Bar­ri­ers to care and missed oppor­tu­ni­ties for inter­ven­tion

The bur­den of VHD in Sau­di Ara­bia can be sig­nif­i­cant­ly reduced by address­ing cur­rent gaps in patient care and the bar­ri­ers that lead to these missed oppor­tu­ni­ties for time­ly diag­no­sis, refer­ral that links to treat­ment, and opti­mal dis­ease man­age­ment.

1 out of 3

Peo­ple with aor­tic steno­sis go unde­tect­ed because they nev­er go to a pri­ma­ry care doc­tor to dis­cuss their con­cerns.21

1
Poor pub­lic aware­ness pre­vents indi­vid­u­als with symp­toms from seek­ing a diag­no­sis or pur­su­ing treat­ment
There is a lack of aware­ness among the Sau­di pub­lic regard­ing VHD and its relat­ed symp­toms. This knowl­edge gap, com­bined with mis­con­cep­tions about the effects of aging, often results in the dis­missal of ear­ly warn­ing signs such as fatigue, short­ness of breath, faint­ness, and oth­er symp­toms by both patients and HCPs.49,50

2
Lack of epi­demi­o­log­i­cal data results in under-recog­ni­tion of VHD
There is a lack of nation­al data regard­ing the occur­rence of aor­tic steno­sis and degen­er­a­tive VHD in Sau­di Ara­bia. Even at a glob­al lev­el, epi­demi­o­log­i­cal data is scarce. The con­di­tion suf­fers from inad­e­quate detec­tion and under-report­ing, which leads to a lack of pub­lic recog­ni­tion and insuf­fi­cient pri­or­i­ti­za­tion with­in the health care sys­tem. This issue is par­tic­u­lar­ly evi­dent in poli­cies and prac­tices con­cern­ing indi­vid­u­als aged 60 and above.

3
PCPs lack suf­fi­cient aware­ness, result­ing in a fail­ure to accu­rate­ly diag­nose VHD in a time­ly man­ner
For treat­ment to be effec­tive, it is essen­tial to have an accu­rate and prompt diag­no­sis of VHD.30 Fail­ure to diag­nose VHD can be linked to a lack of aware­ness and knowl­edge gaps among PCPs, which can have fatal con­se­quences for patients. VHD is not com­mon­ly encoun­tered in pri­ma­ry care prac­tices in Sau­di Ara­bia. This rar­i­ty of VHD cas­es may lead to a lack of con­fi­dence among PCPs in accu­rate­ly iden­ti­fy­ing and diag­nos­ing the con­di­tion, espe­cial­ly when a heart mur­mur is present.

4
PCPs often do not per­form car­diac aus­cul­ta­tions
VHD can be detect­ed by lis­ten­ing for a heart mur­mur. Aus­cul­ta­tion is an inex­pen­sive and non-inva­sive tool for detect­ing detect heart mur­murs. How­ev­er, in many coun­tries few­er than one quar­ter of PCPs reg­u­lar­ly car­ry out this sim­ple check in peo­ple over 6051,52 PCPs encounter mul­ti­ple chal­lenges that deter thor­ough exam­i­na­tions in their busy prac­tices. For exam­ple, exam­in­ing the chest may require patients to par­tial­ly dis­robe, which can be uncom­fort­able for women and pose prac­ti­cal dif­fi­cul­ties for over­weight indi­vid­u­als. Inac­cu­rate diag­nos­tic equip­ment fur­ther com­pli­cates accu­rate aus­cul­ta­tions for PCPs in Sau­di Ara­bia.

5
Rou­tine screen­ing for VHD is under­uti­lized in pri­ma­ry care
In Sau­di Ara­bia, heart aus­cul­ta­tion in old­er adults is not rec­om­mend­ed as a rou­tine check.21 Local experts report that most patients with aor­tic steno­sis are iden­ti­fied as severe and symp­to­matic at a late stage, and many peo­ple in remote regions are not being iden­ti­fied at all. Time con­straints with each patient can wors­en the chal­lenges doc­tors face in deliv­er­ing com­pre­hen­sive care, includ­ing rou­tine check-ups.

6
The health sys­tem set-up delays the prac­tice of rou­tine screen­ing in pri­ma­ry care
In Sau­di Ara­bia, PCPs often face chal­lenges in main­tain­ing con­ti­nu­ity of care for their patients. It is com­mon for patients to be assigned to dif­fer­ent PCPs in sub­se­quent ses­sions, which makes it dif­fi­cult to track and man­age their health care needs effec­tive­ly. Fur­ther­more, patients can seek med­ical ser­vices from var­i­ous loca­tions, and some may even bypass pri­ma­ry care entire­ly. Con­se­quent­ly, doc­tors may encounter dif­fi­cul­ties in stay­ing informed about their patient’s symp­toms and sched­ul­ing time­ly check-ups.

7
Clin­i­cal guide­lines on the man­age­ment of VHD and treat­ment path­way options are not avail­able
In Sau­di Ara­bia, there are cur­rent­ly no stan­dard­ized pro­to­cols or guide­lines on VHD treat­ment and man­age­ment for HCPs to fol­low. HCPs rely on inter­na­tion­al guide­lines for treat­ing and man­ag­ing patients with VHD, includ­ing aor­tic steno­sis.

8
Refer­ral path­ways for echocar­dio­grams can be unclear for health care providers
Access to echocar­dio­g­ra­phy is cru­cial for man­ag­ing valvu­lar dis­eases in the com­mu­ni­ty.30 How­ev­er, it is com­mon for patients to expe­ri­ence delays in access­ing these tests, lead­ing to delays in both diag­no­sis and treat­ment.23 This delay is influ­enced by fac­tors such as insuf­fi­cient knowl­edge or clear guide­lines for refer­ring patients for an echocar­dio­gram, even after detect­ing a heart mur­mur.53 Addi­tion­al­ly, even after under­go­ing an echocar­dio­gram, patients may not be pro­vid­ed with rec­om­men­da­tions for reg­u­lar mon­i­tor­ing by a car­di­ol­o­gist.54

9
Echocar­dio­gram eval­u­a­tions are not accu­rate­ly per­formed
To accu­rate­ly per­form an echocar­dio­gram, it is cru­cial to have a skilled and knowl­edge­able tech­ni­cian or spe­cial­ist in imag­ing.55  In Sau­di Ara­bia, the under­re­port­ing of aor­tic steno­sis may, in part, be attrib­uted to the lack of exper­tise among tech­ni­cians in accu­rate­ly con­duct­ing echocar­dio­grams. There­fore, there is a need for addi­tion­al train­ing in this area. Addi­tion­al­ly, there is an oppor­tu­ni­ty to enhance sup­port for tech­ni­cians and physi­cians in eval­u­at­ing, diag­nos­ing, and man­ag­ing aor­tic steno­sis by pro­vid­ing access to remote vir­tu­al health­care ser­vices.

“Valvu­lar heart dis­ease, com­pared to oth­er dis­eases, isn’t well-rec­og­nized among the sci­en­tif­ic and pro­fes­sion­al com­mu­ni­ty. There’s a lack of knowl­edge about the dis­ease preva­lence, its bur­den, and the impor­tance of ear­ly pre­ven­tion strate­gies and treat­ment plans with­in cur­rent prac­tice.”

Dr Hus­sain Al-Omar

Asso­ciate Pro­fes­sor of Phar­ma­coeco­nom­ics and Direc­tor of the Health Tech­nol­o­gy Assess­ment Unit, King Saud Uni­ver­si­ty (KSU)

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