Our study was the first to assess adherence to heart failure care performance and quality measures post-discharge in the Gaza strip, Palestine. Adherence with prescribing β blockers was high (85%), followed by MRA and ACEi/ARB. 30% of patients had an outpatient appointment. Only 10% of patients received all measures.
In LMIC, the leading cause of morbidity and mortality is switching from infectious diseases to chronic medical conditions, especially cardiovascular. Multiple studies showed that outcomes are worse in these settings(22-24). Despite that, there is limited research on the quality of care delivered in such settings. Studies like ours that assess the care of chronic medical conditions are essential, especially in LMIC.
We found a gap between the recommendations and what is applied. Several factors are contributing. There is no official national guideline for heart failure care in Palestine. Each center and physician was practicing according to personal knowledge and expertise. Besides, a limited number of qualified practicing cardiologists in the Gaza Strip hinder the quality of care delivered. Third is the challenging economic and political situation in Gaza Strip. Resources are limited, restricting hiring new personnel, updating infrastructure, and providing required medication and treatments, costly ones such as ARNI(25).
β blockers, ACEi/ARB, and MRA significantly improve survival in patients with HFrEF(26-29). In-hospital initiation has been shown to increase the long-term use of these medications (30-33). In our population, there was high adherence to prescribing β blockers. However, several patients were discharged not on ACEi/ARB and MRA. The exact cause was not clear. It might be related to the concern over potassium level or renal function. There is a need for initiatives to understand the concerns of the treating physician and facilitate prescribing these medications to patients on discharge. None of the patients were prescribed hydralazine/nitrate. The population in Gaza Strip is Caucasian which is likely the cause of the low prescription of hydralazine/nitrate.
Adherence to outpatient follow-up appointments was poor. Only 30% of patients had an appointment with a median time of 22 days, longer than the recommended seven-day period. The extent and quality of outpatient care are limited, especially in LMIC(34), which leads to fragmentation of care, poor patient outcomes, and an increased burden on acute care settings. Initiatives to improve outpatient care of chronic disease, particularly cardiovascular disease, are vital to improving care and outcomes.
We faced several obstacles while conducting our research. First, there was no national dataset with heart failure patients. We had to visit each center, create a list of patients admitted for heart failure and choose a random sample. In addition, currently, the health records are handwritten and then scanned to be archived. Data had to be extracted manually from the paper chart. Besides, several charts had poor documentation and handwriting, which made data extraction more difficult. Employees helped try to explain and clarify what was written.
We could not precisely identify patients with HFrEF. Not all patients had an echocardiogram(echo) done during their visit. For whom it was done, the previous records of ejection fraction were not available. As a result, we could not classify patients with an ejection fraction of more than 40% as HF with improved ejection fraction(HFiEF) or HF with preserved ejection fraction(HFpEF). We had the option to include only patients in whom echo was done and showed EF of less than 40%; however, this might introduce bias. Patients who did not have an echo done likely received inferior care. As a result, we decided to include all patients admitted for heart failure.
Our study was the first to assess adherence to inpatient performance and quality measures in Gaza Strip, Palestine. It adds to the body of literature regarding the care of chronic diseases, cardiovascular in particular, in LMIC. In addition, we collected our sample in stratified random sampling, which aids in generalizing the results of our study.
The study was in only one geographical area of Palestine. We aim in the next project to get an estimate from other parts of the country to provide a comprehensive assessment of the quality of care for heart failure patients in Palestine. Our study assessed adherence with the inpatient performance and quality measures. In the next project, we aim to estimate adherence to the outpatient performance measures.