Table 2

Thematic matrix: GPs’ perceptions of managing chronic HF in primary care

	HF-specific factors	Patient factors	Physician factors	Contextual factors
Use of guidelines
Barriers			Overload of information Not useful in patients with comorbidities and polypharmacy Influence of dated medical training	Not applicable to the local situation
Facilitators			Motivated by a sense of duty towards patients Feel more confident when using guidelines
Ideas for improvement			Education of GPs	Need for locally drafted guidelines
Diagnosis
Barriers	Non-discriminating HF symptoms and signs	Difficulties in older patients with comorbidities Patient's reluctance to be referred	Doubts about value of diagnostic tests Lack of confidence in diagnosing HF and interpreting test results Unawareness of the importance of HF classification (HFrEF, HFpEF) Inertia or fear of initiating an intensive course of action	Lack of availability of diagnostic tests , and Long waiting lists for echocardiography Time constraints and No imaging modalities in LTC homes
Facilitators		Younger patients		Rapid access to echocardiography by direct referral to consultants
Ideas for improvement			Education of GPs	Improving access to diagnostic tests and services and Access to portable imaging devices in LTC homes
Communication with patients
Barriers	Uncertainty about diagnosis The gradual drift to diagnosis Anxiety-laden terminology	Patient's lack of understanding of HF	The challenge of balancing prognostic information	Involvement of different parties, disrupting the flow of communication
Facilitators
Ideas for improvement			Education of GPs
Treatment
Barriers	Uncertainty about diagnosis No effective treatment for HFpEF	Difficulties associated with comorbidities and polypharmacy Reluctance in treatment of older patients Immobility	Lack of confidence in managing HF in general practice Unawareness of the role of other agents than ACE-I and β-blockers Unawareness of indications for electrical therapy Still treating HF as an acute illness Use of ACE-I and β-blockers Fear of side effects Fear of initiating drugs outside the hospital Burden of monitoring Unawareness of potential benefits of ACE-I and β-blockers Use of optimal doses of ACE-I Fear of side effects Reluctance to increase dosage if patients were asymptomatic or stable Lack of knowledge of target dose	Time constraints and Cost of treatment , and
Facilitators		Younger patients A connection between patient and physician that transcended the professional relationship	A good understanding of treatment options	Possibility of home visits for frail and immobile patients
Ideas for improvement			Promoting a holistic and chronic care approach Education of GPs
ACP
Barriers	Lack of key moments Unpredictable disease progression	Patient's belief that heart disease can be fixed	Lack of familiarity with the terminal phases of HF Fear of giving bad news too soon Lack of attention to ACP in chronic diseases Lack of knowledge of palliative care and its functional organisation	Unequal access to palliative care compared with cancer
Facilitators			Recognising the importance of timely initiation of ACP	Availability of hospice care for patients with HF End-of-life care pathways for patients with HF
Ideas for improvement			Education of GPs
Interdisciplinary collaboration
Barriers			Fear of being de-skilled because of task delegation Perception that others do not trust GPs’ clinical competence Fear of losing patients to specialists Specialist assistance leads to fragmented care instead of integrated care Lack of clear reports and interdisciplinary communication Negative attitude towards collaboration with nurses	Limited access to specialised care with long waiting lists for referral , and Specific context of care homes Concerns about staffing, continuity of care, and variable quality of nurses Lack of trust in other health professionals’ competences Perception of hierarchical boundaries, compromising communication Lack of role clarity—‘it's somebody else's responsibility’ and Lack of specialist availability in LTC homes
Facilitators			Close relationship with specialists and mutual respect Positive previous experiences with specialist HF nurses Motivation to invest (time) in practice organisation with a positive attitude towards collaboration with nurses Accepting the valuable input of nurses who have more time to spend with patients	Specific context of care homes Stable staffing in LTC homes Close observation and monitoring of LTC residents by nurses and personal support workers Role of GP: to assume greater leadership and responsibility
Ideas for improvement			Active role for community health providers in HF care Promoting a holistic and chronic care approach	Improved access to HF clinics and HF nursing teams and Need for locally drafted guidelines Specific context of care homes Empowerment of LTC staff Need for a greater leadership role among GPs

derived from data of study/studies performed in UK; derived from data of study/studies performed in Australia; derived from data of study/studies performed in Canada; derived from data of study/studies performed in Uzbekistan.
ACE-I, ACE inhibitors; ACP, advance care planning; GP, general practitioner; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LTC, long-term care.