HRV:Clinician's Perspective
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Clinician's Perspective
Significance
It is safe to assume that initial issue identification is of paramount importance in the solution of any problem. The task at hand with this project – the investigation and development of signalling methods for HRV extraction – is an important one to thoroughly study and understand. One can hence argue that obtaining a clinician’s point of view (POV) is an essential primary step in establishing the prerequisite for this project.
Survey
To obtain the clinician’s POV, we surveyed a number of healthcare professionals from a number of medical backgrounds, including but not limited to:
1. Doctors
2. Nurses
3. Healthcare Assistants (HCAs)
Questions asked as part of the survey were intended to gauge current use of HRV and ECGs in clinical settings, as well as the perceived usefulness of HRV as a clinical parameter and additionally, an indicator of health. The survey was also vital in highlighting concerns around current techniques used for HRV calculations, as well as assess means of improvement to allow growth for the use of this parameter in clinical medicine. The survey was circulated via social media, and the time-period for collating responses was 14 days.
The number of clinicians who filled out the survey up until analysis was n=37. Of these, 23 were registered doctors, 10 were nurses, and 4 were other healthcare professionals (HCPs), such as healthcare assistants (HCAs). 28 were directly responsible for recording patient observations, such as blood pressure and heart rate, and 30 carried out ECGs at least once a week.
Clinician Survey Results
General awareness of HRV as a parameter was high amongst these clinicians, with 28/37 knowing what it was. This number dropped significantly when asked if they calculated it regularly and dropped further when asked if they used it in clinical decision-making, with only 7 clinicians saying yes. Clinicians were able to choose multiple options as to why they didn’t use HRV more often.
A visual guide to the questions and results of the clinician survey are illustrated below:
General Practice
We also decided that, to widen participation and improve expediency of this project, it would be wise to survey clinicians outside of hospital settings, namely, those in general practice (GP). As these clinicians are responsible for looking after patients with chronic conditions, HRV could be a useful parameter in their clinical decision-making as it has been shown to be a good reflection of health in conditions such as obstructive coronary disease [1].
To investigate HRV use in GP settings, we contacted local GPs and telecommunicated our questions surrounding current use of this parameter. Some of the results are in available the next section, and our recommendations based off of these consultations are further explored in the discussion.
GP Survey Results
Questions were asked in an interview manner over the phone - the ones relevant to HRV and this project are transcribed below:
Q. Do you routinely carry out ECGs at the GP?
Ans. “We usually refer cardiac patient to specialist facilities, but we do have the capacity to carry out ECGs here and do them occasionally.”
Q. Do you normally calculate Heart Rate Variability from those ECGs?
Ans. “It’s a tricky one – I believe the specialized cardiac centers do in fact look at HRV, but we don’t really do that in general practice. That being said, I do get patients coming in and asking about it specifically after they’ve looked at stats from their smart watches, but unless I am genuinely concerned about the patient’s wellbeing, these things tend to not be the most accurate. ”
Q. Why do you think we don’t use this parameter more often in general practice?
Ans. “Another tricky question. We are obviously here to provide a more wholesome, total approach to healthcare and aren’t cardio specialists, but there hasn’t really been a lot of training around what to do with it, so unless you’ve done extra research as part of your CPD or so on, it can be difficult to navigate. ”
Q. If it was to become routinely available, do you think there is potential for application in GP?
Ans. “Absolutely. From personal interest, I know that HRV is generally a good reflection of cardiac health, and we look after a lot of patients with these chronic conditions. So yeah, I think it would be useful to have that for extra insight into how our patients are really doing.”
Q. How do you think we could improve HRV awareness and use in GP?
Ans. “Just through your bog-standard signposting. Posters, leaflets, informational emails – we skip through a lot of emails everyday, but if it’s something that’s likely to make us better doctors, we’ll definitely look at it. ”
These questions, although not exhaustive, provided us with essential knowledge and information on how we can best translate our project from a theoretical one to a practical one.
Discussion
Running both surveys proved a great aid to our project in issue identification, confirming some of our initial suspicions as well as introducing us to difficulties we weren’t initially aware of.
One of the issues we identified amongst clinicians was lack of awareness of what HRV translated to. Without this knowledge, it can be difficult to effectively use HRV in clinical care, and even more tricky to give patients information on the status of their cardiorespiratory systems.
Surveying the GPs gave us valuable insight into increasing reach and awareness of HRV. Although outside the scope of this project, our signal processing methods would be more useful clinically if education around HRV, as a cardiorespiratory parameter, was improved. Furthermore, it was imperative for them to validate the current direction of this project, consolidating the importance of focusing on simplicity and time-efficiency as the primary aims of our newly proposed methodology.
Lack of availability of HRV without extra calculations was also problematic to our clinicians, who sought convenience in their day-to-day decision-making. As these clinicians are already carrying out ECGs regularly, the introduction of our signalling methods could be done in a way that allows incorporation of HRV into pre-existing devices. Based on these issues, the recommendation is that we introduce our HRV signal processing methods as a software update, or perhaps introducing an easy-to-use device that is compatible with pre-existing ECG and cardiorespiratory measurement devices. Increasing accessibility to this parameter in this way is bound to be effective in increasing its clinical use.
The utility of our signal processing methods in GP settings is of great salience. As previously mentioned, HRV can act as a good risk assessment tool for conditions such as myocardial ischemia in patients with known coronary artery disease [2]. Many of these diseases for which HRV can provide insight are chronic in nature, meaning patients are looked after primarily by their GPs for these health problems. As such, equipping these practitioners with extra information surrounding HRV will not only improve outcome predictability in the short-term, but will further facilitate an advance in patient care long-term. Although these are merely extrapolations based on potential applications of HRV, one cannot deny that the prospective purposes offered by this parameter are very exciting.
Our research suggests that the current leader in the market for HRV analysis software is called “Kubios” [3]. In further dialogue with clinicians, we sought to identify issues with this particular software. This route was not fruitful unfortunately, and clinicians didn’t seem to be aware of the platform.
References
- ↑ D. Kotecha, G. New, M. Flather, D. Eccleston, and H. Krum, “61 Five-min heart rate variability can predict obstructive angiographic coronary disease,” Heart, vol. 97, no. Suppl 1, pp. A38–A39, Jun. 2011, doi: 10.1136/heartjnl-2011-300198.61.
- ↑ A. M. Catai, C. M. Pastre, M. F. de Godoy, E. da Silva, A. C. de M. Takahashi, and L. C. M. Vanderlei, “Heart rate variability: are you using it properly? Standardisation checklist of procedures,” Brazilian J. Phys. Ther., vol. 24, no. 2, pp. 91–102, Mar. 2020, doi: 10.1016/j.bjpt.2019.02.006.
- ↑ www.kubios.com [Accessed 08th March 2021] .
