Abstract
BackgroundThe 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.MethodsTo 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.ResultsPatients (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).ConclusionsA 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.
Highlights
Heart failure (HF) remains a deadly and costly, treatable disease [1,2,3]
Despite the consensus on clinical practice guidelines (CPG) that recommend the use of renin angiotensin aldostererone inhibitors (RAAS-I) in target doses [8,9,10], there seems to be imperfect transfer into practice, especially in primary care
This study focused on primary care physicians’ competency levels and patient-related barriers as predictors of actual guideline-conform prescription of ACE inhibitors or angiotensin receptor blockers (RAAS inhibitors) at daily doses equal or more than 50% of target
Summary
The clinical management of HF is complex and includes a repeated evaluation of the clinical course of the syndrome and its’ comorbidities. It encompasses patient education, non-/pharmacological treatment, devices and surgery. Despite the consensus on clinical practice guidelines (CPG) that recommend the use of RAAS-I in target doses [8,9,10], there seems to be imperfect transfer into practice, especially in primary care. Doses were titrated to only 50% of the target doses recommended in the CPGs [11,12] Understanding this gap between a physician’s knowledge and his actual acting might be essential for the development of strategies aiming to improve the care of HF patients [13]. Physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
