Faculty of Health, York University, Keele Campus, Toronto, Ontario, Canada.
Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada.
BMJ Open. 2024 Mar 14;14(3):e076664. doi: 10.1136/bmjopen-2023-076664.
There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria.
DESIGN, SETTING AND PARTICIPANTS: Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada.
Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa).
Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines.
There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes.
心力衰竭（HF）诊所的入院标准存在很大差异，导致提供者为这些救命服务转诊的人群存在差异。本研究调查了实际与理想 HF 诊所纳入或排除标准之间的差异，以及这与转诊提供者对理想标准的看法有何关系。
设计、地点和参与者：通过研究电子数据捕获向加拿大各地的诊所提供者和转诊者（例如，心脏病专家、家庭医生和执业护士）进行了两项横断面调查。
根据文献和 HF 指南选择了 27 项标准进行测试。要求受访者列出任何其他标准。评估了一致性程度（例如，Kappa）。
从 48 个诊所收到了提供者的回复（响应率为 37.5%）。最常见的实际纳入标准是新诊断的射血分数降低或保留的 HF、纽约心脏协会 IIIB/IV 级和近期住院（每个标准均得到> 74%的受访者认可）。排除标准包括先天性病因、静脉内正性肌力药、缺乏专科医生、一些非心脏合并症和后勤因素（例如，农村地区和技术获取）。实际和理想标准之间的差异最大的是：同一机构的住院患者（κ=0.14）、先天性心脏病、肺动脉高压或遗传性心肌病（所有 κ=0.36）。三分之一（n=16）的诊所已经改变了标准，通常是出于非临床原因。73 名转诊提供者完成了调查。转诊者比诊所更认可的标准包括心率高的低血压、反复除颤器电击和静脉内正性肌力药——这些标准也与指南一致。
主要诊所入院标准得到了相当大的认可，但鉴于存在一些差异，可能需要设立两级诊所。宣传基于证据的标准，并在转诊来源系统地应用这些标准，可以支持改善 HF 患者的护理流程和结果。
