A mixed-methods landscape assessment of supportive care for heart failure

Abstract

Aim: Understanding factors that shape leading health systems’ (LHS) perspectives around heart failure (HF) treatment. Patients & methods: First of its kind study using a cross-sectional, descriptive, mixed-method design (from executives and frontline healthcare providers) with quantitative survey (n = 35) and qualitative interview (n = 12) data from 47 participants (41 different LHS). Results: 97% of LHS had dedicated HF programs, but variations in maturity highlights opportunities for care standardization. Treatment innovations continue, though practitioners may struggle to keep pace amid provider/patient barriers. HF programs strive to co-locate supportive care services to optimize treatment, but access can prove challenging. Conclusion: Opportunities exist, with external partner support, for LHS to become more comprehensive HF care providers, increasing standardization of care across LHS and improved HF treatment.

Plain language summary

What is this summary about?

We interviewed frontline healthcare workers (such as doctors and nurses) as well as executives at large US health systems to understand how they treat people with heart failure.

What were the results?

We learned that healthcare workers as well as executives would like to provide many different services to help people with heart failure. However, many health systems do not have all of these services available and can only provide a few basic services. We also learned healthcare workers sometimes struggle to keep up to date with new scientific discoveries and heart failure treatments.

What do the results mean?

With support from external healthcare partners, health systems can improve their ability to treat people with heart failure.

Tweetable abstract

A survey of frontline healthcare workers and executives from large health systems showed there are opportunities to improve heart failure treatment and become more comprehensive providers.

Keywords: :

• healthcare perspective
• heart failure
• integrated delivery system
• mixed methods
• supportive care

Heart failure (HF) is a rapidly growing public health concern, expected to affect over 8 million Americans by 2030 [1]. Advanced HF is characterized by symptoms that are refractory to optimized therapy and often requires advanced treatments including mechanical circulatory support, cardiac transplantation or palliative inotrope infusions [2]. A recent retrospective cohort study found that 6 years after a new diagnosis the cumulative incidence of advanced HF is 11.5% [2].

Caring for patients with HF requires a comprehensive program that, based on Heart Failure Society of America recommendations, includes chronic disease management, serial functional and quality of life assessment, optimized guideline-based medical and device therapy, nutritional assessment, lifestyle education, advanced care planning and caregiver education [3]. However, mortality due to HF remains high, particularly among those with advanced disease [1]. As the US population ages, leading health systems (LHS) will need to prioritize investments in clinical innovation and treatment paradigms to improve HF outcomes. Thus, it is critical to understand the forces shaping LHS perspectives around the treatment of HF. The objective of this research study was to understand the current and future state of HF, including supportive care (e.g., nutritional counseling, physical therapy) and symptom management (e.g., behavioral/psychological counseling, selective serotonin inhibitors, loop diuretics), at LHS in the USA.

Patients & methods

We utilized a cross-sectional, descriptive, mixed-method design including quantitative survey data and qualitative interview data. The Health Management Academy is a community of >1600 executive and C-suite leaders from over 150 of the largest LHS (over $2B in total operating revenue) in the USA as of July 2021 [4]. In 2022, The Health Management Academy distributed (via email) a survey and interview request to members at over 50 LHS. Individuals were targeted because of their expertise and engagement with their system’s HF strategy/program. A mix of executives and frontline healthcare providers (HCPs) was identified to represent both system and frontline experiences relevant to HF. Follow-up emails were sent to encourage participation. No compensation was provided to participants. All information and responses collected were blinded and aggregated.

Online surveys consisted of 27 questions related to four domains and took approximately 20 min to complete (Supplementary Figure 1). Domains included I) participant demographics, II) strategic decision-making for advanced HF, III) clinical treatment options for advanced HF, and IV) supportive care services and symptom management for advanced HF. Supportive care and symptom management included cardiac rehabilitation; patient education on early signs, risk factors, and treatment options; nutrition and wellness counseling; physical therapy; patient support groups; pharmacy; palliative care and social work referrals. The survey utilized a mix of different response formats for questions including multiple choice, 5-point Likert scales, task-based, and open-ended responses. Responses were summarized descriptively for the total survey population and are presented in the results section of this manuscript.

Interviews were conducted virtually and took approximately 30–60 min to complete (Supplementary Figure 2). Interviews consisted of eight core questions (asked of all participants) related to management of HF and questions specific to either executives or HCPs (3 questions each). Interview responses were aggregated, and findings were summarized using a rapid qualitative analysis approach that incorporated inductive and deductive approaches to report key themes identified in a timely manner with methodological rigor [5,6]. Quotes were blinded and provided in the final report as spoken by participants. Findings from the interviews are not presented in the results section of this manuscript because they were not quantitative in nature, but they are used in the discussion of the manuscript to support and expand upon insights derived from the survey data.

This research was considered exempt from institutional research board review according to the US Department of Health and Human Services, Office for Human Research Protections, Title 45 of the Code of Federal Regulations §46.104, (d)(2) because it involved survey procedures, and the information obtained could not be linked to the participants or place them at risk [7]. All responses were anonymous, and no protected health information or personal identifying information was collected. Quantitative data were collected using a secure online survey platform. Quantitative data and interview transcripts were stored on a secure server at The Health Management Academy.

Results

Sample demographics

The research sample consisted of executives and frontline HCPs from LHS. Of 41 screened participants, quantitative survey data were obtained from 35 (19 executives and 16 HCPs), resulting in an 85% response rate. Qualitative interview data were obtained from 12 additional participants (6 executives and 6 HCPs), resulting in 47 total participants. Participants’ roles included head of cardiology service line/department (n = 20), physician specialist (e.g., cardiologist, primary care physician; n = 15), chief medical officer (n = 4), advanced practice provider (e.g., nurse practitioner, physician assistant; n = 4), nurse (n = 3) and chief nursing officer (n = 1).

These 47 participants represented 41 different LHS. LHS regions included the Northeast (29%), Midwest (20%), Southeast (15%), Pacific Coast (12%), Northwest (10%), Southwest (7%), Rocky Mountains (5%) and Mid-Atlantic (2%). 15% of LHS had net patient revenue of $0.5–1 billion, 29% had revenue from $1–3 billion, 27% had revenue from $3–5 billion and 29% had revenue exceeding $5 billion. Overall, 56% of the represented LHS had Academic Medical Center (AMC) status, and 44% had non-AMC status. Nearly all survey participants (97%) indicated their LHS has a dedicated HF program or strategy.

When survey participants were asked to identify the top priorities they consider when diagnosing and managing advanced HF (Figure 1), the most common responses (>65% of participants) were ’improve clinical outcomes for HF treatment’, ’reduce readmission rates for HF patients’, ’improve care standardization for HF patients’, and ’improve outcomes related to symptom reduction and management’. Other priorities (>50% of survey participants) included ’improve care coordination for HF patients’, ’integrate data and analytics for tracking HF patients in the electronic health record’ and ’improve patient-reported outcomes such as patient quality of life or reduction in caregiver burden’.

Figure 1. Top priorities considered to diagnose, treat and manage advanced heart failure.

Based on responses of 35 survey participants. Percentages do not add up to 100% because respondents could choose multiple responses. ’Other’ (open-ended) included directing patients to heart transplant or left ventricular assist device.

EHR: Electronic health record.

Strategic decision-making

Most survey participants (89%) indicated their LHS tailors treatment protocols on the basis of HF type, few (9%) indicated that treatment is not altered, and the remaining (3%) were unsure. ’Comorbidity burden’, ’low efficacy of current treatments’ and ’limited patient and/or caregiver awareness and education on HF’ were selected as significant barriers to the management of patients with HF with preserved ejection fraction (HFpEF) by a majority of survey participants (Figure 2A). ’Comorbidity burden’, ’complexity of the self-care process for HF’, ’symptom burden’ and ’cost/coverage for care management and treatment options’ were indicated by a majority of participants as significant barriers to the management of patients with HF with reduced ejection fraction (HFrEF; Figure 2B).

Figure 2. Perceived barriers to the management of patients with (A) HFpEF or (B) HFrEF.

Based on responses of 35 survey participants.

HFpEF: Heart failure with preserved ejection fraction; HFrEF: Heart failure with reduced ejection fraction.

Clinical treatment options

A majority of the 16 HCP survey participants selected beta blockers (88%), angiotensin-converting enzyme inhibitors (75%), mineralocorticoid receptor antagonists (75%), angiotensin receptor blockers (69%) and diuretics (56%) as effective treatments to improve clinical outcomes for advanced HF. ’Other’ treatments such as angiotensin receptor/neprilysin inhibitors, sodium-glucose cotransporter-2 inhibitors, vasodilators and ivabradine were selected by 44% of HCPs (data not shown for executives because the question was related directly to clinical treatment guidelines and was not applicable to their role). Survey participants provided a range of responses to the open-ended question “What metrics are most important when tracking treatment and care delivery outcomes for advanced HF patients?“. In addition to mortality, 30-day readmissions rates, and patient quality of life, survey participants indicated they track metrics such as body weight, diet, medication use, NYHA classification, HF phenotype, comorbidities, electrocardiogram and echocardiogram findings and clinical laboratory results.

Supportive care services & symptom management

When asked how their LHS prioritizes supportive care and symptom management, 69% of all survey participants indicated it was a ’high priority’, and 9% indicated it was a ’low priority’; the remainder were neutral with respect to priority. When stratified according to AMC status, 73% of AMC systems considered supportive care and symptoms management a ’high priority’ compared with 62% of non-AMC LHS; 5 and 15% of AMC and non-AMC LHS, respectively, considered this issue a ’low priority’.

Survey participants considered behavioral/psychological counseling (57%) and nutritional counseling (46%) as the most effective treatments for symptom management (Figure 3A). Over 70% of participants indicated the most common supportive or ’wraparound’ services offered at LHS were ’cardiac rehabilitation’, ’education for patients on early signs, risk factors, and treatment options’ and ’nutrition and wellness counseling’ (Figure 3B). Additional services noted by >50% of participants included ’physical therapy’ and ’patient support groups’.

Figure 3. (A) Most effective treatment for improving symptom-related outcomes and (B) most common supportive or ’wraparound’ services offered at leading health systems.

Based on responses of 35 survey participants. Percentages do not add up to 100% because respondents could choose multiple responses. In (A), ’Other’ responses included education on importance of medications, weight loss program, loop diuretics, reducing congestion, helping create a support network, continuous home intravenous inotrope therapy, guideline-directed medical therapy and validated symptom questionnaire.

When considering patients with HFpEF or HFrEF, over 70% of survey participants selected ’shortness of breath with activity or when lying down’, ’chest pain if HF is caused by a heart attack’ and ’fluid buildup’ as the top 3 ’high priority’ symptoms (Figure 4). There was some disparity among HCPs and executives when asked whether supportive care/symptom management should differ between patients with HFpEF and HFrEF. ’Yes’ was reported by 26% of executives and 38% of HCPs, ’yes but only slightly’ by 16% of executives and 31% of HCPs, ’no’ by 47% of executives and 31% of HCPs, and ’not applicable to their role or expertise’ by 11% of executives and 0% of HCPs. Reasons for answering ’yes’ or ’yes but only slightly’ included the different mechanisms underlying HFpEF and HFrEF, and that HFrEF treatment is more focused on reducing mortality while HFpEF is focused more on treating comorbidities and risk factors. Reasons for answering ’no’ revolved around the theme that overall goals of effective supportive care and symptom management are largely similar, though different resources may be used to achieve these goals.

Figure 4. Leading health system symptom prioritization for patients with (A) HFpEF or (B) HPrEF.

Based on responses of 35 survey participants.

HFpEF: Heart failure with preserved ejection fraction; HFrEF: Heart failure with reduced ejection fraction.

A variety of responses were provided to the open-ended survey question “What challenges and gaps still exist in managing symptoms for advanced HF patients?“. Using rapid qualitative analysis, researchers used a structured summary template incorporating deductive and inductive approaches to identify three issues: I) LHS infrastructure (e.g., staffing issues related to both healthcare and data analysis, difficulty coordinating care across multidisciplinary LHS/offices/teams); II) access to care (e.g., palliative, cardiac rehabilitation and physical rehabilitation services, social support, medication cost support); and III) patient/provider awareness and patient adherence/compliance to treatment. Two-thirds (66%) of survey participants reported treatment challenges and gaps do not differ between patients with HFpEF and HFrEF. A variety of examples were described among the 34% who indicated there is a difference between the two types of patients. In particular, participants noted the complexity of comorbidities, medication gaps, and more ambiguous treatment algorithms associated with HFpEF (relative to HFrEF).

Over 90% of survey participants indicated ’impact on quality of life’ was the top attribute they would consider when assessing a new agent for HF symptom management (Figure 5A). ’Benefit to patient’ and ’impact on survival’ were also selected by a majority of participants. Over 80% of survey participants were somewhat or very interested in precision medicine/diagnostic tools to tailor treatment of advanced HF (Figure 5B).

Figure 5. (A) Key attributes of a new agent for symptom management and (B) interest in using precision medicine and other diagnostic tools to tailor clinical treatments or to alleviate symptoms.

(A) Based on responses of 35 survey participants. In (A), ’Other’ responses included increasing patient adherence.

Discussion

This study sought to understand the driving forces shaping LHS executive and frontline HCP perspectives around the current and future state of HF treatment in the USA. Key insights derived from the research findings are discussed below, including identification of areas where external partners could collaborate with LHS in the management of HF.

Variation in HF program maturity spotlights an opportunity for care standardization

Although 97% of survey participants reported their LHS had a dedicated HF program/strategy, findings indicate program maturity varies across systems. Insights from participant interviews indicate LHS typically have some supportive care and symptom management services in-house but mostly rely on referrals. Comprehensive programs apply clinical practice guidelines and utilize standardized medication management, use risk models to identify high-risk patients, have the capability to implant artificial heart and ventricular assistant devices or employ heart transplantation for end-stage HF, and incorporate advanced care planning (such as palliative and hospice care) to relieve suffering and optimize quality of life [3]. Additional elements of a comprehensive program may include nutritional assessment, continuous follow-up care, effective patient–provider communication and continued provider education [3]. Providing physical and emotional supportive care has been seen to have a positive impact on patient quality of life [8]. Less progressive programs rely on referrals to address complex care needs, and many lack the infrastructure to offer advanced surgical interventions (such as heart transplantation), which requires specialized providers and accreditation. This can lead to challenges in care coordination for a patient population with complex needs.

Regardless of maturity, the study findings highlight LHS are focused on improving clinical outcomes and quality of care for patients with advanced HF. As such, LHS have prioritized care standardization and care coordination, with just over half recognizing data analytics should play a role in these processes. During qualitative interviews, LHS executives and HCPs reported using datasets to develop dashboards integrated within electronic health records that serve as a ’single source of truth’ to monitor a variety of measures including patient readmissions, medication reconciliation, follow-up and patient satisfaction. Leveraging real-time data analytics has helped frontline HCPs to deliver preventative care and targeted therapies within these participating systems. Some health systems are already using data warehouses – centralized repositories for electronic health records and clinical data – to inform clinical decision making. However, data analysis and visualization are labor-intensive pursuits, and some LHS may struggle to share and act on data-driven insights. This is evident from quotes obtained from interview participants. For example, one stated that “we started building our own database to identify HF patients at high risk for readmission. It’s labor-intensive work and we didn’t know how to design it but we did it to the best of our ability. We’re hoping to decentralize this and tie the quantitative and qualitative data together to be predictive and catch patients early“. Another noted that “our dream state would be to have a data-driven approach to quality and cost since we don’t have a high-level focus here currently“.

As LHS continue to evolve data and analytics strategies, an opportunity exists for external partners to provide additional support to help coordinate and improve care. For example, while participants indicated LHS use quality metrics to track progression and severity of HF across patient populations, there is room to standardize these processes. Research could be conducted to better understand LHS metric prioritization and engagement with electronic health record vendors and quality reporting agencies to integrate benchmarks into current systems. Likewise, external partners could lend resources and expertise to LHS that are looking to advance their data visualization/analytic capabilities and their use of technology (e.g., remote monitoring and wearable devices) to monitor patients.

Innovation transforms HF care pathways amid ongoing provider & patient barriers

Advancements in research, medications, and treatment guidelines [9] strive to improve quality of life and life expectancy for patients with advanced HF. However, qualitative interviews suggest frontline HCPs struggle to keep up with the pace of innovation. As clinical research and guidelines advance, frontline HCPs need to stay up to date in order to incorporate new technology/approaches, such as precision medicine and diagnostic therapies, into patient care. Further, while innovation progresses, frontline HCPs continue to customize treatment and care management based on individual patient needs, which can lead to variation in care and outcomes. In response, some LHS are exploring new educational strategies such as multidisciplinary conferences and grand rounds to educate the clinical workforce trying to keep abreast of evolving treatment options and guidelines, as shared in qualitative interviews. Notably, frontline HCPs report increasing provider education as top priority for managing patients with advanced HF.

Participants identified barriers to the treatment of patients with HFpEF (e.g., comorbidity burden, low efficacy of current treatments, and limited patient and caregiver awareness/education on HF) and HFrEF (e.g., comorbidity, complexity of self-care, symptom burden and cost/coverage of treatment). LHS have developed strategies to address some of these challenges. Interviewees described, for example, approaches their LHS use to improve patient education and reduce the complexity of self-care including discharge planning (with medication education), automated post-discharge follow-up, nutrition education, family caregiver education and transportation services. Likewise, interviewees noted partnerships their LHS have with external partners to provide patients with low-cost medications or wearable/remote technology to monitor symptoms. There is, however, an opportunity for external partners to further support LHS in addressing these aforementioned barriers to treatment, including the development of patient/caregiver educational initiatives, evidence-based training for LHS staff to help manage HF symptom and comorbidity burden, and expanded access to clinical trials that investigate new, potentially more efficacious treatments.

HF programs strive to co-locate supportive care services to drive outcomes

Insights from participant interviews highlighted the positive impact symptom management has on patient quality of life, and most survey participants indicated their LHS prioritizes supportive care and symptom management (AMCs, 73%; non-AMCs, 62%). A systematic literature review found that symptom self-management (e.g., physical activity, medication adherence, patient education) reduced HF-related hospitalization or death (hazard ratio 0.80 [95% CI: 0.71–0.89]) and increased HF-related quality of life (mean difference 0.15 [95% CI: 0.69–0.92]) [10]. Greater prioritization at AMCs may reflect the increased resourcing (e.g., access to clinical trials) these institutions have to pursue and implement novel solutions. Additionally, insights from interviews showed that while symptom management may be a priority at the clinician level, it is not necessarily a high priority at the system level where factors such as reducing readmission rates or lowering cost of care are prioritized.

To manage complex symptoms and to deliver comprehensive HF care, supportive care services (e.g., nutrition, physical therapy) are essential [3]. Insights gained from qualitative interviews demonstrate a consensus among LHS that co-locating supportive care services, which consists of integrating supportive services and personnel directly within a HF program, is the ideal state. In qualitative interviews, LHS executives and frontline HCPs reported they rely heavily on referrals for certain services. Therefore, in the absence of co-located services, transitions of care are the cornerstone of effective HF care delivery because effective care coordination can impact patient adherence and outcomes, cost of care for patients and the system, and provider satisfaction [11]. However, LHS executives and frontline HCPs expressed challenges with transitioning care during discharge to outpatient clinics. LHS are using a variety of techniques to solve these issues and ensure timely follow-up. For example, one LHS is partnering with a patient engagement platform to facilitate a series of automated calls to discern patient needs post discharge. These calls strategically target high-risk patients by leveraging internal readmissions data. If patients respond affirmatively to screening questions, a nurse facilitates same-day follow-up to bridge the ’vulnerable period’ and provide a safety net of resources. Reflective of the key elements of comprehensive HF programs, LHS executives and frontline HCPs underscore the importance of palliative care throughout a patient’s journey and consistently express a need for additional palliative care support services. Stronger integration within programs is imperative, however, as the shortage of palliative care providers is a particular challenge [12]. As a result, palliative care is often limited to the inpatient setting and is based on provider availability. As the HF population continues to grow, LHS are eager for solutions to expand access to palliative care services. This point is illustrated best by a quote from one of the interview participants: “Inpatient, palliative care is well-integrated. There are physicians and nurse practitioners who are streamlined and can consult around goals of care and planning. On the outpatient side, it’s not as easy. We have a few outpatient palliative care providers and they’re mostly dedicated to oncology. We want more but it’s hard when we can’t consistently predict how much support we’ll need. If patients need palliative care, it’s mostly coming from the inpatient side“.

Advance practice providers (APPs; e.g., nurse practitioners, physician assistants) play an important role within multidisciplinary HF programs [13]. In addition to delivering care, APPs act as conduits for transitioning care [13]. The APP role across both inpatient and outpatient care delivery creates provider continuity that may improve patient satisfaction and outcomes. For example, one interviewee noted how integration of APPs in the outpatient setting led to less fragmented care, improved patient satisfaction, and, for their system, greater APP job satisfaction. All qualitative interview participants suggested investment and partnership with APPs is a major future trend to track. Two interview anecdotes include the following: “APPs are embedded in all aspects of care“ and “we have multiple APPs integrated in our advanced HF service line. They round on the acute and outpatient service side and independently see patients, with some exceptions…“

Executives and frontline HCPs agree supportive care and symptom management services (e.g., palliative care, behavioral health, nutrition services) should be a priority in order to deliver high-quality HF care. Recent studies also highlight the unmet need of supportive care in patients and further research needed to improve quality of life [14,15]. These efforts, however, may also be hindered by a lack of trained clinical staff at some LHS, and issues with workforce recruitment and retention that have been exacerbated by the COVID-19 pandemic could continue to be a challenge for health systems. Training development modules and team-based coaching to promote team effectiveness, communication and foster a patient-centered culture may address some of these barriers. Additionally, extending clinical partnerships through remote monitoring or digital care pathways [16] (which digitize elements of patient care to maximize ease and efficiency) can assist LHS as they work to integrate additional supportive care services.

Limitations & strengths

The study sample was relatively small, and findings represent the views of individual participants. As this study solely surveyed US LHS executives and healthcare workers, the potential participant sample size was already limited. Additionally, LHS of smaller size may be under-represented because 85% of participating LHS had an annual revenue of ≥$1 billion. Finally, there was substantial variation in the geographic spread of participating LHS, with nearly half from the Northeast or Midwest. These factors potentially limit the generalizability of findings across different health systems. However, the intent, and a strength of the research, was to focus on strategy and practices at large, innovative health systems that treat a substantial volume of patients with HF. Additionally, we sought perspectives from both executive and frontline healthcare workers, using a study design that utilized qualitative and quantitative approaches. To our knowledge, this is the first study of its kind in the published literature, and this novel approach provides a comprehensive picture of the current and future state of HF management in the USA.

Conclusion

This research, the first of its kind combining quantitative survey data with qualitative interview findings, provides perspectives on the current state of advanced HF treatment from executives and HCPs at LHS in the USA. Opportunities exist for LHS, with support from external partners, to build and strengthen aspects of their HF programs in order to become more comprehensive providers of care. This would lead to increased standardization of care across LHS, better treatment options, and improvement in overall care, outcomes and satisfaction for patients with HF.

Summary points

• Heart failure is a leading health concern in the USA, and treatment requires comprehensive patient management.

• We sought to better understand the state of heart failure in the USA by surveying and interviewing executives and practitioners at leading healthcare systems.

• This was a cross-sectional, descriptive, mixed-method design (survey and interview data from executives and frontline healthcare providers) was utilized to understand the state of heart failure treatment in the USA.

• Quantitative survey (n = 35) and qualitative interview (n = 12) data were obtained from 47 participants representing 41 different leading health systems.

• Heart failure treatment programs vary in maturity, and practitioners can struggle to keep up to date with new treatments and innovations available for patients with heart failure.

• Innovation transforms heart failure care pathways, though practitioners may struggle to keep up with the pace of innovation amid provider and patient barriers.

• Heart failure programs strive to co-locate supportive care services to optimize symptom management and outcomes, though access to some services can be challenging.

• Standardizing US health systems to be providers of comprehensive heart failure treatment programs would allow for better treatment options and improved overall patient care.

Author contributions

K Naik, C Redman, L Tarasenko and I Jacobs were involved in conception of the research and study design. K Naik and C Redman were involved in study conduct and collection/analysis of data. All authors were involved in data interpretation, review and revision of the manuscript, and approved the final version of the manuscript.

Financial disclosure

This study was funded by Pfizer. L Tarasenko and I Jacobs are full-time employees of, and own stock/options, in Pfizer. In their role as authors, they were involved in study design, data interpretation and manuscript development in collaboration with the wider author group. The final decision to publish, and where to publish, was made by the author group. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Competing interests disclosure

This study was funded by Pfizer. N Sulemanjee and V Vizgirda declare no conflicts of interest. Krishna Naik is an employee of The Health Management Academy, which was contracted by Pfizer to conduct the research described in this manuscript. C Redman was an employee of The Health Management Academy at the time this study was conducted. L Tarasenko and I Jacobs are full-time employees of, and own stock/options, in Pfizer. The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.

Writing disclosure

Medical writing support was provided by M Soulsby and A Frings of Engage Scientific Solutions and funded by Pfizer.

Ethical conduct of research

This research was considered exempt from institutional research board review according to the US Department of Health and Human Services, Office for Human Research Protections, §46.101, (b)(2) because it involved survey procedures, and the information obtained could not be linked to the participants and did not place them at risk.

Data sharing statement

Upon request, and subject to review, Pfizer will provide the data that support the findings of this study. Subject to certain criteria, conditions and exceptions, Pfizer may also provide access to the related individual de-identified participant data. See www.pfizer.com/science/clinical-trials/trial-data-and-results for more information.

Open access

This work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/

Supplementary data

To view the supplementary data that accompany this paper please visit the journal website at: www.tandfonline.com/doi/suppl/10.2217/fca-2023-0146