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 · 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.
Heart failure is a significant health problem in the United States for which primary care and specialist physicians provide care. Gross estimates suggest that more than 1 million hospitalizations and 400,000 new cases occur annually, at a cost of $10 billion.1 Heart failure is a lethal condition with a mortality rate approaching 50% in 5 years.2 Given the seriousness and prevalence of this condition and scientific evidence demonstrating reduced mortality with specific medical interventions, researchers have raised concerns about the care heart failure patients receive in primary care settings.3-6
Evidence-based clinical practice guidelines were developed to educate physicians about appropriate processes of care.1,7 Specifically, one guideline published by the Agency for Health Care Policy and Research (AHCPR) has been disseminated through pamphlets and published in the literature for primary care physicians.8 Yet, the extent of the dissemination and the effectiveness of applying the guideline in actual practice are unknown.9
The evaluation of clinical practice and measures of physician performance require appropriate translation of evidence-based clinical practice guidelines into explicit review criteria.10 Recommendations for review criteria for this clinical guideline have been published Table 1, and specific adherence rates have been recommended.9,11 Few studies to date have examined the quality of care delivered in primary care settings using this rigorous methodology.12
We examined the quality of care provided to heart failure patients in upstate New York primary care offices. We measured quality using performance rates representing adherence to specific review criteria translated from the AHCPR heart failure clinical practice guideline. We studied 2 research questions: (1) How many heart failure patients in primary care settings found through claims data are actually eligible for measuring quality of care in accordance with an evidence-based guideline for systolic dysfunction? and (2) What are the adherence rates to specific measurable review criteria among this sample of primary care physicians?
Methods
Design and Sampling
We used a retrospective case review study design. Twenty-five practices from a practice-based research network in upstate New York voluntarily participated in a larger quality improvement project for heart failure. We solicited all physicians (n = 226) who had expressed interest in participating in a quality improvement program on a 1996 mail survey,13 as well as all physician members of the Western New York Practice-Based Research Network. Practices were selected according to practice location (urban, suburban, or rural), type of practice, order of receipt of physician-signed informed consent, and our goal of enrolling at least 400 patients with heart failure. Twenty-five physicians were selected from 35 respondents who signed informed consent forms. Their practices represented 47 physicians and 12 mid-level providers. We included solo (n = 9), group (n = 16), and hospital-affiliated (n = 5) practices with patient populations representing a broad case mix. They were located in rural (n = 13), urban (n = 4), and suburban (n = 8) sites.
Each practice was asked to provide a list of patients with the International Classification of Diseases (ICD-9-CM) code for congestive heart failure (428.00) from their billing database. Patient lists were generated, and primary care physicians were asked to review the lists to delete any names of deceased patients or those given a misdiagnosis. From 20 practices, every medical record of patients listed with heart failure was examined. In the 4 largest group practices and 1 solo practice, patients were systematically selected by ordering the patient list alphabetically and selecting every nth patient. To meet our goal of enrolling approximately 400 patients, 25 to 40 patients were selected from each of these 5 practices. These samples represented 19% to 55% of all patients on the lists provided by the practices. A total of 420 patients were selected.