Elsevier

American Heart Journal

Volume 138, Issue 5, November 1999, Pages 826-834
American Heart Journal

Variations in family physicians’ and cardiologists’ care for patients with heart failure,☆☆

https://doi.org/10.1016/S0002-8703(99)70006-2Get rights and content

Abstract

Background: Improved understanding of the reasons for underuse of diagnostic tests and treatments for congestive heart failure (CHF) may be helpful for designing future interventions to improve quality of care. Methods: To determine differences between family physicians’ and cardiologists’ practice styles for diagnosis and treatment of CHF, a random sample of family physicians and cardiologists were surveyed with standardized case scenarios. Results: Survey respondents were 182 family physicians and 163 cardiologists. Family physicians were less likely than cardiologists to rate measurement of left ventricular ejection fraction as “very important” for patients with new CHF, less likely to order an echocardiogram or test for ischemia, and much less likely to identify diastolic dysfunction as a cause of CHF. Family physicians were more likely to prescribe digoxin when it was not indicated (diastolic dysfunction) and less likely to prescribe digoxin and an angiotensin-converting enzyme (ACE) inhibitor when they were indicated (moderately to severely reduced left ventricular ejection fraction). Family physicians expressed more concern over the risks of ACE inhibitors in patients with blood pressure of 100/70 mm Hg or serum creatinine of 2.0 mg/dL and were less likely to prescribe an ACE inhibitor in these settings. Family physicians overestimated the risks of warfarin use for atrial fibrillation and were therefore less likely to prescribe warfarin. Conclusions: Family physicians appear to have less understanding of CHF pathophysiology (ie, systolic versus diastolic dysfunction) and how treatment differs according to the underlying disease process. Overestimation of the risk of ACE inhibitor and warfarin use may result in underprescribing these medications. (Am Heart J 1999;138:826-34.)

Section snippets

Study group and sample size

To compare the self-reported practices of family physicians and cardiologists, it was estimated that responses from 250 physicians in each group were required to achieve an 80% power (β error .20) to detect 10% absolute intergroup differences with an α error of .05. Assuming a minimal response rate of 40% and an undeliverable rate of 20%, surveys were mailed to 500 physicians from each group. The sample was randomly selected from the American Medical Association’s physician master file.

Physician survey

This

Response rate to survey

Of 1000 surveys mailed, 3% were sent to physicians who were deceased or retired and 7% were undeliverable at the addresses provided. Seven percent of the physicians returned the survey but indicated their refusal to respond. Of the remaining 825 physicians, 401 returned the questionnaire. This figure includes 224 family physicians and 177 cardiologists. Forty-two family physicians and 14 cardiologists were not included in the final analysis because of predetermined criteria of not seeing at

Discussion

Previous studies have shown that quality of care for patients with CHF in community practice is suboptimal for both in-patients13, 14 and out-patients.15, 23 Better understanding of the reasons why physicians may not use recommended diagnostic or therapeutic modalities should help guide future quality improvement efforts. The results of this survey indicate several factors that may influence quality of care for family physicians who care for patients with CHF.

First, our results suggest that

Acknowledgements

We thank the physicians who completed the survey, the Kerr L. White Institute staff who helped in the administration of this survey, and Lindsay Gressard for assistance in the preparation of the manuscript.

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  • Cited by (53)

    • 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation

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      Citation Excerpt :

      Insufficient evidence exists to allow for recommendations about the most appropriate roles for generalist physicians and cardiologists in the care of patients with HF. Several studies indicate that primary care physicians as a group have less knowledge about HF and adhere to guidelines less closely than cardiologists (805–807). Some studies have noted better patient outcomes in patients cared for by cardiologists than in those cared for by generalist physicians (808,809), whereas another study reported that cardiologists deliver more costly care that is accompanied by a trend toward improved survival (810).

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