Heart failure in primary care: measuring the quality of care.
BACKGROUND
Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure.


METHODS
We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status.


RESULTS
Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF (91%) than among those with a normal LVEF (62%). Among patients with systolic heart failure taking ACE inhibitors, 87% were at target doses. Adherence measures were low for laboratory evaluation and patient-education criteria.


CONCLUSIONS
Heart failure with normal LVEF was as prevalent as systolic heart failure in these primary care practices. Performance profiles for the physicians' prescriptions of ACE inhibitors exceeded those published in the literature. Patients who did not have a documented measure of LVEF, however, received lower quality of care as measured by this disease-specific guideline. This underscores the importance of measuring LVEF.
James
P A
PA
Department of Family Medicine, State University of New York at Buffalo, USA. paj@acsu.buffalo.edu
Cowan
T M
TM
Graham
R P
RP
Jaén
C R
CR
Majeroni
B A
BA
Schwartz
J S
JS
D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001168:Arthritis / Q000453:epidemiology; D015331:Cohort Studies; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D019317:Evidence-Based Medicine; D006333:Heart Failure / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D009518:New York / Q000453:epidemiology; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D011787:Quality of Health Care; D012189:Retrospective Studies; D013318:Stroke Volume / Q000187:drug effects
D000806:Angiotensin-Converting Enzyme Inhibitors