Access to multidisciplinary outpatient heart failure clinics in Qatar: a qualitative study from the perspectives of patients and cardiologists

Abstract

Objective

Heart failure clinics (HFCs) are associated with increased survival rates, lower hospitalisation and improved quality of life. This study investigated factors influencing patient access to multidisciplinary outpatient HFCs from the perspective of patients and cardiologists.

Design

This was a qualitative study. A trained researcher conducted semistructured face-to-face interviews with patients and online interviews with cardiologists. Interviews, conducted between March and October 2023, were audio-recorded. Transcripts were cleaned (deidentification, translation verification) and analysed by two trained researchers independently using systematic text condensation in NVivo v12. Codes were derived from the transcripts and grouped and organised into themes. Two authors independently coded data, reconciling disagreements with the senior author, followed by respondent validation. Member checking ensued.

Setting

Outpatient multidisciplinary HFCs in Qatar.

Participants

A purposive sample of patients diagnosed with heart failure who had attended at least one HFC appointment at Qatar’s Heart Hospital were approached in person or via phone, and cardiologists with the authority to make referrals to these clinics via the electronic medical record system were emailed; interviews ensued until theme saturation was achieved.

Results

26 individuals (14 patients and 12 cardiologists) participated in the interviews. Four major themes were identified: health system organisation (subthemes: benefits, HFC triage criteria, need/capacity), HFC referral processes (subthemes: electronic record system, patient communication and education), care continuity and communication (subthemes: patient navigators, clinician preferences) and access challenges (subthemes: transportation, costs).

Conclusions

Resources are needed to expand HFC capacity and coverage, leverage electronic medical record tools as well as telehealth, educate physicians and patients on referral guidelines and processes and engage primary care to ultimately improve patient outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A comprehensive, in-depth investigation of the barriers and facilitators to clinic access, integrating perspectives from both patients and cardiologists, strengthened the validity and contextual depth of the findings. Data collection was standardised through a structured interview guide, and interviewers were trained to minimise bias.

• Two authors independently coded data, reconciling disagreements with the senior author, followed by respondent validation.

• The selection of participants may have introduced bias; with purposive sampling, transferability of results to other jurisdictions or healthcare systems cannot be known.

• Participants’ responses might have been affected by social desirability or recall bias.

Introduction

Heart failure (HF) is a chronic, complex, incurable disease. HF affects 64.3 million individuals globally.¹ It results in significant mortality, morbidity and healthcare costs.² As with the significant increase in cardiovascular disease incidence in the Eastern Mediterranean Region (EMR), HF is of particular concern in the region.³ Patients are often diagnosed younger than those in Western nations, and they more frequently have risk factors such as hypertension, obesity and sedentary lifestyle as well as comorbidities such as diabetes and renal disease, complicating the course and worsening prognosis.³ Further, poor dietary habits and medication non-adherence are prevalent among HF patients in the EMR,^{4 5} which can lead to more frequent HF-related readmissions.⁶

 HF clinics (HFCs) provide specialised outpatient care and management to mitigate this burden. These clinics comprise a multidisciplinary team of healthcare professionals providing assessment, patient education, medication titration and optimisation as well as monitoring.^{7 8} Reviews have shown that HFCs are associated with increased HF survival rates, lower hospitalisation and improved quality of life.^{9 10} Therefore, clinical guidelines recommend high-risk patients are referred to HFCs.¹¹

Despite their demonstrated benefits, only approximately one out of 10 indicated patients access an HFC.¹² This underutilisation is due to factors related to the healthcare system—including issues around capacity, physician referral and clinic organisation—as well as patient barriers,¹³ which affect healthcare professional referral and patient access to the HFCs.¹⁴

There is a lack of studies on outpatient HF care in the EMR and access to HFCs in the region.¹⁵ Therefore, the objectives of this study were to investigate the factors impeding optimal outpatient HF care and patient management with particular focus on access to HFCs in Qatar from multiple stakeholders’ perspectives, namely cardiologists referring HF patients and outpatients with HF.

Methods

Design

A qualitative study was conducted in Qatar. Semistructured interviews were conducted to glean in-depth information from a purposive, diverse sample of HF patients and cardiologists. The study was reported according to the ¹⁶Consolidated criteria for Reporting Qualitative research (online supplemental file 1), as well as best practices to guarantee the rigour of the methods.¹⁷

Setting and participants

The study was undertaken in Qatar, where healthcare is primarily funded publicly. HMC (Hamad Medical Corporation) is the largest healthcare provider, comprising 12 hospitals, inclusive of the main Heart Hospital for the country, where HF care is centralised.

The Heart Hospital is the only national referral centre for outpatient HF management. Access to HFCs is restricted to patients referred by an HMC-based cardiologist. Primary healthcare does not have any direct referral mechanism. Referrals to HFC by the HMC-based cardiologists follow HMC-specific inclusion guidelines (ie, patients with advanced HF, poor response to therapy, need for advanced diagnostics or worsening symptoms). These referrals are evaluated by Heart Hospital’s cardiologists (ie, eight consultants and specialists review and make triage decisions). HMC support staff notify accepted patients about their appointments by text and phone call.

HMC cardiologists with the authority to make referrals to HFCs were recruited for interviews. Cardiologist participants were identified from those with referral privileges to the HFCs via the HMC electronic medical record system. All eligible cardiologists were invited via email.

Qatar has two HFCs at HMC’s Heart Hospital. They provide identical services and follow the same clinical guidelines. The clinics serve 1700 unique patients annually.¹⁸ The clinics have substantial waiting lists; over 6 months for external referrals and 2 weeks for postdischarge patients. The clinics are staffed by multidisciplinary teams of cardiologists, nurses, pharmacists and other healthcare professionals, offering diagnostic services, patient education, pharmaceutical counselling, lifestyle advice and short-stay programmes. Delivery modalities include telemonitoring and teleconsultations.

Patient participant inclusion criteria were age ≥18 years, English or Arabic language proficiency and attendance at ≥1 HFC appointment (note, almost all accepted patients attend). Exclusion criteria were cognitive impairment or if patients were unwilling to have their interview recorded.

Patients were identified using HFC clinic data at HMCs. They were selected from the active appointment schedules of HMC’s HFCs. They were approached in person or via phone by the research team. Most recent patients were purposively selected to ensure a comprehensive representation of diverse perspectives and a thorough examination of factors affecting HFC access and referral within the country’s cultural and healthcare setting. Participants were interviewed until theme saturation was achieved.

Interview guide

To capture the diverse array of perspectives by stakeholder type, a separate semistructured interview guide was designed for each (online supplemental file 2). The interview guides were developed based on our reviews of literature as well as Andersen’s Behavioural Model for healthcare utilisation.¹⁹ The interview guides were adapted from previous work in this area undertaken in North America.¹⁴ Open-ended questions were posed to delve into participant perceptions of outpatient HF care access and the HFC referral process. The questions were pilot tested for clarity, cultural sensitivity and relevance to the healthcare system with two physicians and two patients independently in Qatar. Based on their feedback, necessary amendments were made.

Qualitative procedure

Potential participants were emailed an informed consent form to review and sign before the interview, and/or they could discuss the contents at the outset, as long as they signed before it began.

Face-to-face patient interviews were conducted in a private location near the HFCs. They were online for cardiologists, with cameras on, via MS Teams. Prior to the interview, cardiologists were asked to be in a private and quiet room. All interviews were attended solely by the researcher-interviewer (AH) and the participant. Patients’ and cardiologists’ anonymity and confidentiality were ensured throughout the research. For patients, interviews were offered in Arabic or English to allow full expression. The interviewer was fluent in both languages.

Interviews were conducted between March and October 2023 by AH and were supervised closely by KT-A, who were both unknown to interviewees. AH had completed doctoral-level coursework on qualitative research, had prior experience in qualitative studies and was trained by three senior scientists on the research team. Interviews lasted 30–40 min, with detailed notes recorded, capturing contextual details and non-verbal cues. No participant dropped out, and each was interviewed only once.

Audio recordings of the interviews were meticulously transcribed verbatim, capturing nuances of participants’ responses and pauses. For Arabic interviews, the recordings were transcribed in Arabic and then translated into English for analysis by AH.

Data analysis

Each interview transcript was cleaned to ensure accuracy and anonymity. The transcripts formed the foundation for a thorough thematic analysis, allowing the research team to identify recurring themes and patterns across stakeholder responses, using systematic text condensation.²⁰

The analysis of the collected data was done by two well-trained researchers independently to reduce bias (AH and SA). The process was carried out using NVivo V.12 (QSR International, Burlington, Massachusetts), a qualitative analysis software that facilitated systematic and in-depth exploration of the data. Researchers immersed themselves in the transcripts to gain a holistic understanding of the participants’ narratives and experiences before data analysis.

The two researchers independently analysed the transcripts line by line, assigning preliminary codes to segments of text that encapsulated key concepts, opinions and emotions expressed by the participants. Then, the preliminary codes were grouped and organised into potential themes that emerged from the data. These themes were overarching concepts that captured various dimensions of the participants’ perspectives.

The two researchers engaged in thorough discussions to compare the individual coding and theme generation. Disagreements or variations in coding and theme interpretation were reconciled by the senior author. To ensure credibility, themes with subthemes were shared with all interviewees to inquire whether they resonated (ie, member checking) and request any input to ensure trustworthiness. Finally, analysis was validated within the research team. The entire data analysis process, including coding, theme generation and reconciliation, was documented in detail for transparency and reliability.

Patient and public involvement

An eight-member expert panel was convened to develop the initial North American studies, comprised of a representative of an HF patient organisation, an HF administrator, HF physician subspecialists, an HFC provider, members of leading HF committees, among others. Panellists supported the development of the research questions and methods.

Results

Interviewee characteristics

Of the 22 patients approached, eight declined due to illness, lack of interest or logistical obligations. 14 patients were interviewed; their characteristics are shown in table 1. Five were female, they ranged in age from 33 to 68, and one participant was unmarried. Occupations ranged from unpaid domestic labour to retail and professions (eg, teacher, engineer, accountant), with two participants retired. Many of the participants had percutaneous coronary intervention or arrhythmia treatment. Common comorbidities included diabetes.

Table 1. Aggregated characteristics of patient participants (n=14).

Characteristic	Category	N (%)
Sex	Male	9 (64%)
	Female	5 (36%)
Duration with HF	<1 year	6 (43%)
	1–5 years	3 (21%)
	>5 years	5 (36%)

Of all the cardiologists who responded to the invitation email, six declined to participate due to busy schedules. With regard to the 12 cardiologists interviewed, one participant was female, all were married, and their ages ranged from 33 to 57 years. Nationalities were all non-Qatari and included India (n=4) and Syria (n=3), among others (eg, Egypt, Iraq, Oman, Turkey and Pakistan). Participants had from 3 to 24 years of cardiology experience.

Thematic coding

Analysis revealed four major themes, with associated subthemes (figure 1). Illustrative quotes are shown in the online supplemental file 1.

Figure 1. Thematic analysis of patient and physician perspectives on outpatient heart failure care in Qatar. HFC, heart failure clinic.

The first theme pertained to health system organisation and comprised four subthemes. First, the benefits of centralised HFCs were emphasised by cardiologists; the HFCs were perceived to offer essential resources and support, which enhanced patient treatment and outcomes. The second subtheme highlighted the need to ensure that healthcare professionals providing care to HF patients are fully aware of the policies and criteria regarding which patients should be referred to HFCs. Additionally, respondents noted it is not enough for referrers to know about the criteria; they must also be able to effectively implement them in their daily practice. The need for other HFCs was the third subtheme, underscoring the need to expand HFC services to primary care, the private sector and other HMC facilities to minimise travel and enhance access. Finally, HFC capacity issues underlined the need to increase existing clinic space, staffing and other resources to avert the long waiting lists and enable thorough care.

Both patients and cardiologists stressed the benefit of centralised HFCs and the necessity for expanding clinic capacity, underscoring that infrastructure is important. While cardiologists focused on system limits, patients focused on long waiting times and insufficient capacity as immediate impediments to service.

The second theme pertained to the HFC referral process, encompassing four subthemes (online supplemental file 1). First, facilitators and barriers related to the electronic referral system were raised; effectiveness was noted as well as obstacles, such as delays and misunderstandings related to its use. Delays were perceived to be caused by a lack of referrer training and familiarity with the system as well as workflow bottlenecks. Inefficiencies in the workflow, such as too many steps and the requirement of multiple approvals, were perceived to slow down the referral process. Communication was also raised here; delays in receiving necessary information from other healthcare providers or departments such as laboratory results were perceived to delay the referral process. Second, challenges engaging and educating patients about HFCs were raised, emphasising the need to increase patient participation in, and education about, the referral process. Third, interviewees highlighted the need for a standardised process to communicate HFC referral and acceptance to patients, which could better support their engagement in care. The final subtheme pertained to the stepwise referral policy of the institution. Patients lacked awareness regarding the necessity of a cardiologist appointment, also raising logistical issues for patients residing in distant locations.

Cardiologists were mostly concerned about operational inefficiencies in the computerised referral system, such as workflow bottlenecks and insufficient training on institutional norms. Patients, on the other hand, stressed uncertainty or unfamiliarity with the referral process, claiming a lack of explanation or follow-up. Both groups, however, agreed on the need to improve communication: cardiologists through improved interdepartmental cooperation and patients through more open, language-accessible information concerning referral status and clinic procedures.

The third theme pertaining to continuity of care and communication comprised four subthemes (online supplemental file 1). First, respondents expressed a need for patient navigators to facilitate smooth transitions and continuity of care. Second, respondents stressed the need to educate patients about using the electronic appointment systems for effective scheduling and engagement in their treatment. The third subtheme emphasised the need for comprehensive HF self-management education and shared decision-making regarding treatment. The final subtheme concerned patients’ desire for fewer clinicians to promote better care coordination.

Both stakeholder groups stressed the significance of smooth transitions and continuity of care. Cardiologists advocated for the use of patient navigators and improved digital scheduling tools to simplify care. Patients, on the other hand, expressed a strong need for continuity in their relationships with providers, preferring to see the same doctors to avoid repeating their medical history and to build trust.

Finally, the last theme pertained to access challenges, comprising two subthemes (online supplemental file 1). First, the transportation barriers subtheme highlighted how such constraints, including availability, cost and distance to clinics, affect patients’ capacity to attend HFC appointments. Second, the costs of HF treatment and management subtheme emphasised the financial constraints associated with HF medications or out-of-pocket expenses for diagnostics and clinic consultations, and relatedly the importance of offering financial assistance or ensuring comprehensive health insurance to promote equal access to care.

Indirect expenditure and transportation issues were mentioned by participants in both groups as the main barriers to using HFC services. Cardiologists agreed that physical distance and financial barriers might delay or prevent follow-up care. Patients shared detailed experiences of travel constraints and logistical challenges, particularly for those residing outside of downtown Doha.

Discussion

The major themes, which coalesced across the multiple stakeholders interviewed, were health system organisation, the HFC referral process, continuity of care and communication, as well as access challenges.

This dearth of HFC is concerning, given the burden of HF in the region and the proven benefits of these services.^{9 10} As of 2019, the age-standardised prevalence of HF in the EMR was approximately 706.43 per 100 000 people, reflecting an increase of approximately 8% since 1990.²¹ This increase is contrary to the global trends of decreasing HF burden.^{22 23} While national prevalence varies within the EMR, it is known that Kuwait has the highest burden, and increases have been greatest in Oman.³ The two countries did indeed have HFC, although certainly with insufficient capacity and geographic distribution to meet need.

In the context of Qatar’s unique healthcare environment and its location within the larger EMR, the findings herein are consistent with and build on insights obtained from research undertaken in other healthcare contexts.¹⁴ For instance, findings revealed major barriers to receiving outpatient HF care owing to the limited number and distribution of HFCs in the country. Patients living in remote areas in particular encountered geographic limitations, resulting in inequities in access to care, as reported in previous studies.24,26

Findings regarding issues with the HFC referral process are also consistent with prior research in the field.^{13 27} Patients are reliant on cardiologists’ action to inform them about HFCs and refer them. Patient dissatisfaction with communication as well as communication obstacles between physicians was reported as challenges. Furthermore, patients’ lack of knowledge and understanding of the referral process (ie, the need to visit a cardiologist) led to delays and gaps in treatment.²⁸ Previous research has also demonstrated the difficulties physicians have in tracking the status of referrals and coordinating treatment.^{29 30}

Moreover, the physician’s lack of HF medication prescription privileges was suggested to negatively impact patient care. In Qatar, regulations are in place to govern which physicians are authorised to prescribe HF medication to ensure patient safety, and HMC policies restrict prescribing rights to maintain high standards of care and ensure treatment appropriateness.³¹ It is known, however, that most HF patients are not taking all classes of recommended HF medications, nor at the recommended doses.³²

The findings also highlight the potential value of clinical coordinators to enable smooth transitions between medical visits and achieve treatment continuity for HF patients. Indeed, previous research has shown that care coordination approaches, including leveraging clinical coordinators or trained HF nurses, improve HF adherence to treatment, ultimately improving outcomes, such as fewer hospitalisations and higher quality of life.³³

This study extends the existing literature regarding challenges in delivering optimal, patient-centred outpatient HF services. Findings revealed that resource constraints, such as a shortage of specialised staff and restricted clinic space, are substantial challenges to providing HF treatment in the community, which is consistent with prior studies.^{25 34 35} Furthermore, our findings are consistent with previous research showing the effect of parking and other transportation-related issues on access to healthcare services.^{36 37} Patients in the study also indicated a lack of awareness of available services at HFCs, such as the short-stay area, which is consistent with previous studies on patient understanding of healthcare options.^{38 39}

Implications

The study findings raise practical strategies to improve outpatient HF care in Qatar. At a system level, findings highlight the broad and urgent need to tackle limitations in outpatient HF care capacity and delivery. Health insurance coverage should be augmented to reduce out-of-pocket HF care expenses for patients. While Qatar’s healthcare system is mostly subsidised by the government, certain treatments, such as diagnostic tests and prescriptions, may require out-of-pocket payments, particularly for expatriate patients who lack comprehensive insurance coverage. HF patients of low-income and non-Qatari nationalities may be disproportionately affected by these financial constraints, as highlighted through study results.

The findings also highlight important structural barriers within the current system, particularly the restrictive prescribing policies that prevent even cardiologists outside specialised HFCs from initiating or adjusting life-saving HF therapies. This creates a paradox in which essential treatment is only accessible through referral to HFCs, yet access to these clinics is limited by long wait times and administrative triage. Such dynamics risk reinforcing inequities, particularly if more privileged patients are able to navigate or bypass these constraints more effectively. These findings suggest a need to re-examine prescribing authority and referral pathways to ensure timely, equitable access to evidence-based HF care across the system.

There is a need to increase the capacity of HFCs based on modelling of the prevalence of HF. This should include a better understanding of the number of patients that can optimally serve in HF clinics. Other approaches to expand capacity include mobile health units and community-based healthcare initiatives and augmenting existing clinic telemedicine capacity, which would have the ancillary benefit of mitigating geographic obstacles for patients living outside the main centre. Furthermore, policy makers should allocate funds to improve hospital parking and surrounding transportation infrastructure.

While these findings underscore the benefits of HFCs in improving access, continuity and patient outcomes, it is important to acknowledge that such clinics function within, and are shaped by, the broader health system context. In Qatar, the health system has historically emphasised hospital-based specialty care, with primary care playing a more limited role in chronic disease management. Strengthening the primary care sector (including enhancing its capacity to manage HF) may offer a complementary or alternative approach, particularly in light of international models where primary care physicians are central to HF treatment.⁴⁰ These results per se should not be interpreted as advocating for expanded specialisation alone, but rather as highlighting opportunities to optimise HF care across the continuum, including through better integration with and investment in primary care services.

At the institutional level, better leveraging of established referral and appointment scheduling protocols through electronic health record system tracking, as well as use of patient navigators or care coordinators, could enable more patients to receive timely HFC care. Moreover, cardiologists themselves raised that education of HMC clinicians regarding the institutional HFC policies is needed, and this could include education about heart association clinical guidelines on which patients warrant referral.⁴¹ Cardiologists did report confidence in their ability to manage stable HF patients, such that institutional policies regarding HF medication prescription privileges should perhaps be revisited and revised.

By adopting these overarching recommendations, Qatar can strengthen its HF care ecosystem, ensuring patients receive comprehensive, coordinated and equitable care, ultimately leading to improved quality of life and outcomes for patients with HF.

A visual overview of the inter-related barriers and associated possibilities for organisational change raised is shown in figure 2.

Figure 2. Barriers and suggested interventions to heart failure clinics in Qatar. HFC, heart failure clinic; PHC, primary healthcare.

Limitations

Caution is warranted in interpreting these results. While purposive sampling was used and saturation was achieved, results transferability to other jurisdictions or healthcare systems cannot be known. Participants’ responses might have been affected by social desirability or recall failure. Moreover, language and translation challenges may have influenced data analysis, as subtleties may have been lost or changed through the process. Finally, the nature of the study design precludes causal conclusions. Future research is needed exploring the perspectives of indicated patients in the region who did not access HFCs.

Conclusions

The main themes identified related to health system organisation, HFC referral processes, care continuity and communication, as well as access challenges. Qatar can improve HF care through infrastructure development to augment capacity, strengthen care coverage, leverage telemedicine, as well as educate physicians on referral guidelines and patients regarding outpatient self-management and care, to ultimately enhance health outcomes and quality of life for those living with HF.

Data availability statement

Data are available upon reasonable request.