title: Physician and patient predictors of evidence-based prescribing in heart failure: a multilevel study.
abstract: BACKGROUND
  The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence.
  
  
  METHODS
  To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models.
  
  
  RESULTS
  Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92-0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02-1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38-1.05, p = 0.08).
  
  
  CONCLUSIONS
  A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.
authors.affiliation: Department of General Practice and Health Services Research, University Hospital Heidelberg, Baden-Wuerttemberg, Germany. frank.peters-klimm@med.uni-heidelberg.de
authors.forename: Frank
authors.initials: F
authors.lastname: Peters-Klimm
authors.forename: Gunter
authors.initials: G
authors.lastname: Laux
authors.forename: Stephen
authors.initials: S
authors.lastname: Campbell
authors.forename: Thomas
authors.initials: T
authors.lastname: Müller-Tasch
authors.forename: Nicole
authors.initials: N
authors.lastname: Lossnitzer
authors.forename: Jobst-Hendrik
authors.initials: JH
authors.lastname: Schultz
authors.forename: Andrew
authors.initials: A
authors.lastname: Remppis
authors.forename: Jana
authors.initials: J
authors.lastname: Jünger
authors.forename: Christoph
authors.initials: C
authors.lastname: Nikendei
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D011307:Drug Prescriptions; D019317:Evidence-Based Medicine / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D010817:Physician-Patient Relations; D058007:Physicians, Primary Care / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors