Article type
Abstract
Background: The Agency for Care Effectiveness (ACE) within the Singapore Ministry of Health sought to develop an ACE Clinical Guidance (ACG) on ischemic heart disease (IHD) for primary care, due to its high health and economic burden, limited local guidance, and reported diverse practices in assessment, diagnosis, and management.
Objective: To identify the scope for a clinically relevant guidance, a qualitative study was conducted to understand current practices and challenges associated with IHD management in primary care.
Method: A focus group discussion and two one-to-one interviews were conducted virtually in August 2023 among a purposive sample of six general practitioners (GPs) working in public (n=3) and private (n=3) clinics. Interviews were recorded, transcribed verbatim, and analyzed using inductive thematic analysis.
Results: Findings of current practices and challenges were mapped in 5 domains corresponding with stages of IHD management in primary care: initial investigation and risk assessment, referral to emergency department (ED) and cardiologists, pharmacotherapy management of stable IHD, monitoring and follow-up, and shared care with cardiologists. The findings validated and deepened our understanding of local practices and needs, which more clearly informed ACG scoping. For example, coronary artery disease (CAD) risk prediction tool for symptomatic patients, including one with local validation, could aid clinical decision for discreet referral to ED and cardiologists. However, their utility in local primary care was low among interviewed GPs, due to barriers relating to perceived redundancy and lack of IT integration. Therefore, evidence-based recommendations in the ACG regarding such tools as part of initial assessment would inform subsequent management decisions. Furthermore, anti-thrombotic agents are part of cornerstone pharmacotherapy in IHD management, but potential knowledge gaps may exist in local primary care, including substituting oral anticoagulant (OAC) with aspirin, and determining optimal OAC dose and monitoring parameters, which warranted detailed discussion and guidance in the ACG.
Conclusion: Engaging primary care physician representatives as the main target audience of the proposed ACG provided a clearer direction for the scoping and development of the ACG aimed at addressing identified needs and gaps of local practitioners and improving care for stable IHD patients in primary care.
Objective: To identify the scope for a clinically relevant guidance, a qualitative study was conducted to understand current practices and challenges associated with IHD management in primary care.
Method: A focus group discussion and two one-to-one interviews were conducted virtually in August 2023 among a purposive sample of six general practitioners (GPs) working in public (n=3) and private (n=3) clinics. Interviews were recorded, transcribed verbatim, and analyzed using inductive thematic analysis.
Results: Findings of current practices and challenges were mapped in 5 domains corresponding with stages of IHD management in primary care: initial investigation and risk assessment, referral to emergency department (ED) and cardiologists, pharmacotherapy management of stable IHD, monitoring and follow-up, and shared care with cardiologists. The findings validated and deepened our understanding of local practices and needs, which more clearly informed ACG scoping. For example, coronary artery disease (CAD) risk prediction tool for symptomatic patients, including one with local validation, could aid clinical decision for discreet referral to ED and cardiologists. However, their utility in local primary care was low among interviewed GPs, due to barriers relating to perceived redundancy and lack of IT integration. Therefore, evidence-based recommendations in the ACG regarding such tools as part of initial assessment would inform subsequent management decisions. Furthermore, anti-thrombotic agents are part of cornerstone pharmacotherapy in IHD management, but potential knowledge gaps may exist in local primary care, including substituting oral anticoagulant (OAC) with aspirin, and determining optimal OAC dose and monitoring parameters, which warranted detailed discussion and guidance in the ACG.
Conclusion: Engaging primary care physician representatives as the main target audience of the proposed ACG provided a clearer direction for the scoping and development of the ACG aimed at addressing identified needs and gaps of local practitioners and improving care for stable IHD patients in primary care.