Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy.
BACKGROUND
There is robust evidence for effective pharmacotherapy of chronic (systolic) heart failure (CHF) which has led to the creation of guidelines, but many surveys evaluating CHF treatment show an under-utilisation of relevant drugs, while setting and patient population appear to be crucial for adequate appraisal of treatment patterns.


OBJECTIVE
To evaluate the guideline adherence (GA) of general practitioners (GPs) in a well-defined patient population with CHF in primary care (PC).


METHODS
A cross-sectional analysis was performed with the data of 167 patients enrolled in 37 GP practices (Germany) with documented left ventricular systolic dysfunction (LVEF: 33.3 +/- 6.9%). GA was assessed as usual (prescribing "yes" or "no"), through evaluation of target dosing, while adjusting for potential clinical contraindications, and through a modified Guideline Adherence Indicator-3 (mGAI-3), which assesses three relevant groups of substances according to New York Heart Association (NYHA) functional class: ACE-Inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone-antagonists (AA).


RESULTS
Prescription rates for ACE-I/ARB, BB or both were 80%, 75% and 62%, respectively. The proportion of target doses reached for ACE-I was 16%, for BB only 8%. When adjusted for potential (mainly relative) contraindications (COPD, heart rate <60/min, hypotension, hyperkalaemia and renal dysfunction), the percentage of target doses reached increased to 49% for ACE-I/ARBs and 46% for BB. Application of the mGAI-3 showed moderate to perfect GA for usual assessment, proportion of target dose reached and adjusted in 83%, 16% and 55% of the patients, respectively.


CONCLUSIONS
In the context of this patient and doctor setting, life-saving treatment was provided above average when assessed by usual criteria. The application of additional criteria showed further room for improvement. Future interventions aiming at optimisation should be tailored to the needs of doctors and patients likewise.
Department of General Practice and Health Services Research, University Hospital Heidelberg, Vossstrasse 2, Heidelberg 69115, Germany. frank.peters@med.uni-heidelberg.de
F
F
Peters-Klimm
T
T
Müller-Tasch
D
D
Schellberg
A
A
Remppis
A
A
Barth
N
N
Holzapfel
J
J
Jünger
W
W
Herzog
J
J
Szecsenyi
D000319:Adrenergic beta-Antagonists / Q000592:standards / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000592:standards / Q000627:therapeutic use; D002908:Chronic Disease; D003430:Cross-Sectional Studies; D019317:Evidence-Based Medicine / Q000592:standards; D005194:Family Practice / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D054143:Heart Failure, Systolic / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000592:standards / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000451:Mineralocorticoid Receptor Antagonists