Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure.
OBJECTIVE
To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.


METHODS
Survey of a national systematic sample of physicians.


METHODS
Five hundred family practitioners, 500 general internists, and 500 cardiologists.


RESULTS
Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%).


CONCLUSIONS
Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.
Chin
M H
MH
Section of General Internal Medicine, University of Chicago (Ill) Medical Center 60637, USA.
Friedmann
P D
PD
Cassel
C K
CK
Lang
R M
RM
D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D002309:Cardiology; D002983:Clinical Competence; D017723:Drug Utilization Review; D005194:Family Practice; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D014481:United States
D000806:Angiotensin-Converting Enzyme Inhibitors