title: A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future?
abstract: BACKGROUND
  In North America and other industrialized countries, heart failure (HF) has become a national public health priority. Studies indicate there is significant heterogeneity in approaches to treat and manage HF and suggest targeted changes in health care delivery are needed to reduce unnecessary health care utilization and to optimize patient outcomes. Most recent published studies have reported on the care of HF patients in tertiary care hospitals and the perspective of non-specialist stakeholders on HF management, such as general practitioners and clinics or hospital administrators is rarely considered. This study explores the current state of community-based HF care in Canada as experienced by various healthcare stakeholders providing or coordinating care to HF patients.
  
  
  METHODS
  This study employed a qualitative exploratory research design consisting of semi-structured telephone interviews conducted with health care providers and health care administrators working outside of tertiary care in the four most populous Canadian provinces. A modified thematic analysis process was used and the different data sources were triangulated. Findings were collectively interpreted by the authors.
  
  
  RESULTS
  Twenty-eight participants were recruited in the study: eight cardiologists, five general practitioners/family physicians, eight nurse practitioners/registered nurses, four hospital pharmacists and three health care administrators/directors. Participants reported a lack of stakeholder engagement throughout the continuum of care, which hinders the implementation of a coordinated approach to quality HF care. Four substantive themes emerged that indicated challenges and gaps in the optimal treatment and management of HF in community settings: 1) challenges in the risk assessment and early diagnosis of HF, 2) challenges in ensuring efficient and consistent transition from acute care setting to the community, 3) challenges of primary care providers to optimally treat and manage HF patients, and 4) challenges in promoting a holistic approach in HF management.
  
  
  CONCLUSIONS
  As health systems evolve from tertiary-based care to community-based outpatient services for the management of chronic diseases, this study's findings pinpoint challenges that have been observed in the Canadian context and can stimulate and orient dialogue toward solutions for a more coordinated approach to improve the care of HF patients and reduce pressure on the healthcare system.
authors.affiliation: AXDEV Group Inc., Brossard, QC, Canada. hayess@axdevgroup.com.
authors.forename: Sean M
authors.initials: SM
authors.lastname: Hayes
authors.affiliation: AXDEV Group Inc., Brossard, QC, Canada. peloquins@axdevgroup.com.
authors.forename: Sophie
authors.initials: S
authors.lastname: Peloquin
authors.affiliation: Department of Cardiac Sciences and Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada. howlettjonathan@gmail.com.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Howlett
authors.affiliation: Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada. harkness@HHSC.CA.
authors.forename: Karen
authors.initials: K
authors.lastname: Harkness
authors.affiliation: McGill University Health Centre, Montreal, QC, Canada. nadia.giannetti@mcgill.ca.
authors.forename: Nadia
authors.initials: N
authors.lastname: Giannetti
authors.affiliation: Servier Canada, Laval, QC, Canada. carol.rancourt@servier.com.
authors.forename: Carol
authors.initials: C
authors.lastname: Rancourt
authors.affiliation: Servier Canada, Laval, QC, Canada. nancy.ricard@servier.com.
authors.forename: Nancy
authors.initials: N
authors.lastname: Ricard
mesh_terms: D000553:Ambulatory Care; D002170:Canada; D002908:Chronic Disease / Q000628:therapy; D019058:Community Networks; D019468:Disease Management; D005260:Female; D006282:Health Personnel; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010595:Pharmacists; D010821:Physicians, Family; D036301:Qualitative Research