title: Patient-, provider-, and system-level barriers to heart failure care.
abstract: BACKGROUND
  The effectiveness of many heart failure (HF) treatments has been demonstrated, and national guidelines have been widely disseminated, yet HF care remains suboptimal. Numerous studies have examined barriers to HF care, but to date, there has been limited synthesis of these findings.
  
  
  RESULTS
  Sixty articles reporting data on barriers to HF care published between 1998 and 2007 met the criteria for inclusion in this review. Barriers to care were reported at the patient, provider, and system levels. Patient barriers were reported in 45 studies and were categorized in the main themes of knowledge, adherence, communication, functional limitations, comorbidities, psychosocial, and socioeconomic factors. Provider barriers were examined in 23 studies and included knowledge, diagnostic challenges, pharmacological concerns, communication issues, and personal factors. Barriers at the healthcare system level were reported in 13 studies and pertained to problems with organizational structure, communication, and lack of resources. Several barriers were interrelated and could not be exclusively categorized to a single level of care, with overlap also occurring within the main barrier themes.
  
  
  CONCLUSIONS
  Barriers to HF care were common and pervasive throughout the continuum of care. To effectively improve the quality of care and outcomes among HF patients, obstacles to HF care must be addressed at multiple levels.
authors.affiliation: School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Mindy L
authors.initials: ML
authors.lastname: McEntee
authors.forename: Lori R
authors.initials: LR
authors.lastname: Cuomo
authors.forename: Cheryl R
authors.initials: CR
authors.lastname: Dennison
mesh_terms: D000203:Activities of Daily Living; D003142:Communication; D019983:Guideline Adherence; D006297:Health Services Accessibility / Q000458:organization & administration*; D006301:Health Services Needs and Demand / Q000458:organization & administration*; D006333:Heart Failure / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D010349:Patient Compliance; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care / Q000458:organization & administration*; D012959:Socioeconomic Factors; D013597:Systems Analysis