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

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.