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Br J Gen Pract. 1999 May; 49(442): 353–357.
PMCID: PMC1313419

Barriers to optimum management of heart failure by general practitioners.


BACKGROUND: Published research offers clear pointers to the management of heart failure; however, the evidence for implementation into practice is sub-optimal. AIM: To identify the salient barriers to adopting evidence-based management of heart failure in the community. METHOD: Structured interviews were used to elicit the views of a stratified sample of 100 general practitioners (GPs) about the diagnosis and treatment of heart failure. Responses to three heart failure case scenarios provided an indication of the degree to which GPs' knowledge of heart failure and trial results might be applied to diagnosis and treatment intentions. RESULTS: Participants were generally well aware of clinical trials that showed that prognosis could be improved by treatment, but trial results appeared to have little influence on treatment intentions in the three case scenarios. The major barriers to optimum management were the difficulties of differential diagnosis and the perceived properties of angiotensin-converting enzyme inhibitors (ACE-I) relative to diuretics. In the case scenarios, less than 30% reported that they would undertake basic investigations, such as chest X-ray or haemoglobin, or prescribe ACE-I. Over 70% perceived diuretics to be a useful diagnostic tool. The most frequent reasons for not prescribing ACE-I were the perceived inconvenience and risks of adverse effects (41%) and the view that most patients can be managed successfully on diuretics alone (27%). Over two-thirds of the sample were dissatisfied with the quality of information accompanying heart failure patients discharged from hospital. CONCLUSION: Facilitating evidence-based management of heart failure in the community requires further support for GPs in the form of additional training in the diagnosis of heart failure and the optimum use of both ACE-I and diuretics, and by improved communication between GPs and hospital doctors on a case-by-case basis.

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Selected References

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  • Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993 Jul;88(1):107–115. [PubMed]
  • Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong M, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991 Aug 1;325(5):303–310. [PubMed]
  • Bowers PJ. Selections from current literature: treatment of congestive heart failure with angiotensin converting enzyme inhibitors. Fam Pract. 1992 Sep;9(3):362–366. [PubMed]
  • Haines A, Jones R. Implementing findings of research. BMJ. 1994 Jun 4;308(6942):1488–1492. [PMC free article] [PubMed]
  • Remes J, Miettinen H, Reunanen A, Pyörälä K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J. 1991 Mar;12(3):315–321. [PubMed]
  • Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J. 1994 Jun;71(6):584–587. [PMC free article] [PubMed]
  • Mair FS, Crowley TS, Bundred PE. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract. 1996 Feb;46(403):77–79. [PMC free article] [PubMed]
  • Williamson J, Chopin JM. Adverse reactions to prescribed drugs in the elderly: a multicentre investigation. Age Ageing. 1980 May;9(2):73–80. [PubMed]
  • Stannard VA, Hutchinson A, Morris DL, Byrne A. Gastric exocrine "failure" in critically ill patients: incidence and associated features. Br Med J (Clin Res Ed) 1988 Jan 16;296(6616):155–156. [PMC free article] [PubMed]
  • Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams KF, Cody RJ, Smith LK, Van Voorhees L, Gourley LA, Jolly MK. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med. 1993 Jul 1;329(1):1–7. [PubMed]
  • Dargie HJ, McMurray JJ. Diagnosis and management of heart failure. BMJ. 1994 Jan 29;308(6924):321–328. [PMC free article] [PubMed]
  • Francis CM, Caruana L, Kearney P, Love M, Sutherland GR, Starkey IR, Shaw TR, McMurray JJ. Open access echocardiography in management of heart failure in the community. BMJ. 1995 Mar 11;310(6980):634–636. [PMC free article] [PubMed]
  • Colquhoun MC, Waine C, Monaghan MJ, Struthers AD, Mills PG. Investigation in general practice of patients with suspected heart failure. How should the essential echocardiographic service be delivered? Br Heart J. 1995 Oct;74(4):335–336. [PMC free article] [PubMed]
  • Hampton JR, Barlow AR. Open access. BMJ. 1995 Mar 11;310(6980):611–612. [PMC free article] [PubMed]
  • Murphy JJ, Frain JP, Ramesh P, Siddiqui RN, Bossingham CM. Open-access echocardiography to general practitioners for suspected heart failure. Br J Gen Pract. 1996 Aug;46(409):475–476. [PMC free article] [PubMed]

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