Innovative strategy for implementing chronic heart failure guidelines among family physicians in different healthcare settings in Berlin.

AIMS: The aim of this study was to improve drug therapy for chronic heart failure (CHF) patients. METHODS AND RESULTS: This prospective interventional pilot study was performed with cross-sectional comparative analysis before and after the intervention. Usual pharmacotherapy was observed for 8 months in two different outpatient healthcare settings in Berlin [11 family physicians from individual GP (IGP) practices and 12 working in a medical care centre (MCC)]. Medical care centres provide a novel structure for outpatient care and have recently been introduced in Germany. The subsequent intervention entailed implementation of heart failure guidelines via a computer-based reminder system, followed by renewed cross-sectional observation of prescription behaviour for 1 year. Family physicians recruited patients, assessed CHF severity according to the NYHA class, and referred patients for echocardiography. The study included 190 patients in the baseline phase and 209 in the intervention phase. Longitudinal follow-up was performed in 172 cases. Echocardiography was ordered by 94.6% of MCC-physicians and 79.9% of IGP's. Undermedication was observed in both settings. Guideline-based beta-blocker therapy was prescribed for 46.3% of patients (44.8% of IGPs and 48.5% of MCC-GPs). Prescription improved by 12.3% after the intervention. There were marked deficiencies in the prescription of aldosterone antagonists (35%) for severe heart failure, which improved to 44.2% after the intervention. CONCLUSION: The problem of inadequate implementation of evidence-based therapy for CHF was partially overcome by using the reminder system, which provided participating physicians with short guideline recommendations during the intervention phase.

[Are there any differences in guideline adherence to pharmacotherapy of heart failure between individual GP practices and Medical Care Centres (MCCs)?]. / Leitliniengerechte Pharmakotherapie bei herzinsuffizienten Patienten--Gibt es Unterschiede der Behandlung durch Hausärzte in Einzelpraxen und in Medizinischen Versorgungszentren?

BACKGROUND: Chronic heart failure is one of the most important cardiovascular diseases. Patients with this common disease are primarily treated by general practitioners (GPs). Previous research showed deficits in drug therapy. Ambulatory care in Germany is changing; new structures for medical care (Medical Care Centres) have been registered since 2003. It was of interest to evaluate medical procedures of these new structures and compare them to the one applied in traditional single practices. Aim of this study was to investigate compliance with guidelines regarding drug therapy of chronic heart failure performed by GPs working in two different outpatient settings. METHODS: A prospective observational study was conducted. Over a period of eight months medical pharmacotherapy in individual practices and a Medical Care Centre (MCC) was compared. To ensure comparability in both settings GPs treating randomly selected patients were asked to recruit patients with heart failure, encode their NYHA class and conduct echocardiography to verify the diagnosis. RESULTS: 241 heart failure patients were enrolled by general practitioners (137 in individual practices and 104 in MCCs). GPs working in MCCs performed more diagnostic echocardiographies than physicians in individual practices. ACE inhibitors/sartans, beta blockers and diuretics were prescribed less often than recommended in the guideline. DISCUSSION: The hypothesis of insufficient adherence to guideline recommendations for pharmacotherapy of ambulatory heart failure patients was confirmed. However, the prescribing behaviour for pharmacotherapy of heart failure among the physicians in Berlin was better than among their European colleagues. There were only minor differences in drug prescription between the 11 GPs from single practices and the 12 GPs working in an MCC.