Abstract
BackgroundDiagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines.MethodsThink-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines.ResultsInformation about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument.ConclusionsThe clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way.
Highlights
Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not implemented in everyday practice
Diagnostic reasoning Assessments to be performed routinely according to guidelines The information that was used most frequently in diagnostic arguments was the ejection fraction value on ECHO, pulmonary congestion, and cardiac volume (Figure 1)
general practitioners (GPs)' diagnostic reasoning compared with guidelines When comparing the GPs' diagnostic reasoning with guidelines, we found that the clinical information in the case vignettes was not used to the extent recommended in the guidelines
Summary
Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines. Diagnosing CHF is known to be difficult, especially in mild cases, as many features of the condition are not organ specific, and there may be few clinical features in the early stages of the disease [3,4,5]. A large proportion of patients with CHF are managed by general practitioners (GPs), especially older patients and patients early in the course of disease, i.e. those patients for whom the diagnostic process is characterized by the greatest uncertainty [6]
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