This research raises important questions about the measures and methods for studying quality in primary care. Our attempt to apply a rigorous method of guideline adherence measurement to primary care settings resulted in measurable review criteria that revealed the complexities of care over time. Despite the emergence of evidence-based medicine, there remains significant uncertainty in the day-to-day care of patients with chronic disease. The diagnostic uncertainty of systolic heart failure has been emphasized, but we would also emphasize that uncertainty surrounds the complex care of the elderly with multiple comorbidities. Our study did not address these issues. Moreover, the application of treatment efficacy studies from younger patients to effectiveness in primary care senior populations raises concerns about the external validity of these randomized clinical trials.
Also, cross-sectional assessments of quality miss the purpose and process of longitudinal physician-patient relationships and underestimate the potential for diagnoses and therapeutic approaches to evolve over time. Our criteria for accepting physician performance as appropriate were likely more lenient because of the time frame used for compliance. For example, the dose of an ACE inhibitor had to remain constant for at least 6 months before we declared that the target dose had not been reached. Our experience in primary care settings suggests that the appropriateness for certain interventions, such as medication changes, is highly time sensitive, yet we know little of the contributors to timing of interventions in primary care.
Limitations
Though the 25 practices represent different types of offices in rural, suburban, and urban sites, the generalizability of our findings is limited, and larger studies should replicate this work, specifically with respect to the clarification of the syndrome of heart failure in primary care. The representativeness of the participating practices should be questioned. These practices are participants in a practice-based research network and were more likely to teach medical students; therefore, they may have been more up-to-date about heart failure, assessing LVEF, and using ACE inhibitors. However, we analyzed data from an earlier adherence survey of physicians in New York State13 and found no difference in the use of guidelines or in physician knowledge of the heart failure clinical practice guideline by participants and nonparticipants.
For studies of this magnitude, errors in data collection and data entry are possible. Our quality checks reduced this bias, as did a re-examination of the medical records at a later date for changes in care. Questions also arise about the validity and reliability of the quality measures. The reliability of some of the review criteria is hindered by the complexities of physician decision making and the inadequacies in documentation. Although we measured multiple indicators of quality, only 2 were solid with good interrater reliability and scientific evidence supporting them.
Although assessing LVEF and ACE inhibitor prescriptions does approximate a standard of technical quality that evidence increasingly asserts improves patient outcomes, most physicians might argue that even these do not measure quality. Other activities, such as patient education about low-salt diets, exercise, and medication compliance, are important, but concerns about the quality of the data for these measures limit their utility for judging quality of care.16 Also, examination of patient care should better evaluate the causes of variability, especially patient and other nonclinical factors that might supersede the technical standards established. For example, other work has suggested that physicians are less likely to order an echocardiogram if patient-centered nondisease factors become a priority.32
We believe the most reliable, accurate, and valid performance measures for systolic heart failure are those for pharmaceutic use and measures of LVEF, but the optimum time frame for observation requires further study. All other measures are suspect because of the variability of chart documentation, complexity of decision making, and timing of actions. Despite these difficulties, our study does establish benchmarks for comparison, and thus may serve as a foundation for others to attempt quality studies in primary care. Finally, our study does not answer the most important question of whether adherence to the guideline translates into improved outcomes.
We used review criteria translated from an evidence-based clinical guideline to evaluate the quality of care for primary care patients with heart failure in upstate New York. Primary care physicians should critically examine their practices for testing LVEF in patients suspected to have heart failure, as this appears below standard. Performance rates for ACE inhibitor use were above those noted in other studies and were acceptable for patients with documented systolic dysfunction. For patients who did not have a measure of LVEF documented, however, we noted lower quality of care as measured by this disease-specific guideline. Improved dosing of ACE inhibitors is needed to achieve target dosages in heart failure patients, while further study is needed to clarify the syndrome of heart failure in primary care settings.