Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study
Authors: Raja Shariff R , Ibrahim KS , Zainal Abidin HA , Md Radzi AB , Muhmad Hamidi MH , Sani H , Kasim S 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD.

Purpose
To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia.

Methods
We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions.

Results
A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long.

Conclusion
The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey item on echocardiography Abstract Figure. Survey item on cardiology referrals