Clinical Decision-Making for Heart Failure in Kosovo: A Conjoint Analysis

Abstract

Background: Heart failure represents a life-threatening progressive condition. Early diagnosis and adherence to clinical guidelines are associated with improved outcomes for patients with heart failure. However, adherence to clinical guidelines remains limited in Kosovo. Objective: To assess the clinical decision-making related to heart failure diagnosis by evaluating clinicians’ preferences for clinical attributes. Method: Conjoint analysis with 33 clinical scenarios with physicians employed in public hospitals in Kosovo. Setting: Two public hospitals in Kosovo that benefited from quality improvement intervention. Participants: 14 physicians (internists and cardiologists) in two hospitals in Kosovo. Outcome measures: The primary outcome was the overall effect of clinical attributes on the decision for heart failure diagnosis. Results: When considering clinical signs, the likelihood of a heart failure diagnosis increased for ages between 60 to 69 years old (RRR, 1.88; CI 95%, 1.05–3.34) and a stable heart rate (RRR, 1.93; CI 95%, 1.05–3.55) and decreased for the presence of edema (RRR, 0.23; CI 95%, 0.15–0.36), orthopnea (RRR, 0.31; CI 95%, 0.20–0.48), and unusual fatigue (RRR, 0.61; CI 95%, 0.39–0.94). When considering clinical examination findings, the likelihood for heart failure diagnosis decreased for high jugular venous pressure (RRR, 0.49; CI 95%, 0.32–0.76), pleural effusion (RRR, 0.35; CI 95%, 0.23–0.54), hearing third heart sound, (RRR, 0.50; CI 95%, 0.33–0.77), heart murmur (RRR, 0.57; CI 95%, 0.37–0.88), troponin levels (RRR, 0.59; CI 95%, 0.38–0.91), and NTproBNP levels (RRR, 0.36; CI 95%, 0.24–0.56). Conclusions: We often found odd and wide variations of clinical signs and examination results influencing the decision to diagnose a person with heart failure. It will be important to explore and understand these results better. The study findings are important for existing quality improvement support efforts and contribute to the standardization of clinical decision-making in the public hospitals in the country. This experience and this study can provide valuable impetus for further examination of these efforts and informing policy and development efforts in the standardization of care in the country.

Management of Non-Communicable Diseases in Kosovo: A Scoping Review

“…Supply issues hamper the provision of care related to NCDs [ 23 , 48 ]. The availability of clinical guidelines has been supported primarily by external assistance and has resulted in positive effects [ 31 , 59 , 84 ], but overall, it remains limited [ 59 , 76 , 84 ].…”

“…[ 23 ] Self-referral to secondary or tertiary clinics persists [ 23 ]. The application of protocols also seems to be limited according to existing evidence [ 33 , 48 ], but there are several important efforts to bring them to practice [ 48 , 74 , 84 ].…”

“…It confirms many publicly known facts about the management of NCDs that are valid for most of the healthcare provided in the country. For example, studies have reported that the system is underfunded, [ 4 , 11 , 87 ] care availability is limited in quality and quantity, [ 4 , 83 ] issues exist relating to availability and impact of the application of clinical standards [ 4 , 15 , 84 ], and there are issues with supply with the workforce [ 11 , 88 ]. This review highlights the issues with a defragmented system of provision of NCD care, as well as efforts in the function of improvement of the existing situation.…”

“…This review notes the increasing amount of publication in relation to NCD care, as well as a trend in the use of advanced research designs to examine NCD care in Kosovo. Use of conjoint design in understanding clinical decision making with regard to NCDs care [ 84 ] or qualitative designs to understand the effects of NCDs-related counseling services on users of care are among notable examples. [ 81 ] These efforts should continue, be institutionally supported, and grow together with the data availability of NCDs care.…”