title: Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance?
abstract: BACKGROUND
  The aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice.
  
  
  METHODS
  Barriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling.
  
  
  RESULTS
  GPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses.
  
  
  CONCLUSIONS
  Variation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of care.
authors.affiliation: Department of Clinical Pharmacology, University Medical Center Groningen, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands. willeke.kasje@gmail.com
authors.forename: Willeke N
authors.initials: WN
authors.lastname: Kasje
authors.forename: Petra
authors.initials: P
authors.lastname: Denig
authors.forename: Pieter A
authors.initials: PA
authors.lastname: de Graeff
authors.forename: Flora M
authors.initials: FM
authors.lastname: Haaijer-Ruskamp
mesh_terms: D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005194:Family Practice / Q000592:standards*; D006300:Health Services Misuse; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008485:Medical Audit; D015999:Multivariate Analysis; D009426:Netherlands; D018024:Peer Review, Health Care; D010821:Physicians, Family / Q000523:psychology* / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors