostic services, resources, and interaction between primary and secondary care influence how general practitioners manage heart failure Implementation strategies for heart failure management across primary and secondary care are needed that are specific to their locality and multifaceted   Article Focus: • A study in 2003, by authors of this paper, identified key barriers to the implementation of best evidence in the diagnosis and management of heart failure by GPs. • Key barriers included a lack of confidence in diagnosis and management, a lack of awareness of the relevant evidence-base for care, and variation in GPs' personal preferences and organisational care pathways. • Evidence from subsequent research about any changes to these barriers has been lacking.

Key Messages:
• The same barriers to the way heart failure is diagnosed and managed are apparent at the present time; variable access to diagnostic tests, modes of care delivery and a non-uniform management approach persist and extend from primary to secondary care. • Lack of clarity about responsibility for end-of-life care for heart failure has emerged as an additional concern. • The NHS context within which heart failure is diagnosed and managed falls short of optimal requirements, which require more co-ordinated care, responsibility and effective training.

Strengths and Limitations:
• Focus groups were held with a wide range of clinical staff to the point of data saturation and are validated against historical work. • The questionnaire response rate was low although 514 professionals responded.
• Nonetheless this study provides new understanding of the reasons behind the evidence-practice mismatch for heart failure diagnosis and management in the UK; in particular, findings highlight the difficulties faced by clinicians in implementing current guidelines.

Introduction
Heart failure (HF) is a major health problem in industrialised countries with ageing populations. 1 HF diagnosis and management are complex with variable care provision. 2 Some variability may relate to access to services, 3 regardless of public or private provision. 2,4 The key to reducing mortality, morbidity and costs associated with HF is early, accurate diagnosis and appropriate management. [5][6][7] Traditionally, heart failure has been attributed to left ventricular systolic dysfunction (LVSD), generally measured as reduced ejection fraction. The evidence base for treatment with medication and device therapy relates to LVSD, 8 but over 50% of heart failure hospitalisations occur in patients with preserved ejection fraction (HFpEF). [9][10][11][12] HFpEF has sometimes been equated with diastolic heart failure although the existence of HFpEF per se has been questioned and an evidence base for treatment is lacking. 13,14 Heart failure is difficult to diagnose accurately as symptoms are often nonspecific and physical signs can be difficult to elicit; 15,16 there is evidence to suggest that diagnosis is missed in up to two thirds of cases. 17 In 2003, we reported reasons why GPs had not implemented best evidence in the diagnosis and management of HF. 2 Key barriers included a lack of confidence in diagnosis and management, a lack of awareness of the relevant evidence-base for care, and variation in GPs' personal preferences and organisational care pathways. Since then there have been major NHS re-organisations including dedicated HF services 18 and the introduction of technologies such as cardiac resynchronization therapy (CRT). 19 Despite, or perhaps because of, on-going developments, there is variability in the diagnosis and management of HF 20 including service access 3,4 , which includes both the availability and use of services. This two-phase study evaluated the key barriers and facilitators to the appropriate management of HF in the UK, comparing findings with those reported in 2003, 2 and extending the previous evaluation to include cardiologists, general physicians and heart failure nurses as well as GPs in a national survey. The previous study 2 employed purely qualitative methods (focus groups) with general practitioners in the North East of England. The current (national) study sought to replicate and expand this to include focus groups with GPs and other relevant clinicians, and a national survey of specialist and non-specialist clinicians.

Methods
Focus group participants were recruited from health authority registers for the North East of England, including salaried GPs and GP partners, cardiologists, general physicians and HF nurses.
Purposive sampling 21 allowed diverse representation of gender, role, seniority, ethnicity, geographical distribution, employment status (part or full time) and practice size (group or single

Data analysis
Thematic data analysis 23,24 conducted by two phenomenologists (HH and HC) produced a textural description of experiences of diagnostic and care provision for heart failure from the focus groups; 25 neither analyst was involved in the 2003 study. Preliminary codes were identified by each analyst, refined as coding progressed, and grouped into categories. From these, a set of themes emerged which were tested using diverse accounts within and between cases to challenge and define the integrity of the theme boundaries. Findings were subsequently discussed by the whole team. Descriptive data analysis, using SPSS version 19, was used to summarise survey findings and explore subgroup patterns. The key subgroups were salaried (permanent, locum, and out-of-hours) GPs, GP partners, Cardiologists, General Physicians and HF Nurses. A lower than expected response rate was achieved and prevented a meaningful analysis of differences between groups.

Research Governance and Ethics
Approval

The diagnostic process
The majority of survey respondents had responsibility for diagnosing HF due to LVSD with the exception of nurses of whom 23% reported doing so. Co-morbidities and non-specific symptoms and signs were the most challenging aspect of making a diagnosis. Cardiologists, general physicians and nurses rated co-morbidities highest while GPs rated non-specific signs and symptoms as most highly challenging. A lower proportion of HF nurses (32%) were confident in their ability to diagnose LVSD than any other group, followed by GPs (66%) when compared with 95% and 92% of cardiologists and general physicians. "I'd leave it to specialists" (Out-of-hours GP) The majority of cardiologists (87%) identified that they had responsibility for diagnosing HFpEF, followed by general physicians (59%). Of the 13 cardiologists who did not diagnose HFpEF, 9 were not convinced that HFpEF exists. Most GPs (84%) and nurses (87%) did not diagnose HFpEF. A lower proportion of GPs (7%) were confident in their ability to diagnose HFpEF than any other group. One cardiologist commented that they would like access to "A crystal ball" to inform HFpEF diagnosis, while a GP partner asked "What is HFpEF?".
A cardiologist highlighted the complex nature of diagnosis: "I've rescued a few people with heart failure from asthma clinics … But we all know it's very hard to do sometimes, isn't it, in someone who's breathless and they've got crackles and they've got a funny looking x-ray, and distinguishing between fibrosis and chronic lung disease and heart failure, just on that first visit isn't always very easy." (Cardiologist)

Diagnostic tests
The majority of survey respondents who diagnosed LVSD used ECGs, chest x-rays and clinical assessment, the exception being nurses. Around a quarter of nurses (23%) and half of GPs (49%) were confident in interpreting the results of an ECG while most cardiologists and general physicians (both: 87%) were confident. One third of nurses (33%) and two thirds of GPs (65%) were confident in interpreting the results of an echocardiogram while the majority of cardiologists and general physicians (98% and 85% respectively) were confident. Cardiologists were more likely to use ECGs and chest x-rays (64% and 63% respectively) to diagnose HFpEF than other groups; clinical assessment was almost never used by any group. This was reflected in confidence levels interpreting these results (see Table 2).

Availability and use of echocardiography services
For LVSD, echocardiographic findings were used by 97% of cardiologists, 91% of general physicians, 52% of salaried GPs, 35% of GP partners and 31% of nurses. Even though generally availability was high, some GPs and general physicians were reluctant to use open access echocardiography because of a lack of knowledge about interpreting results; many preferred to refer the patient to a cardiologist or to a specialist HF clinic.

"… I don't understand a lot of the [echocardiograms]…" (GP partner)
Cardiologists and nurses were more confident in using and interpreting echocardiography reports than GPs, but expressed frustration about patients not routinely referred for echocardiography testing, and the poor quality of referral information: "… we go onto the ward, we read the notes, and it's screaming heart failure at you, screaming it. And nobody's considered doing an echo. And …you want to just say, will you please echo this patient!" (HF nurse) To diagnose HFpEF, most cardiologists used echocardiography (91%) followed by physicians (67%), salaried GPs (30%), nurses (21%), and GP partners (17%). Again confidence in using results reflected this pattern of usage (Table 2).

Availability and use of BNP and NT-pro BNP
GPs were more likely to use BNP (28%) than other groups; NT-pro BNP was used in similarly low proportions. Between 10% and 50% of all respondents expressed a need for access to natriuretic peptides. However, a general physician commented: "We have tried BNP and found that it added no value." Between 10% and 61% of all respondents expressed confidence in interpreting the results of natriuretic peptides in LVSD diagnosis (  The difficulty of achieving an accurate diagnosis of heart failure has changed little in the last ten years despite improved access to diagnostics including natriuretic peptides and echocardiography.
Non-specific symptoms and signs, and significant co-morbidities in increasingly elderly patients, continue to contribute to the complexity of diagnosis. Despite NICE guidance recommending natriuretic peptide testing when diagnosing heart failure, availability and use remains variable.
Although the vast majority of survey respondents now have open access echocardiography, NICE guidelines now discourage this and suggest referral for specialist assessment for diagnosis and management. 26 Comments from focus group respondents highlighted the lack of awareness among some clinicians about the existence or content of relevant guidelines. Thus, it is possible to suggest that while the guidelines themselves may have utility, variations in perceptions and awareness of their content may have been a barrier to optimum care.
A lack of knowledge about diagnosis and management of HFpEF was evident across all professional groups, including many cardiologists. Issues around communicating the diagnosis of heart failure to patients and carers, was highlighted. Generally the lack of evidence base for diagnosis and management of HFpEF meant the guidelines for this condition were deemed to be less useful than those for LVSD. Of note was the fact that 9% of cardiologists remained unconvinced about the existence of HFpEF, which may have influenced the confidence of other clinicians when considering a diagnosis of HFpEF.
Despite a decade of availability, and clear guidance, clinicians still vocalise concerns about initiating beta-blockers or digoxin, although survey findings suggest that most clinicians initiate and titrate evidence-based drugs for heart failure. The previous study identified ageism as a potential source of variability although in this study ageism per se was not seen as a problem, rather the comorbidities associated with age.
Availability of diagnostics (including natriuretic peptides), access to heart failure specialist services and rehabilitation were variable and thus subject to geographical locality. Cardiologists felt that lack of continuity of care and service availability at weekends increased hospital admissions and delayed In the previous study, 2 participants were given the opportunity during each focus group to identify and discuss any sources of variation or difficulty in diagnosing and managing heart failure. End of life care for heart failure was not identified during these focus groups, perhaps reflecting a lack of focus on this issue within the NHS. In the current study, end of life was a pre-agreed topic for discussion but most participants highlighted the issue without prompting from the facilitator, thus demonstrating its increasing relevance and importance to clinicians today. Many participants felt that the main barrier to a coordinated end of life management plan was the inability to predict when the palliative phase should commence in heart failure patients. There was a difficult balance to strike between increasingly invasive technologies (including CRT and ICD) and palliative care planning There appeared to be a lack of consensus about who is responsible for heart failure care, from diagnosis, through management to palliative care. This is despite the fact that NICE guidelines recommend specialist care by multidisciplinary heart failure teams for patients with suspected heart failure, and in-patients with heart failure. Potential solutions to the difficulties highlighted by this paper lie in improved service availability, access, co-ordination of care and education. Previous national and international research has demonstrated the value of a co-ordinated, multidisciplinary approach to care in reducing hospital admissions, reducing treatment variability, and improving quality of life for people with HF. [27][28][29][30] Thus, specialist heart failure clinics are available in many centres across the UK. However, these services may not provide end-of-life care or address some of the other issues raised by this study, such as the education needs of GPs. One innovative solution to the variability of heart failure care, recently implemented by study team members, demonstrated the acceptability and feasibility of an on-site specialist HF service for people in UK care homes. [31][32][33][34] Other research has evaluated cardiology-palliative care teams, demonstrating their potential to address some of the uncertainty around care for these patients. 35 Given the aging population and the increasing burden of heart failure, implementing more innovative solutions is key to addressing the challenges of HF care.

Strengths and Limitations of the Study
The mixed methods approach used in this study permitted the key themes and issues experienced by clinicians to be identified and a questionnaire to be developed to quantify current beliefs and behaviours. Focus groups were conducted to the point of data saturation and can be validated to some extent against historical work although it would be useful for independent research to confirm these themes. The response rate to the questionnaire appears low at 3.1%, however this was an

Conclusions
Reported reasons for variability in heart failure diagnosis and management have changed little in the last decade. Issues of service availability, access, delivery of care and a lack of co-ordination persist.
The current working environment appears not to be conducive to promoting ownership or engagement with such difficulties. Rather than interventions targeted at clinicians to improve care, the primary need may be for a health service, which enables coordinated care, responsibility and training. This article presents independent research and all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Data sharing:
No additional data available.

RG2576]
Role of sponsor: This work was sponsored by Durham University. The research was independently conducted and the sponsor had no role in data collection, analysis, interpretation, or reporting other than to provide the necessary infrastructure.

com/about-bmj/resources-authors/forms-policies-and-checklists/copyright-openaccess-and-permission-reuse). The terms of such Open Access shall be governed by a Creative
Commons licence-details as to which Creative Commons licence will apply to the research article are set out in our worldwide licence referred to above.

Contributorship statement:
HH: I declare that co-designed the study, led data collection, participated in data analysis, interpretation and writing this report, and that I have seen and approved the final version.
HC: I declare that I participated in data collection, data analysis, interpretation and writing this report, and that I have seen and approved the final version.
AF: I declare that I devised the research question, participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
JJM: I declare that I participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
APSH: I declare that I participated in data interpretation and writing this report, and that I have seen and approved the final version.
JMM: I declare that I co-designed the study, participated in data collection, led data analysis, interpretation and writing this report, and that I have seen and approved the final version.         Article Focus: • A study in 2003, by authors of this paper, identified key barriers to the implementation of best evidence in the diagnosis and management of heart failure by GPs. • Key barriers included a lack of confidence in diagnosis and management, a lack of awareness of the relevant evidence-base for care, and variation in GPs' personal preferences and organisational care pathways. • Evidence from subsequent research about any changes to these barriers has been lacking.

Key Messages:
• The same barriers to the way heart failure is diagnosed and managed are apparent at the present time; variable access to diagnostic tests, modes of care delivery and a non-uniform management approach persist and extend from primary to secondary care. • Lack of clarity about responsibility for end-of-life care for heart failure has emerged as an additional concern. • The NHS context within which heart failure is diagnosed and managed falls short of optimal requirements, which require more co-ordinated care, responsibility and effective training.

Strengths and Limitations:
• Focus groups were held with a wide range of clinical staff to the point of data saturation and are validated against historical work. • The questionnaire response rate was low although absolute numbers were substantial (n=514 professionals responded). • Nonetheless this study provides new understanding of the reasons behind the evidence-practice mismatch for heart failure diagnosis and management in the UK; in particular, findings highlight the difficulties faced by clinicians in implementing current guidelines.

Introduction
Heart failure (HF) is a major health problem in industrialised countries with ageing populations. 1 HF diagnosis and management are complex with variable care provision. 2 Some variability may relate to access to services, 3 regardless of public or private provision. 2,4 The key to reducing mortality, morbidity and costs associated with HF is early, accurate diagnosis and appropriate management. [5][6][7] Traditionally, heart failure has been attributed to left ventricular systolic dysfunction (LVSD), generally measured as reduced ejection fraction. The evidence base for treatment with medication and device therapy relates to LVSD, 8 but over 50% of heart failure hospitalisations occur in patients with preserved ejection fraction (HFpEF). [9][10][11][12] HFpEF has sometimes been equated with diastolic heart failure although the existence of HFpEF per se has been questioned and an evidence base for treatment is lacking. 13,14 Heart failure is difficult to diagnose accurately as symptoms are often nonspecific and physical signs can be difficult to elicit; 15,16 there is evidence to suggest that diagnosis is missed in up to two thirds of cases. 17 In 2003, we reported reasons why GPs had not implemented best evidence in the diagnosis and management of HF. 2 Key barriers included a lack of confidence in diagnosis and management, a lack of awareness of the relevant evidence-base for care, and variation in GPs' personal preferences and organisational care pathways. Since then there have been major NHS re-organisations including dedicated HF services 18   Nurses and 13,504 for Salaried GPs and GP Partners). Aiming for a 5% sample, the survey was sent to all staff within these groups.

Data analysis
Thematic data analysis 23,24 conducted by two phenomenologists (HH and HC) produced a textural description of experiences of diagnostic and care provision for heart failure from the focus groups; 25 neither analyst was involved in the 2003 study. Preliminary codes were identified by each analyst, refined as coding progressed, and grouped into categories. From these, a set of themes emerged which were tested using diverse accounts within and between cases to challenge and define the integrity of the theme boundaries. Findings were subsequently discussed by the whole team.
Descriptive data analysis, using SPSS version 19, was used to summarise survey findings and explore subgroup patterns. The key subgroups were salaried (permanent, locum, and out-of-hours) GPs, GP partners, Cardiologists, General Physicians and HF Nurses. A lower than expected response rate was achieved and prevented a meaningful analysis of differences between groups.

Research Governance and Ethics
Approval was obtained from Durham University's School of Medicine, Pharmacy and Health Ethics Committee, relevant research governance committees and the National Research Ethics Committee (ref 09/H0905/43) prior to starting the research.

Study findings
From the focus groups, four categories were identified which contribute to variations in the diagnosis and management of HF: uncertainty about clinical practice, the value of clinical guidelines, tensions between individual and organisational practice, and, uncertainty about end-of-life care. The first three categories virtually replicated 2003 2 findings, the fourth was new.

The diagnostic process
The majority of survey respondents had responsibility for diagnosing HF due to LVSD with the exception of nurses of whom 23% reported doing so. Co-morbidities and non-specific symptoms and signs were the most challenging aspect of making a diagnosis. Cardiologists, general physicians and nurses rated co-morbidities highest while GPs rated non-specific signs and symptoms as most highly challenging. A lower proportion of HF nurses (32%) were confident in their ability to diagnose LVSD than any other group, followed by GPs (66%) when compared with 95% and 92% of cardiologists and general physicians. "I'd leave it to specialists" (Out-of-hours GP) The majority of cardiologists (87%) identified that they had responsibility for diagnosing HFpEF, followed by general physicians (59%). Of the 13 cardiologists who did not diagnose HFpEF, 9 were not convinced that HFpEF exists. Most GPs (84%) and nurses (87%) did not diagnose HFpEF. A lower proportion of GPs (7%) were confident in their ability to diagnose HFpEF than any other group. One cardiologist commented that they would like access to "A crystal ball" to inform HFpEF diagnosis, while a GP partner asked "What is HFpEF?".
A cardiologist highlighted the complex nature of diagnosis: "I've rescued a few people with heart failure from asthma clinics … But we all know it's very hard to do sometimes, isn't it, in someone who's breathless and they've got crackles and they've got a funny looking x-ray, and distinguishing between fibrosis and chronic lung disease and heart failure, just on that first visit isn't always very easy." (Cardiologist)

Diagnostic tests
The majority of survey respondents who diagnosed LVSD used ECGs, chest x-rays and clinical assessment, the exception being nurses. Around a quarter of nurses (23%) and half of GPs (49%) were confident in interpreting the results of an ECG while most cardiologists and general physicians (both: 87%) were confident. One third of nurses (33%) and two thirds of GPs (65%) were confident in interpreting the results of an echocardiogram while the majority of cardiologists and general physicians (98% and 85% respectively) were confident. Cardiologists were more likely to use ECGs and chest x-rays (64% and 63% respectively) to diagnose HFpEF than other groups; clinical assessment was almost never used by any group. This was reflected in confidence levels interpreting these results (see Table 2).

Availability and use of echocardiography services
For LVSD, echocardiographic findings were used by 97% of cardiologists, 91% of general physicians, 52% of salaried GPs, 35% of GP partners and 31% of nurses. Even though generally availability was high, some GPs and general physicians were reluctant to use open access echocardiography because of a lack of knowledge about interpreting results; many preferred to refer the patient to a cardiologist or to a specialist HF clinic.

"… I don't understand a lot of the [echocardiograms]…" (GP partner)
Cardiologists and nurses were more confident in using and interpreting echocardiography reports than GPs, but expressed frustration about patients not routinely referred for echocardiography testing, and the poor quality of referral information: "… we go onto the ward, we read the notes, and it's screaming heart failure at you, screaming it. And nobody's considered doing an echo. And …you want to just say, will you please echo this patient!"

Availability and use of BNP and NT-pro BNP
GPs were more likely to use BNP (28%) than other groups; NT-pro BNP was used in similarly low proportions. Between 10% and 50% of all respondents expressed a need for access to natriuretic peptides. However, a general physician commented: "We have tried BNP and found that it added no value." Between 10% and 61% of all respondents expressed confidence in interpreting the results of natriuretic peptides in LVSD diagnosis (Table 2). Few practitioners use natriuretic peptides to diagnose HFpEF.

Communicating a diagnosis
All cardiologists (100%), and most physicians (94%) and nurses (95%) took responsibility for informing patients of a heart failure diagnosis; a minority of GPs felt that this was not their responsibility (16%) but a cardiologist's. One cardiologist commented: "In some patients it is very easy and in some very difficult. Communicating difficult information well requires training and experience." And another: "I think it's something we haven't been trained to do." (Cardiologist) Most participants felt it was important to educate patients about their illness but some expressed concerns about informing patients of their diagnosis as this might lead to anxiety.
"I don't tend to tell them that their prognosis is pretty lousy if they've got a bad heart, which it is,

The value of clinical guidelines
When diagnosing LVSD, a third of nurses (33%) and about a half (50%-56%) of other groups found clinical guidelines helpful. All groups identified NICE guidelines as the most helpful for the management of LVSD (50%-89%). Information overload was seen as a common cause of anxiety among both salaried and partnered GPs. Some participants felt that it was 'too late' for them to be educated.  Some GPs and HF nurses felt duty bound to follow guidelines but expressed frustration that they did not offer enough scope for individualised care: "I try and use them but I think a lot of people don't fit into them, the little boxes." (GP partner) Some salaried and locum GPs valued guidelines and expressed the view that they led to more confident decision making: ".. it gives you confidence if you've got some guidelines, sitting with the patient, you can follow, you know, follow instructions a little bit, which does make you feel a bit more confident." (Locum GP). In contrast, cardiologists appeared more confident in using their clinical judgement and discretion in preference to following guidelines and described decision-making in more complex, multi-level and nuanced ways than GPs.
"… trying to keep abreast of what the literature's suggesting you do, but also the fact that you're a little bit constrained by guidelines that are seemingly quite behind the literature." (Cardiologist) Heart failure management Of those who managed LVSD, all groups cited co-morbidities as the most challenging aspect of management. GPs and general physicians cited poly-pharmacy as being the second most challenging aspect, while cardiologists and nurses cited unpredictable disease progression. Some GPs felt that the organisation of care, with an emphasis on specialist HF services, led to deskilling in primary care.
"The thing that concerns me most is being deskilled because as I'm doing much less management of heart failure than, the heart failure nurses are probably doing a lot more." (GP Partner) A particular concern among GPs, regardless of level of experience, was anxiety about the delicate risk-benefit balance where management required investigations, initiation and titration of evidence

diuretics but the ACE inhibitors as well juggling doses of ACE inhibitors against diuretics, up and down, checking potassium. I do find some of those conflicts difficult to resolve." (GP partner)
There was a reluctance to prescribe additional medications to a group characterised by polypharmacy and comorbidities; this was seen as a particular problem in the elderly: "Particularly in more frail/elderly people for example, particularly if the blood pressure is hovering around 100-110 anyway, because of their age and you crank their ACE inhibitor as far as it can go, maybe a little bit dry as well, I think a beta blocker on top of that is always a bit of a concern. Relatively easy to do, maybe, when the patient's already in hospital, and is going to be in for another day or so and they can see probably what's going to happen but it's more difficult out in the community." (GP partner) All professional groups shared a reluctance to increase dosage if the patient was asymptomatic or

Tensions between individual and organisational practice
In addition to specialist medical training (or lack thereof) and clinical experience, another important theme influencing clinicians' diagnosing behaviour arose from the provisions made by outside organisations (health authorities, secondary care trusts and primary care trusts). For example, cardiologists and general physicians expressed concern about the organisation of specialist care by

Discussion
Among the five health professional groups studied, variable opinions and practices persist in the diagnosis and management of heart failure. Uncertainty about appropriate clinical practice (including the diagnostic process and medical management), utility of clinical guidelines and individual practice preferences with local organisational influences were similar to themes identified a decade ago. 2 Uncertainties around end of life care emerged as a new theme.
The difficulty of achieving an accurate diagnosis of heart failure has changed little in the last ten years despite improved access to diagnostics including natriuretic peptides and echocardiography.
Non-specific symptoms and signs, and significant co-morbidities in increasingly elderly patients, There appeared to be a lack of consensus about who is responsible for heart failure care, from diagnosis, through management to palliative care. This is despite the fact that NICE guidelines recommend specialist care by multidisciplinary heart failure teams for patients with suspected heart failure, and in-patients with heart failure. Potential solutions to the difficulties highlighted by this paper lie in improved service availability, access, co-ordination of care and education. Previous national and international research has demonstrated the value of a co-ordinated, multidisciplinary approach to care in reducing hospital admissions, reducing treatment variability, and improving quality of life for people with HF. [27][28][29][30] Thus, specialist heart failure clinics are available in many centres across the UK. However, these services may not provide end-of-life care or address some of the other issues raised by this study, such as the education needs of GPs. One innovative solution to the variability of heart failure care, recently implemented by study team members, demonstrated the acceptability and feasibility of an on-site specialist HF service for people in UK care homes. [31][32][33][34] Other research has evaluated cardiology-palliative care teams, demonstrating their potential to address some of the uncertainty around care for these patients. 35 Given the aging population and the increasing burden of heart failure, implementing more innovative solutions is key to addressing the challenges of HF care.

Strengths and Limitations of the Study
The mixed methods approach used in this study permitted the key themes and issues experienced by clinicians to be identified and a questionnaire to be developed to quantify current beliefs and behaviours. Focus groups were conducted to the point of data saturation and can be validated to some extent against historical work although it would be useful for independent research to confirm these themes. The response rate to the questionnaire appears low at 3.1%, however this was an

Conclusions
Reported reasons for variability in heart failure diagnosis and management have changed little in the last decade. Issues of service availability, access, delivery of care and a lack of co-ordination persist.
The current working environment appears not to be conducive to promoting ownership or engagement with such difficulties. Rather than interventions targeted at clinicians to improve care, the primary need may be for a health service, which enables coordinated care, responsibility and training. This article presents independent research and all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Data sharing:
There is no additional data available. Commons licence-details as to which Creative Commons licence will apply to the research article are set out in our worldwide licence referred to above.

Contributorship statement:
HH: I declare that co-designed the study, led data collection, participated in data analysis, interpretation and writing this report, and that I have seen and approved the final version.
HC: I declare that I participated in data collection, data analysis, interpretation and writing this report, and that I have seen and approved the final version.
AF: I declare that I devised the research question, participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
JJM: I declare that I participated in data collection, interpretation and writing this report, and that I have seen and approved the final version.
APSH: I declare that I participated in data interpretation and writing this report, and that I have seen and approved the final version.

Abstract
Objective To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care. Design A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory. Setting North east England.
Results Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care. Conclusions The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies-for example, the provision of guidelines-are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.

Introduction
Heart failure is difficult to define and diagnose. 1 It is common, increasing in prevalence, and has high morbidity and mortality akin to common cancers. 2 It is managed largely in primary care, imposing a heavy burden on the NHS, and accounts for 5% of admissions to medical wards, with high readmission rates. 3 4 Diagnosis by clinical assessment is difficult and is correct in less than half of cases confirmed by echocardiography. 5 6 Heart failure is poorly managed in general practice for many reasons. [7][8][9][10][11] Uncertainty about diagnosis 8 11 ; lack of access to diagnostic services 10 ; lack of awareness of research evidence and guidelines 7 9 ; worries about adverse effects, cost, and inconvenience of angiotensin converting enzyme inhibitors 7 ; and poor communication between professionals in primary and secondary care 11 lead to variable practice, and the reasons for this variability need to be elucidated further.
Much of the current evidence on how to diagnose and manage heart failure comes from a secondary care perspective, where the difficulties of primary care, including differences in patient populations, are not necessarily appreciated. Studies have usually relied on quantitative methods, with little exploration of the complexity of general practice and its relations with patients and secondary care. 7 10 This study aimed to ascertain the beliefs, current practices, and decision making of general practitioners around the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to optimal care.

Methods
Focus groups with general practitioners were our chosen format for the study, which was set in north east England, an area with a population of 617 532 and with 316 general practitioners in 88 practices. We used a mixed purposive sampling strategy to select participants. 12 Stratification of general practitioners allowed proportionate representation of sex, ethnic group, geographical distribution, employment status (part time or full time), and practice size (group or singlehanded) and avoided selecting general practitioners from the same practice. We contacted 41 general practitioners and organised four focus groups.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Eleven doctors did not attend; their demographic and professional characteristics did not differ from the remaining 30. The four focus groups consisted of six to eight participants, and a co-moderator was used in three of them.
The 30 participants (25 men, overall age range 33-64 years, years since graduation 10-42) represented a wide range of practice size and length of experience, including three singlehanded practices. Twenty seven doctors worked full time and three part time; 20 (66%) had open access echocardiography. The ratio of male to female general practitioners in the locality was 3:1; in the focus groups it was 5:1.
To help the discussion the principal investigator (AF) used a list of points to be considered, compiled from a literature review. The sessions were audiotaped, transcribed, and then corrected and verified by AF.

Analysis
We analysed the contents of the interviews following the principles of the theory of "pragmatic variant" grounded theory. 13 14 We read transcripts and identified broad themes as the groups progressed. This iterative process allowed ideas and thoughts that were emerging to be brought back to subsequent groups. We analysed deviant cases to question widely accepted practice. 14 No new major themes arose by the end of the fourth focus group, implying that saturation was being reached. 14 The transcripts were read several times, data organised into codes from which categories were identified, and major themes were constructed by AF and APSH. All three investigators contributed to multiple coding and agreed final themes. Analysis was enhanced by constant comparison with the transcripts and available research in this field from the initial literature review. 14

Respondent validation
To validate the findings we sent all 30 participants a report summarising the study results and conclusions. 15 Of 28 respondents 27 "strongly agreed" or "agreed" and one "neither agreed, nor disagreed" that the report was an accurate representation of their opinions and the group outcomes.

Results
We identified three themes that contributed to reasons for the variation in medical practice and why general practitioners experienced difficulties in diagnosing and managing heart failure: firstly, uncertainty about clinical practice, including the availability and use of echocardiographic services; secondly, lack of awareness of relevant research evidence; and thirdly, influences of individual references and local organisational factors.

Uncertainty about clinical practice
Most participants expressed a lack of confidence in establishing the diagnosis of heart failure. This affected the management of individual patients. Three main categories were identified: the diagnostic process, availability and use of echocardiography services, and treatment issues.

The diagnostic process
Heart failure was perceived to be a difficult diagnosis to make in general practice because of: x Problems with subtlety of clinical symptoms and signs: "Some of the clinical signs, if you have a raised JVP or third heart sound, hepatomegaly, are often difficult in the obese to detect, and ankle oedema is common anyway." x Difficulty in differential diagnosis, especially in elderly patients with comorbidity such as chronic obstructive airways disease and obesity: "I think heart failure would be not too difficult a subject if it occurred in young fit people but the biggest problem is that it's always inevitably older people who get it. It's a co-pathology intermingled with other things, and that makes it often quite difficult to disentangle." x Time constraints and generally increasing clinical and administrative workload for general practitioners: "20 plus patient surgeries, and having to try and stick to close to 10 minutes, it can be quite difficult to do a really full assessment." x Lack of availability of diagnostic tests, including electrocardiography, chest radiography, and echocardiography, and lack of confidence in interpreting the results of these: "You get a kind of slightly reduced ejection fraction, and you know an iffy tricuspid valve or two, and you know you're not really that much further forward." x Inertia or fear of initiating action because of anxieties about committing to an intensive course of action, including investigations, initiation, titration, and monitoring of treatment: "I think it's the milder degrees of heart failure . . . that is the difficulty. But once you've diagnosed it you're committed to a course of action, and I suppose it seems quite a drastic course of action, you've obviously got the diuretics, ACE inhibitors, and possibly other medication as well, full investigations, and I suppose that could lead to a bit of inertia, couldn't it." x Patients' choices, including reluctance to be investigated or treated further: "Some patients obviously don't want to be hospitalised or don't want a second opinion, and sometimes don't want to go to hospital, so you end up treating them yourself."

Availability and use of echocardiography services
Perceived handicaps included the variability of open access echocardiography in the same locality; two thirds of the participants had this facility. Some of the inequity resulted from the continuation of access acquired previously by general practice fundholders.
Several of the open access services had been funded through pharmaceutical sponsorship but disappeared as "monies dried up." A further perceived problem was variability in echocardiography reporting, some by technicians and some by clinicians, and a lack of guidance for using the procedure or for standardising request forms.
Difficulties for general practitioners concerning echocardiography Some general practitioners did not use open access echocardiography even when it was available, chiefly because of not being able to understand it and the inconvenience caused to patients who were often very ill. The reasons given included: x Uncertainty about the importance of results and interpretation of technical reports: "The problem with echocardiograms is that I really just don't understand  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y them. I don't think of myself as being really that old, I mean I'm 43 . . . and when I went through my postregistration years echocardiograms just weren't around . . . I just don't know where I am with them. When does an ejection fraction of such and such per cent stop being reasonable and start being a problem?" x Not being able to cope with echocardiography, many preferred to refer the patient to a consultant: "I would rather refer than do an echocardiogram, the interpretation of which I am not confident with." "I'm not confident in diagnosis of heart failure. I think I just like to have it rubber stamped." x Distance to nearest echocardiography clinic may inconvenience patients: "It takes a whole day to go to hospital, and for an elderly person with breathlessness that's a long day, ambulance there and back, sit in a waiting room, and patients do it once and they won't do it again, and they don't all have relatives to take them in." General practitioners were less likely to use open access echocardiography when reports were technical and lacked a clinical opinion than when a clinician guided report was available. In these circumstances they either treated their patients' symptoms or referred them to hospital; a lack of open access was cited as a reason for increased referrals. Apprehension was expressed about overloading cardiology services, especially with patients who seemed well: "I think there is also a feeling that it's almost an inappropriate cardiac referral . . . the cardiologists are so busy and when you first make the diagnosis they [the patients] are often actually not that poorly."

Treatment issues
Uncertainty about diagnosis cast doubts on the development of strategies for individual treatment of patients. The treatment process was an area that entailed further barriers to evidence based practice.
Doctors had good awareness of nonpharmacological advice and interventions (such as weight reduction, tailored exercise, restriction of salt intake) for patients with heart failure. 16 Most participants agreed the importance of educating patients, but some expressed concerns at informing patients about the diagnosis as this might lead to anxiety. This was countered by those who believed that openness with and involvement of patients improved compliance.

Concerns about using ACE inhibitors in general practice
Although attitudes were felt to be changing, worries still surrounded the use of angiotensin converting enzyme (ACE) inhibitors, especially about starting treatment in primary care as opposed to in hospital, partly because of previous teaching and a fear of side effects, mainly hypotension, in the community setting: x Concerns about the use of angiotensin converting enzyme inhibitors in elderly patients and those with renal impairment and worries about side effects including cough, postural hypotension, and renal failure: "I'm not too sure exactly at what degree of renal impairment one should worry too much." x Polypharmacy and drug interactions was considered a barrier, especially in elderly patients: "The other thing that raises its head is polypharmacy here, where you have got your people who have been chewing their aspirin for years, that a lot of these will be on statins and antiarthritic drugs. You've got your ACE inhibitors and diuretics. Well that's five or six [drugs], and I think you're going to have rebellion on your hands from people who say they are on far too many tablets . . ." x Ageism was flagged up as a consideration in all four groups: "I think there is an ageist agenda with it as well because you know somebody of 60 who has got heart failure you're going to be much more aggressive with than someone who is 78, not just in terms of making the diagnosis but the investigations and treatment." x A few general practitioners were happy to keep patients taking diuretics and "spare them the ACE inhibitor unless they are getting worse." x A minority's perception was that diuretics alone are "OK in mild heart failure." information was seen as a common cause of stress. Many worried about the "rapidity of change in all fields" and "keeping up to date with changes" but believed that "[we] owe it to our patients" to be in touch.
Existing guidelines about the diagnosis and management of heart failure and treatment with angiotensin converting enzyme inhibitors were not familiar to most participants. To some extent this was due to "guideline fatigue"; one general practitioner felt "bombarded and bamboozled by guidelines." Specific to heart failure was the lack of awareness of the importance of confirming left ventricular systolic dysfunction, differences between systolic and diastolic heart failure, and the importance of the NYHA (New York Heart Association) classification-a system of grading the severity of heart failure-in categorising heart failure. A lack of knowledge became obvious as to how this classification could be used to provide a prognosis and guide management.
Some general practitioners were happy to keep patients taking diuretics alone, possibly unaware of potential benefits of angiotensin converting enzyme inhibitors, blockers, and spironolactone. 16 17 Most had little knowledge of the place for agents other than diuretics and angiotensin converting enzyme inhibitors, and a feeling predominated in some quarters that heart failure should be managed in secondary care: "Can we adequately manage heart failure in general practice, given the modern advances that we are all unsure about?"

Influences of personal preference and local organisational factors
Medical training, anecdotal experiences, and outside agencies (health authorities, primary care trusts, and the pharmaceutical industry) emerged as influences on individual clinicians' behaviour and professional culture. In some instances this was deeply entrenched and perversely affected newer influences. An example of this was a participant from a large teaching practice who justified his reluctance to refer all patients for echocardiography; the factors behind this are likely to be complex and to do with coming to terms with a rapidly changing medical environment: "I got through the whole of hospital training, and we didn't use echocardiograms. In cardiology we managed everyone with heart failure without an echocardiogram." Local organisational factors around the provision of diagnostic services, such as open access echocardiography, resources, lack of cardiologists, and professional interactions between primary and secondary care shaped practice and decision making processes among general practitioners. A locality based, contextualised approach was found acceptable: x "A locally drawn up set of guidelines which are pertinent to the local situation, that is primary and secondary care situations, drawn up by representatives from both primary and secondary care and other interested stakeholders that is owned by everyone who is going to use them." x "We are in an imperfect health service, and we are resource starved, and if like every other medical problem we deal with, if we wanted to manage heart failure as we would like to, it's going to have significant resource implications." Waiting lists and the local availability of consultants influenced the general practitioner's decision in relation to the referral to cardiologists of patients with suspected heart failure: "Being pragmatic you look at waiting lists, we've got some very good geriatricians who have excellent clinical skills, and certainly, if the patient has got multiple pathologies, I would have no hesitation in referring to them."

Discussion
Heart failure is poorly managed in the United Kingdom, mainly because of inaccurate diagnosis and inappropriate treatment, including the use of treatment for heart failure in a large group of patients who do not actually have heart failure. 8 18 A major reason for failing to make an accurate diagnosis is that the symptoms and signs are not highly specific. 19 This study provides information about the difficulties perceived by general practitioners in achieving accurate diagnosis and instituting modern treatment. 16 The most accurate method of diagnosis entails the use of echocardiography, but this study confirmed a variation in its availability and discovered that practitioners were not confident about interpreting results. 20 At the same time a reluctance to refer to a consultant for a definitive diagnosis prevailed because of a fear of overloading services and a continuing perception that heart failure remains a problem to be dealt with in primary care.

Perceived advantages and disadvantages of modern management
Diagnosis and management of heart failure have evolved dramatically, such that they rely on specialised investigations and drug regimens that often require specialist input. Clinicians who trained in the distant past have essentially not come to terms with the more modern approach. In turn, services to capitalise on modern management have been insufficiently developed.
Paradoxically, the general practitioners appreciated the benefits of modern treatment shown in large scale trials, particularly those of angiotensin converting enzyme inhibitors. 16 Although confidence in the use of angiotensin converting enzyme inhibitors has increased in the past 10 years, a substantial minority of general practitioners were reluctant to use them, especially in elderly patients. This was related to fears about side effects, especially hypotension and collapse in the community setting, and the lack of monitoring guidelines in the context of primary care.
Polypharmacy was viewed particularly negatively. If between one and five drugs are prescribed, the likelihood of adverse drug reactions is 3.4%, rising to 24% with six or more. 21 The increased numbers of tablets likely to be required by elderly patients with concurrent conditions, such as diabetes and its associated problems, was considered daunting and detracting from compliance. In such situations decisions about the most appropriate regimens were likely to be weighted by the requirements of the different conditions and perceived returns from intervention. Although chronic heart failure is serious and progressive and appropriate drug intervention proved to be beneficial, many clinicians do not find it easy to judge the extent of worthwhile returns in older patients with underlying problems such as ischaemic heart disease. Patients whose heart failure has already been diagnosed, who seem stable having conventional treatment but who might benefit from newer interventions, 17 also posed a dilemma; many clinicians were reluctant to initiate newer treatments that may have been around for decades, such as digoxin and spironolactone. 16 Suboptimal care often results from factors outside the immediate control of the general practitioner. 9 Local circumstances such as resource allocation, priorities, and attitudes of consultants are crucial. This study confirms that general practitioners perceived this to be the case for heart failure. The increasing involvement of primary care in planning local services through primary care trusts may alleviate this problem, providing the trusts can work effectively with secondary care providers.

Methodological aspects
The qualitative method for this research lent itself well to discovering the barriers to optimal care. Rigour was enhanced by multiple coding and validation of respondent validation. 15 The personal and intellectual bias of the principal investigator was minimised by using a co-moderator in three groups, by allowing discussions to develop naturally, and by reporting the wide range of perspectives. Analysis of deviant cases enhanced the validity of the findings by bringing widely accepted practice into question. 14 Generalisability from qualitative research remains an issue with some doctors. Guba and Lincoln have introduced the concept of transferability as an alternative to generalisability. 22 This implies that the onus is on the reader to evaluate the methods, setting, and results and decide if these are transferable to their own situation. We believe that the findings of this study can be transferred to most settings in the United Kingdom.

Barriers and overcoming them
A dilemma is inherent in the management of heart failure. Advances in science have outstripped the ability and capacity of NHS delivery systems; rapidly changing therapeutic paradigms have confused clinicians, sometimes because drugs previously regarded as dangerous, such as blockers, are new cornerstones, and others expelled from the arena, such as spironolactone, are back in vogue. Previous work has explored general reasons why general practitioners do not always implement best evidence. 23 This study identified specific barriers that need to be overcome if aiming for state of the art management. Particular factors needing attention are better and clearer information, improved availability of tests and a useful translation of results from diagnostic methods, and expedient access to specialist advice in case of doubt. Strategies to achieve these objectives might include the development of heart failure clinics and involving general practitioners and nurses with a specialist interest in an integrated care pathway. The national service framework emphasises that substandard care for heart failure is unacceptable, and such new, conjoint strategies are needed urgently. 24 We thank the general practitioners who participated in the study and Jane Pryzborski for transcribing the tapes. AF thanks his practice colleagues for their tolerance in covering his practice workload. Contributors: AF conceived the study. AF and APSH designed the study. AF conducted the focus groups. All authors contributed to the analysis and interpretation of the data. AF wrote the paper, and all authors contributed to revising the paper and approving the final draft. APSH is the guarantor. Funding: Northern and Yorkshire Regional Health Authority, through a research training fellowship awarded to AF.   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  *Give information separately for exposed and unexposed groups.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60