Areas for quality improvements in heart failure care: quality of care from the patient's perspective

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Heart failure (HF) is a serious condition 1 with high rates of hospital admissions, high mortality 2 and a poor quality of life 3, which places great demands on caregivers. Patients with HF experience a high level of symptoms, but it is not always the most prevalent symptoms that are the most distressing ones for the patient 4. Worsening of symptoms in HF often leads to declining functional capacity, diminished quality of life and increased need for health care, and the disease trajectory of HF is unpredictable (1). In addition, patients with HF are often elderly with comorbidities 5. The prevalence of HF is about 1–2% in the adult population in developed countries, and in persons aged >70 years, the prevalence is rising to more than 10% 1. Most patients with HF will be taken care of in primary care, while some patients need more intensive management at HF clinics and some patients will need palliative care services 5.
According to WHO, quality of care can be described in six dimensions. These dimensions require that health care should be effective, efficient, accessible, acceptable/patient‐centred, equitable and safe 6. It is proposed that patients’ perceptions about their care should be evaluated 7, not least because healthcare professionals’ and patients’ perceptions of quality might differ 8 and patients’ evaluations are important to provide improvements in care quality 9. Quality of care can be difficult to define and measure, and it is described as a complex and multidimensional concept 7. Patient's experience of and satisfaction with care is used as indicators of quality, and they are sometime used interchangeably, despite different meanings 11. Patient satisfaction is described based on a relationship between experiences and expectations 13, and patient experience is what actually happened and not patient′s evaluation of it 11. It is discussed that patient satisfaction surveys not always are useful tools for quality improvements because they may not be sensitive enough 11 and global satisfaction questions can be misleading if the patients do not have the opportunity to answer more specific questions, about their care in more detail 12. Patients also tend to overrate satisfaction. These problems have led to an emphasis on measuring patients’ experience rather than satisfaction 11. From a validity point of view, the instruments used to measure patients’ perception of care quality should be based on a theoretical foundation so that they really measure the patients experience from their perspective 10.
Previous studies have investigated the quality of care for patients with HF, and the outcomes are often measured in clinical outcomes such as mortality and hospitalisations, use of evidence‐based treatments, managing patient symptoms, participation, quality of life, self‐care behaviour and reducing costs 15. Studies regarding patients’ perception of HF care have described that patients were dissatisfied with healthcare professionals’ inability to coordinate between hospital and community teams and also to deal with complex medications and to help relieve symptoms 20. The perception of quality of care in patients with HF has also been studied in educational interventions 22, management programmes 23, clinical pathways 24, palliative care 25 and how quality of inpatient care relates to hospital readmissions 26. To our knowledge, there are few studies measuring the quality of HF care from the patient's perspective in an outpatient setting. Consequently we aimed to explore how patients with HF report quality of care, in an outpatient setting.

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