Dataset Information

Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study.

ABSTRACT:

Objective

To investigate whether general practitioners (GPs) follow treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients, and assess whether doctors' characteristics are related to their decisions.

Design

Cross-sectional vignette study.

Setting

Continuing Medical Education meeting.

Participants

451 Dutch GPs.

Main outcome measures

Answers to four multiple-choice treatment decisions in clinical vignettes of a patient with heart failure and a reduced ejection fraction. With univariable and multivariable regression analyses, respondent characteristics were related to optimal treatment decisions.

Results

Of the 451 GPs, none took four optimal decisions: 7% considered stopping statin treatment, 36% initiated ?-blocker treatment at a low-dose and 4% doubled the ?-blocker in the up-titration phase. Finally, for our vignette patient now also suffering from chronic obstructive pulmonary disease, 45% of the GPs continued ?-blocker therapy even when they considered prescribing a long-acting ?2-agonist. While the relation between respondent characteristics and each decision was very different, none was independently associated with all four decisions. Giving priority to evidence-based medicine was independently related to stopping statin treatment and doubling the ?-blocker in the up-titration phase.

Conclusions

GPs seem not to follow treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. The recommendations from guidelines may appear counterintuitive when statin treatment needs to be stopped when a patient feels comfortable, or when a ?-blocker should be up-titrated in patients who experience more symptoms. Giving priority to evidence-based medicine is possibly positively related to difficult treatment decisions.

SUBMITTER: Swennen MH

PROVIDER: S-EPMC3780330 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature

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Publications

Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study.

Swennen Maartje H J MH Rutten Frans H FH Kalkman Cor J CJ van der Graaf Yolanda Y Sachs Alfred P E AP van der Heijden Geert J M G GJ

BMJ open 20130916 9

<h4>Objective</h4>To investigate whether general practitioners (GPs) follow treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients, and assess whether doctors' characteristics are related to their decisions.<h4>Design</h4>Cross-sectional vignette study.<h4>Setting</h4>Continuing Medical Education meeting.<h4>Participants</h4>451 Dutch GPs.<h4>Main outcome measures</h4>Answers to four multiple-choice treatment decisions in clinic ...[more]

PMID: 24041845

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Project description:AimsFabry disease (FD) is often associated with heart failure (HF). However, data on HF prevalence, prognosis, and applicability of echocardiographic criteria for HF diagnosis in FD remain uncertain.Methods and resultsWe evaluated patients with genetically proven FD for symptoms and natriuretic peptides indicating HF. We then analysed the diagnostic utility of the currently recommended European Society of Cardiology (ESC) echocardiographic criteria for HF diagnosis and their relationship to natriuretic peptides. Finally, we examined the association between HF and echocardiographic criteria with mortality and cardiovascular events during follow-up. Of 116 patients with FD, 48 (41%) had symptomatic HF (mean age 58 ± 11 years, 62% male). HF with preserved ejection fraction (HF-pEF) was diagnosed in 43 (91%) patients, representing the dominant phenotype. Left ventricular mass index (LVMi) had the highest diagnostic utility (sensitivity 71% and specificity 83%) for HF diagnosis in FD, followed by E/e' > 9 (sensitivity 76% and specificity 78%) and global longitudinal strain (GLS) <16% (sensitivity 54% and specificity 88%). Log N-terminal pro-brain natriuretic peptide correlated significantly with LVMi (r = 0.60), E/e' (r = 0.54), and GLS (r = 0.52) (all Ps < 0.001) but not with left ventricular ejection fraction (r = -0.034, P = 0.72). During follow-up (mean 1208 ± 444 days), patients diagnosed with HF had a higher rate of all-cause mortality and worsening HF (33% vs. 1.5%, P < 0.001). Abnormal LVMi, E/e' > 9, and GLS < 16% were all associated with higher all-cause mortality and worsening HF.ConclusionsThis study found a high prevalence of symptomatic HF in FD patients. HF-pEF was the dominant phenotype. LVMi, E/e', and GLS yielded the highest diagnostic utility for HF diagnosis and were significantly correlated with natriuretic peptides levels. Echocardiographic criteria proposed by current ESC HF guidelines apply to Fabry patients and predict cardiovascular events. At follow-up, Fabry patients with HF diagnosis had high event rates and significantly worse prognosis than patients without HF.

Project description:BackgroundSeveral studies have focused on stratifying patients according to their level of readmission risk, fueled in part by incentive programs in the U.S. that link readmission rates to the annual payment update by Medicare. Patient-specific predictions about readmission have not seen widespread use because of their limited accuracy and questions about the efficacy of using measures of risk to guide clinical decisions. We construct a predictive model for readmissions for congestive heart failure (CHF) and study how its predictions can be used to perform patient-specific interventions. We assess the cost-effectiveness of a methodology that combines prediction and decision making to allocate interventions. The results highlight the importance of combining predictions with decision analysis.MethodsWe construct a statistical classifier from a retrospective database of 793 hospital visits for heart failure that predicts the likelihood that patients will be rehospitalized within 30 days of discharge. We introduce a decision analysis that uses the predictions to guide decisions about post-discharge interventions. We perform a cost-effectiveness analysis of 379 additional hospital visits that were not included in either the formulation of the classifiers or the decision analysis. We report the performance of the methodology and show the overall expected value of employing a real-time decision system.FindingsFor the cohort studied, readmissions are associated with a mean cost of $13,679 with a standard error of $1,214. Given a post-discharge plan that costs $1,300 and that reduces 30-day rehospitalizations by 35%, use of the proposed methods would provide an 18.2% reduction in rehospitalizations and save 3.8% of costs.ConclusionsClassifiers learned automatically from patient data can be joined with decision analysis to guide the allocation of post-discharge support to CHF patients. Such analyses are especially valuable in the common situation where it is not economically feasible to provide programs to all patients.

Dataset Information

Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study.

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusions

Publications

Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study.

Similar Datasets

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