The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behavior.
OBJECTIVE
The objectives of this study were to apply the Agency for Health Care Policy and Research (AHCPR) guideline for heart failure to the measurement of quality of care in the ambulatory setting, to compare the results for two large practices and to design an educational intervention for the two practices being studied.


METHODS
A retrospective chart review was conducted on a random sample of 50 patients with heart failure selected from each of two outpatient practices: the general internal medicine practice and the family medicine practice at a large academic medical center. Five medical review criteria were developed from the AHCPR guideline for heart failure to compare the two practices with each other and the guidelines. An educational intervention was developed to modify physician behavior in regard to compliance with guidelines.


RESULTS
Assessment of left ventricular function occurred in 79% of all cases. Of eligible patients, 68% were treated with angiotensin-converting enzyme inhibitors (ACE-Is). Of those patients treated with enalapril and captopril, 30% and 12%, respectively, were receiving the target dose as defined in the AHCPR guidelines. Of patients not eligible for treatment with ACE-Is, none were treated with hydralazine and nitrates. When the ejection fraction was less than or equal to 40%, 81% of eligible patients were treated with ACE-Is, whereas 59% were treated with ACE-Is when the ejection fraction was greater than 40%. Calcium channel blockers were used in the treatment of 42% of patients. A statistical difference (P = .05) was found between the two practices for documentation of left ventricular function, the use of ACE-Is for patients with ejection fraction less than or equal to 40%, and the use of calcium channel blockers and beta blockers.


CONCLUSIONS
In the practices studied, there is underutilization of the documentation of left ventricular function, ACE-Is in eligible patients, target doses of ACE-Is, and the use of hydralazine and nitrates for ineligible patients. A higher proportion of patients receive ACE-I therapy when the ejection fraction is less than or equal to 40%. There may be inappropriate use of calcium channel blockers in some patients. There is unexplained clinical variation between the two practices studied.
Chodoff
P
P
Thomas Jefferson University, Philadelphia, PA 19107, USA.
Bischof
R O
RO
Nash
D B
DB
Laine
C
C
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D002303:Cardiac Output, Low / Q000188:drug therapy* / Q000503:physiopathology / Q000523:psychology; D004502:Education, Medical, Continuing / Q000592:standards; D005194:Family Practice / Q000193:education / Q000592:standards*; D006334:Heart Function Tests; D006785:Hospitals, University / Q000592:standards; D006801:Humans; D007388:Internal Medicine / Q000193:education / Q000592:standards*; D015143:Philadelphia; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011787:Quality of Health Care / Q000639:trends*; D014481:United States; D016270:United States Agency for Healthcare Research and Quality