SMJ 2003 49(1): 10-13
Sinéad P McKee Heart Failure Research Nurse
Stephen J Leslie Specialist Registrar in Cardiology
John P LeMaitre Research Fellow in Cardiology
David J Webb1 Professor of Clinical Pharmacology
Martin A Denvir Senior Lecturer in Cardiology
Cardiology and 1Clinical Pharmacology Unit, Department of Medical Sciences, The University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU
Author
for correspondence:
Martin A Denvir, Department of Cardiology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU
E-mail:
martin.denvir@staffmail.ed.ac.uk
Abstract
Background and Aims: To assess physician opinion of, and attitudes to, the Scottish Intercollegiate Guideline Network (SIGN) guideline for chronic heart failure (CHF) due to left ventricular systolic dysfunction.
Methods and Results: A questionnaire examining physicians’ attitudes and their use of the SIGN guideline for CHF was distributed to 158 physicians in two teaching hospitals within one NHS trust. 65% of recipients responded. More cardiologists had read the guideline compared to non-cardiologists (91vs56%, p<0.05). The majority of cardiologists and non-cardiologists agreed that it was applicable to their patients (92vs79%, p>0.1) and that implementation may reduce hospital admissions (65vs59%, p>0.5). In general, compliance was thought to be a problem in only a minority of patients in both groups for angiotensin converting enzyme inhibitors (8vs19%), diuretics (12vs29%) and digoxin (17vs19%, all p>0.1). Beta-blocker compliance was identified as a problem by both groups (50vs53%, p>0.5) while fewer cardiologists reported compliance as a problem with spironolactone (4vs25%, p<0.05). More cardiologists felt that there was a need for a community based CHF nurse specialist (100vs57%, p<0.001), and that this strategy would reduce hospital admissions (92vs57%, p<0.01).
Conclusions: Differences exist between cardiologist and non-cardiologist physicians’ awareness of the SIGN guideline for CHF. Furthermore, we have shown differences in reported implementation of the guideline and perceived difficulties with specific drug therapies. This is in spite of high levels of agreement in both groups with the treatment suggested by the guideline and the anticipated benefits resulting from its implementation.
Keywords: SIGN guideline, left ventricular systolic dysfunction, heart failure.
Introduction
Chronic
heart failure (CHF) is an increasing cause of morbidity and mortality in the
United Kingdom (UK).1 The cost of managing this patient population is
escalating in both primary and secondary care with hospitalisation in 2000
accounting for more than 2.5% of all health care expenditure.2 Treatments
that improve symptoms, reduce hospital admissions and reduce mortality
have been incorporated into several CHF guidelines.
3, 4, 5, 6, 7
Guidelines are
a key way of disseminating clinical trial evidence into everyday practice. The
Scottish Intercollegiate Guideline Network (SIGN) guideline for systolic heart
failure (No. 35)4 was published in February 1999 and distributed to
all medical physicians throughout Scotland. It is also available electronically
at www.sign.org.uk. There have been no
published studies examining how well this guideline has been implemented and
adopted by clinicians in secondary care.
In general, implementation of CHF guidelines is higher in patients treated by cardiologists than non-cardiologists.8, 9, 10 However, the majority of patients in the UK with a diagnosis of CHF will be cared for by non-cardiologists, many of whom are care of the elderly physicians. There are now many evidence based therapies for CHF, and this can lead to polypharmacy, which may be a particular problem in elderly patients. The aims of this study were to assess physician opinions on the implementation of the SIGN guideline No 35 and to assess their views on ways in which this may be improved in the future. These issues have not previously been reported.
Methods
This survey was carried out in 2 teaching hospitals within 1 NHS trust over a 4-month period, more than two years after the SIGN guideline was published. A questionnaire (Table 1) was designed around the diagnosis and management, as recommended in the guideline (SIGN No 35).4 Physicians were asked to rate the appropriateness of these recommendations on a 5 point scale ranging from “strongly agree” to “strongly disagree” or to indicate the percentage quintile. In addition, questions were asked regarding the impact of a community based heart failure nurse. Questionnaires were initially completed by 30 clinicians and modified prior to being distributed to a total of 87 consultants and 71 specialist registrars in secondary care. The questionnaire was resent to physicians who did not respond. This survey corresponded with an ongoing audit of the actual management of CHF patients attending this hospital. This has been reported elsewhere (Figure 1).11
Statistics
Data were entered into a spreadsheet and analysed for differences between cardiologist and non-cardiologist physicians. Data are expressed as a percentage and absolute numbers are included in brackets unless otherwise indicated. Differences were assessed using CHI squared test (SPSS for Windows, version 11) and a p value of <0.05 was considered statistically significant.
Results
There was a 65% (103) response to the questionnaire, 63% (55) from consultants and 68% (48) from specialist registrars. There was a 96% (24) response from cardiologists and 59% (79) from non-cardiologist physicians. The non-cardiologist group comprised physicians from several specialities (Table 2). Of those who did not return the questionnaire (54), the majority were from specialities that were less likely to manage patients with CHF. More cardiologists had read the guideline (91 v 56%, p<0.05). The majority of cardiologists and non-cardiologists who had read it agreed that it was applicable to their patients (92 v 79%, p>0.1). However, there was a trend towards a greater number of cardiologists who felt that the guideline had influenced their management of CHF (61 v 49%, p=0.08). Most cardiologists and non-cardiologists agreed that implementation of the guideline was likely to reduce hospital admissions (65 v 59%, p=0.5).
Investigations
recommended in the guideline
In general, there was a high level of agreement by both cardiologist and non-cardiologist physicians of the importance of the investigations for CHF recommended in the guideline; full blood count (100 vs 99%), urea and electrolyte (99 vs 97%), thyroid function (92 vs 78%), ECG (100 vs 99%), chest radiograph (88 vs 98%), echocardiogram (100 vs 99%) (all p > 0.05).
Use,
contra-indication and intolerance of drug therapies
The estimated use of specific treatments suggested in the SIGN guideline is represented in Figure 2. The perceived use of ACE inhibitors was similar between cardiologists and non-cardiologists. Estimated levels of contra-indication and patient intolerance of these drug therapies by physicians are represented in Figure 3. There were no significant differences between cardiology and non-cardiology physicians. The actual drug use from our audit (Figure 1) showed a relatively high use of ACE inhibitors/ARBs (80%), low use of beta-blockers (32%) and digoxin (36%) and very low use of spironolactone (13%). Cardiologists used more beta-blockers (37 v 21%, p=0.003) and digoxin in sinus rhythm (18 v 5%, p<0.001) than non-cardiologists.11
Patient
compliance with drug therapy
In general, patient compliance was not thought to be a problem by either cardiologists or non-cardiologists for ACE-I (8 vs 19%), diuretics (12 vs 29%) and digoxin (17 vs 19%) (all p>0.1). However, beta-blockers were perceived as causing a compliance problem in about half of all patients by both cardiologists and non-cardiologists (50 vs 53%, p>0.1) while fewer cardiologists reported compliance as a problem with spironolactone (4 vs 25%, p <0.05).
Opinions
on community based heart failure nurse
More cardiologists felt that there was a need for a community based heart failure nurse specialist (100 v 57%, p<0.001), and that this strategy would reduce hospital admissions (92 v 57%, p<0.01). More cardiologists thought that a community based heart failure nurse specialist would improve compliance with drug therapy (88 vs 56%, p<0.01), while the majority of both cardiologists and non-cardiologists thought that a community based heart failure nurse specialist would improve patient education about their condition (83% vs 74%, p = 0.5).
Discussion
We have shown in this survey that differences exist between cardiologist and non-cardiologist physicians’ awareness of the SIGN guideline for CHF. Furthermore, we have shown that there are differences in perceived implementation of the guideline and perceived difficulties associated with the use of specific drug therapies. These views were observed despite a high level of agreement among all physicians that the recommended treatments in the SIGN guideline were appropriate. Support for, and perceived benefit of, a community based heart failure nurse was greater among cardiologists than non-cardiologists.
Treatments
outlined in the guideline
ACE-I
and diuretic therapy
ACE-inhibitors
are of proven mortality benefit in patients with CHF12, 13 while
diuretics are useful for the control of symptoms. Both cardiologists and
non-cardiologist reported high use of ACE-I and diuretic therapy. The actual use
of ACE-I in our clinical audit was 80%.11 Patient compliance was not
seen to be a significant problem and ACE-I and diuretic therapy were thought to
be contra-indicated in few patients.
Beta-blockers
Beta-blockers have proven morbidity and mortality benefits in patients with CHF.14, 15, 16, 17 Cardiologists reported a higher use of beta-blockers and lower rate of contra-indication in their patients. However, the up-titration of beta-blockers was highlighted as a problem by more cardiologists than non-cardiologists. In our clinical audit, 37% of patients managed by cardiologists were prescribed a beta-blocker compared to 21% of patients managed by non-cardiologists, while pulmonary disease or severe peripheral vascular disease was present in less than 20% of all patients.11 This discrepancy suggests that there is ongoing reluctance to use beta-blockers in CHF patients which does not appear to be justified on a clinical basis. The traditional concept that beta-blockers are contra-indicated in patients with CHF may, to some extent, still exist. This survey highlighted that one reason for not prescribing beta-blockers may be related to organisational difficulties of initiation, up-titration and monitoring.
Spironolactone
Fewer
cardiologists felt the use of spironolactone produced a compliance problem in
their patients (4 v 25%, p=0.04). In our CHF audit, spironolactone was
prescribed by both cardiologists and non-cardiologists in only 13% of patients.11
The reasons for this are unclear, but it may be related to the fact that, in
general, non-cardiologists tend to manage older patients in whom it may be more
difficult to introduce additional therapies. Some physicians may be concerned
about the increased risk of hyperkalaemia especially when combining
spironolactone with ACE inhibitors. This has been highlighted in other small
studies18 and may reflect limited resources in primary care to
support regular monitoring of blood chemistry in these patients, and a higher
incidence of hyperkalaemia in routine clinical practice than was reported in the
randomised trial.19
Digoxin
Actual usage of digoxin from our audit was approximately 35% by all physicians.11 This correlated well with the perceived use of digoxin by both cardiology and non-cardiology physicians. Neither group reported contra-indication or intolerance as a significant problem. The low use of digoxin may reflect the lack of reported mortality benefits with its use in CHF although it may still have a role in improving symptoms and preventing hospitalisation.20
Influenza
vaccination
Influenza
vaccination was reported to be used infrequently by both cardiologists and
non-cardiologists. The evidence supporting this treatment comes predominantly
from a large observational study in the United States which demonstrated, during
an influenza epidemic, a significant reduction in hospital admissions of CHF
patients in those receiving immunisation compared with those who did not receive
immunisation.21 Influenza epidemics often contribute to problems with
bed occupancy in the winter months. This is a key area where liaison between
primary and secondary care is essential and may improve uptake of immunisation.
Opinions
on community based heart failure nurse
More
cardiologists felt that there was a need for a community based heart failure
nurse specialist, or that this strategy would reduce hospital admissions.
Significantly more cardiologists valued the role of the heart failure nurse
specialist. Several studies have shown reduced re-admissions to hospital with
heart failure, reduced length of stay during re-admission
22, 23
and a reduced need to attend out-patient clinics.24
In patients reviewed by a community CHF nurse, more were on appropriate
drug therapies at the doses proven to be beneficial in the randomised controlled
trials.23 The role of the heart failure nurse is therefore invaluable
in implementing management guidelines.
Applying the guidelines to elderly CHF patients
Several
care of the elderly physicians expressed concern in comments added to the
questionnaire that a number of drugs recommended in the SIGN guideline do not
have a strong evidence-base for elderly patients. For example, the average age
of patients admitted to hospital with CHF in Scotland is 71 years for men and 77
years for women.25 However, few randomised controlled trials in CHF
include patients over the age of 70 years. Subgroup analysis has suggested that
benefits do extend to more elderly patients in these studies but this has not
been tested as part of a prospective trial examining possible differences in
tolerability and dosing regimens. The
issue of polypharmacy was also a concern for this group of physicians. Elderly
patients with CHF are more likely to have other diseases related to ageing and
may have difficulty complying with a complex medication regime. However, in
general, the elderly CHF population have a higher absolute risk and
extrapolation of evidence to the elderly is also justified on these grounds.
Limitations
of the study
The response rate was only 65% so there could be a possible sampling error involved. In addition, there was a significant difference between the number of cardiologists and non-cardiologists who responded. However, it is possible that the non-cardiologists who did not respond were less interested in replying because they were less likely to look after patients with CHF. This was a survey of physicians in 2 teaching hospitals within 1 NHS trust and therefore does not include the views of all physicians Scotland, in particular those in a non-teaching hospital environment and, more importantly, the views of general practitioners in primary care. Further study is required to obtain these views.
Conclusion
We have demonstrated a variation in awareness and perceived difficulties in implementing CHF guidelines among hospital physicians. We have demonstrated differences between cardiologists and non-cardiologists in terms of the influence of guidelines on their treatment of CHF patients. This may reflect lack of organisational developments to facilitate the increasingly complex management of patients with CHF. There is a clear need for a more integrated approach to the management of CHF involving specialist nurses as part of a managed clinical network.
References
1
Stewart S, MacIntyre K, MacLeod MM, Bailey AE, Capewell S, McMurray JJ.
Trends in hospitalisation
for heart failure in Scotland, 1990-1996. An epidemic that has reached its peak?
Eur Heart J 2001;22:209-217.
2 Berry C, Murdoch DR, McMurray JJ. Economics of chronic heart failure. Eur J Heart Fail 2001;3:283-291.
3
Eccles M, Freemantle N, Mason J. North of England evidence based
development project: guideline for angiotensin converting enzyme inhibitors in
primary care management of adults with symptomatic heart failure. BMJ
1998;316:1369-1375.
4
Scottish Intercollegiate Guidelines Network. Diagnosis and Treatment of
Heart Failure due to Left Ventricular Systolic Dysfunction. Royal College of
Physicians Edinburgh. SIGN Number 35: 1999. ISBN 1 899893 71 7.
5
Hoppe UC, Erdmann E. Guidelines for the treatment of chronic heart
failure. Issued by the Executive Committee of the German Society of Cardiology -
Heart and Circulation Research, compiled on behalf of the Commission of Clinical
Cardiology in cooperation with Pharmaceutic Commission of the German Physicians'
Association. Z Kardiol 2001;90:218-237.
6 Hunt HA, Baker DW, Chin MH, et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration with the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation 2001;104:2996-3007.
7
Remme WJ, Swedberg K. Comprehensive guidelines for the diagnosis and
treatment of chronic heart failure. Task force for the diagnosis and treatment
of chronic heart failure of the European Society of Cardiology. Eur J Heart Fail
2002;4:11-22.
8
Davie AP, McMurray JJ. ACE inhibitors and heart failure in hospital: any
difference between cardiologists and general physicians? Postgrad Med J
1999;75:219-22.
9 Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997;30:518-26.
10 Schreiber TL, Elkhatib A, Grines CL, O'Neil WW. Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes. J Am Coll Cardiol 1995;26:577-82.
11 McKee SP, Leslie SJ, LeMaitre JP, Webb DJ, Denvir MA. Management of chronic heart failure by cardiologist and non-cardiologist physicians. Eur J Heart Fail. 2002 (in press).
12
Effect of enalapril on survival in patients with reduced left ventricular
ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl
J Med 1991;325:293-302.
13 Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med 1987;316:1429-1435.
14 Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Eng J Med 1996;334:1349-1355.
15
The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a
randomised trial. Lancet
1999;353:9-13.
16
Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL
Randomised Intervention Trial
in Congestive Heart Failure (MERIT-HF). Lancet 1999;353:2001-2007.
17
Packer M, Coats AJ, Fowler MB, et al. Effect of carvedilol on survival in
severe chronic heart failure. N Eng J Med 2001;344:1651-1658.
18
Berry C, McMurray JJ. Serious adverse events experienced by patients with
chronic heart failure taking spironolactone. Heart 2001;85:E8.
19
Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on
morbidity and mortality in patients with severe heart failure. Randomised
Aldactone Evaluation Study Investigators. N Eng J Med 1999;341:709-717.
20
The effect of digoxin on mortality and morbidity in patients with heart
failure. The Digitalis Investigation Group. N Engl J Med 1997;336:525-533.
21
Nichol KL, Margolis KL, Wuorenma J, Von Sternberg T. The efficacy and
cost effectiveness of vaccination against influenza among elderly persons living
in the community. N Eng J Med 1994;331:778-784.
22
Blue L, Lang E, McMurray JJ, Davie AP, McDonagh TA, Murdoch DR, Petrie
MC, Connolly E, Norrie J, Round CE, Ford I, Morrison CE. Randomised
controlled trial of specialist nurse intervention in heart failure. BMJ
2001;323:715-718.
23
Cline CMJ, Israelsson BYA, Willenheimer RB, Broms K, Erhardt LR. Cost
effective management programme
for heart failure reduces hospitalisation.
Heart 1998;80:442-446.
24 Smith M, Irving JB. Managing heart failure in the community; the role of the nurse specialist Health Bulletin 2001;59340-342.
25
McMurray JJ, Stewart S. The Burden of Heart Failure. Eur Heart J
2002;4:D50-58.