Are there patients missing from community heart failure registers? An audit of clinical practice.

BACKGROUND: General practitioners in the UK are financially incentivised, via the Quality Outcomes Framework, to maintain a record of all patients at their practice with heart failure and manage them appropriately. The prevalence of heart failure recorded in primary care registers (0.7-1.0%) is less than reported in epidemiological studies (3-5%). Using an audit of clinical practice, we set out to investigate if there are patients 'missing' from primary care heart failure registers and what the underlying mechanisms might be. DESIGN: The design of this study was as an audit of clinical practice at a UK general practice ( n = 9390). METHODS: Audit software (ENHANCE-HF) was used to identify patients who may have heart failure via a series of hierarchical searches of electronic records. Heart failure was then confirmed or excluded based on the electronic records by a heart failure specialist nurse and patients added to the register. Outcome data for patients without heart failure was collected after two years. RESULTS: Heart failure prevalence was 0.63% at baseline and 1.12% after the audit. Inaccurate coding accounted for the majority of missing patients. Amongst patients without heart failure who were taking a loop diuretic, the rate of incident heart failure was 13% and the rate of death or hospitalization with heart failure was 25% respectively during two-year follow-up. CONCLUSION: There are many patients missing from community heart failure registers which may detriment patient outcome and practice income. Patients without heart failure who take loop diuretics are at high risk of heart failure-related events.

Rosiglitazone: safety and efficacy in combination with insulin in poorly controlled type 2 diabetes mellitus patients treated with insulin alone.

AIMS: To assess the safety and efficacy of rosiglitazone and insulin treatment in combination in poorly controlled insulin-treated type 2 diabetes mellitus (T2DM) patient. METHOD: In this prospective, open-labelled, nonrandomised study, rosiglitazone was added to the insulin therapy in T2DM patients with baseline HbA1c>or=7.5%. Patients were followed for 12 months. Insulin dosage was adjusted as necessary. RESULTS: Insulin and rosiglitazone combination was used in 53 patients (29 male, 24 female) for 12 months. Baseline vs. 12-month results shown as mean+/-S.D.: HbA1c reduction 1.53% (9.82+/-1.12 vs. 8.29+/-1.45, P=.0001), insulin dosage reduction 10 U (74+/-34 vs. 64+/-34 U), percentage insulin dose reduction 13.53%, and weight gain 1.0 kg only (84+/-19.93 vs. 85+/-25.73 kg, P=.1). Systolic blood pressure 144+/-22.9 vs. 134+/-15.8 mm Hg (P=.03), total cholesterol 6.18+/-4.15 vs. 4.75+/-2.71 micromol/L, triglyceride 2.62+/-1.49 vs. 2.07+/-1.44 micromol/L, and HDL cholesterol 1.43+/-0.71 vs. 1.63+/-0.36 micromol/L (P=.02). Alanine transaminase actually reduced significantly from 26+/-22 to 19+/-9 IU/L (P=.001). Improved glycaemic control was associated with favourable reduction in cardiovascular risk factors. Rosiglitazone was discontinued only in nine patients (weight gain-4, no improvement noticed-4, ankle swelling-1). No hepatotoxicity was observed. CONCLUSION: Rosiglitazone+insulin combination is safe and effective in inadequately controlled insulin-treated T2DM patients.