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European Journal of Heart Failure 2008 10(10):1020-1025; doi:10.1016/j.ejheart.2008.08.001
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© 2008 European Society of Cardiology

Cardiologists' awareness and perceptions of guidelines for chronic heart failure. The ADDress your Heart survey

Leif Erhardta,*, Michel Komajdab, F.D. Richard Hobbsc and Jordi Soler-Solerd

a Lund University, Malmo University Hospital Malmö, Sweden
b Hopital Pitie-Salpetriere and University Pierre et Marie Curie Paris, France
c University of Birmingham, Birmingham United Kingdom
d Hospital Universitari Vall d'Hebron Barcelona, Spain

* Corresponding author. Lund University, Altonagatan 5, 21138 Malmö, Sweden. Tel.: +46 40 240750; fax: +46 40 240751. E-mail address: Leif.Erhardt{at}telia.com (L. Erhardt).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 
Background: Several surveys show that patients with chronic heart failure (CHF) are sub-optimally managed and treatment guidelines are not implemented in clinical practice.

Aims: To investigate awareness and perceptions of the 2005 European Society of Cardiology (ESC) guidelines for CHF.

Methods: 467 cardiologists from seven European countries completed an on-line interview using a validated, semi-structured questionnaire including questions about awareness and relevance of CHF guidelines. To assess agreement with ESC guidelines, three fictitious patient cases were presented and respondents' management choices compared with those of an expert panel based on the guidelines.

Results: Awareness of CHF guidelines was high, with 98% aware of any guideline and 65% aware of ESC guidelines. ESC guidelines were considered relevant (51%) or very relevant (38%) for guiding treatment decisions. Up to 92% of respondents perceived that they adhered to the ESC guidelines. For the patient cases, ≤25% made treatment recommendations that completely matched those formulated by the expert panel. Respondents considered patient compliance (52%) and guideline complexity (46%) major barriers to implementation.

Conclusion: Cardiologists reported high awareness of and a positive attitude towards ESC CHF guidelines. Provision of guidelines in a concise and accessible format is perceived as a key factor to improve implementation.

Key Words: Chronic heart failure • Treatment guidelines • Survey • Pharmacotherapy • Awareness • Perception • Clinical practice

Received September 10, 2007; Revised June 10, 2008; Accepted August 14, 2008


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 
The importance of clinical guidelines for chronic heart failure (CHF) is evident from the high prevalence of the condition and its major impact on patients' well-being and prognosis, as well as on secondary healthcare costs. Around 2% of the European population is affected by CHF [1,2]. The appropriate use of effective treatment regimens is becoming increasingly important, since we face an increase in the longevity of populations generally and following this an increasing prevalence of CHF with advanced age [3-6]. In addition, the long-term prognosis for untreated patients with CHF is poor [3,5,7-11].

Clinical guidelines provide physicians with evidence-based information on diagnostic and management options to assist decision-making in routine practice. The findings of a number of national and international surveys suggest that the prescription of recommended treatments for patients with CHF, according to clinical guidelines current at the time of the surveys, is suboptimal [12-15]. It appears that polypharmacy is prevalent, but that recommended drugs for specified clinical conditions are either not prescribed or are given in insufficient doses to be of optimal benefit to the patient. Adherence to guidelines is important in improving patient outcomes, as was demonstrated by the MAHLER Survey, which found that adherence of physicians to treatment guidelines for CHF was a strong predictor of fewer cardiovascular hospitalisations in actual practice [16].

Guidelines are to a large extent based on the results of clinical studies, and therefore need to be re-evaluated periodically and the recommendations modified as the findings from new clinical studies are published. Recently the European Society of Cardiology (ESC) updated its guidelines for CHF [17]. The ADDress your Heart study was designed to evaluate physicians' awareness of and attitudes towards the 2005 ESC guidelines for CHF. Agreement with the guidelines for pharmacotherapy was assessed through standardised patient case scenarios mediated by an expert panel. The expert panel consisted of cardiologists familiar with the field of heart failure and who proposed the "orrect treatment" for the cases based on the current CHF guidelines. The study also sought to identify sources of information about the guidelines as well as potential barriers to their implementation.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 
The ADDress your Heart survey was conducted amongst cardiologists in seven countries in Western Europe: France, Germany, Spain, Switzerland, Sweden, Norway and Finland.

To be eligible for inclusion in the study, cardiologists must have had a minimum of 3 and a maximum of 30 years experience in treating patients with CHF, and to be treating at least 10 patients with CHF every month. Country-specific quotas for type of practice (hospital-based, office-based or mixed) were implemented.

The survey was conducted on-line by GfK Healthcare, Nürnberg, Germany in accordance with the EphMRA-PBIRG Internet Research Guidelines [18]. Cardiologists in France, Germany and Spain were identified randomly using an existing research database held by GfK Healthcare of physicians subscribing to an on-line medical community who had agreed to participate in research activities. Cardiologists in Switzerland and Nordic countries were recruited randomly by telephone, using information from local hospital directories and address books listing office-based physicians. All cardiologists who agreed to participate in the survey received an e-mail containing a link to an on-line questionnaire. Respondents were reimbursed for their time to complete the questionnaire at a rate of {euro}1.0-1.5 per minute.

The survey was based upon a validated series of queries, which were initially developed by an expert panel of cardiologists, including two who were involved in the development and publication of the 2005 ESC guidelines. It included questions about patient workload, current approaches to the treatment of CHF patients, and awareness of and attitudes towards treatment guidelines. The survey also sought to assess current treatment patterns in a standardised way that would enable comparison of the physicians' decisions. After reviewing the 2005 ESC guidelines, the expert panel developed three fictitious patient case scenarios that were designed to reflect different aspects of the management of patients with CHF. A selection of treatment options, including some that were not consistent with the 2005 ESC guidelines, was provided (see Appendix A available online). The participants' management choices were compared with those suggested by the expert panel, which were considered to represent the best option for the relevant scenario based on the recommendations in the guidelines.

The questionnaire was piloted in 60-minute face-to-face interviews with 20 cardiologists from France and Germany (both n=10) to test for validity and reliability. The final questionnaire was converted into a semi-structured on-line interview of 20-25 min duration and translated into the appropriate local languages; respondents in Switzerland could choose between the French and German versions. The technical set-up of the internet questionnaire ensured that all entries were automatically checked for plausibility and consistency, while automatic routing guided the respondents and made it easy for them to complete the questionnaire. Finally, the flow of the questionnaire was designed to prevent biasing the reactions to the patient scenarios by other questions.

Data are presented as mean percentage responses and outcomes and findings are descriptive; statistical comparisons were not deemed appropriate due to small sample sizes, particularly those from the Nordic countries and Switzerland, and trends could only be reported in French, German and Spanish cardiologists' responses.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 
3.1. Respondents
Of 484 cardiologists who responded to the invitation to participate in the survey, only 17 participants failed to complete the questionnaire.

A total of 467 cardiologists from France (n=116), Germany (n=108), Spain (n=100), Switzerland (n=41), Sweden (n=45), Norway (n=32) and Finland (n=25) completed the survey. Overall, 11% of respondents were female, with the highest proportion in Finland (36%). The majority of respondents (59%) were hospital-based; of the remainder, 24% had office-based practices and 17% had mixed practices. The proportion of hospital-based physicians was higher in the Nordic countries (76-93%) compared with the other countries surveyed (41-54%). Generally, those cardiologists in office-based practices had more years of experience treating patients with CHF (mean 18.5 years) than those in mixed practices (14.9 years) or in hospital practices (13.1 years).

3.2. Awareness of and attitudes to guidelines
Spontaneous awareness of guidelines for the management of CHF was high, with almost all respondents (98%) stating that they were aware of their existence. Overall, 65% of respondents spontaneously mentioned the ESC guidelines (Fig. 1), while American guidelines (43%) and national guidelines (48%) were mentioned by nearly half of those sampled. Spontaneous awareness of ESC and American guidelines was higher among hospital-based (70% and 67%, respectively) than mixed practice cardiologists (45% and 51%, respectively) or office-based cardiologists (51% and 32%, respectively). No major differences in awareness of national guidelines were noted (48% across all practice types).


Figure 01
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  		Fig. 1 Spontaneous and prompted awareness of ESC guidelines for CHF. For spontaneous awareness, respondents listed the guidelines they were aware of; for prompted awareness they were asked specifically if they were aware of the ESC guidelines.

 
Overall, 90% of respondents regarded CHF guidelines as relevant or very relevant for guiding their treatment choices. In prompted questioning, the ESC and national guidelines were considered to be most relevant. Among 457 respondents who reported that they were aware of more than one guideline, 44% stated that the ESC guidelines were most relevant to them, while 36% noted that national guidelines were most relevant. In Germany, France and Sweden, and for office-based physicians generally, national guidelines still play a major role in their treatment decisions, while 31% of Spanish cardiologists reported that they found the American guidelines relevant.

The majority of respondents (78%) reported that they follow CHF guidelines in general closely. Among 392 cardiologists who were aware of the ESC guidelines in prompted questioning, 78% reported close adherence to the guidelines, regardless of practice type. The highest proportions of cardiologists who reported that they followed the ESC guidelines closely were in Switzerland and Finland, with the lowest in Norway and Sweden (Fig. 2). Among cardiologists who were aware of the ESC guidelines, 63% reported that they were very familiar with the latest update.


Figure 02
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  		Fig. 2 Self-assessment of adherence to CHF guidelines by cardiologists who were aware of the ESC guidelines.

 
3.3. Sources of information
Respondents who were aware of the ESC guidelines in prompted questioning reported that they gained their knowledge of and information about those guidelines mainly from congresses (80% of respondents) and medical journals (75% of respondents), regardless of practice type or country. Approximately 50% of respondents in hospital-based or mixed practices also cited the Internet as a source of information.

3.4. Assessed management patterns
The three patient scenarios and relevant feedback are presented in detail in Appendix A available online. In brief, they were: a 69-year-old man with a history of hypertension and myocardial infarction, newly diagnosed with heart failure; a 70-year-old woman diagnosed with heart failure 2 years ago, now with exacerbation of symptoms; and a 75-year-old woman with CHF and preserved left ventricular function.

In general, the respondents' treatment recommendations were in line with those of the expert panel. However, the proportions of respondents who made recommendations that completely matched those of the expert panel ranged from 1% for the first two scenarios to 25% for the patient with CHF and preserved left ventricular function (Fig. 3).


Figure 03
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  		Fig. 3 Summary of responses for the three patient scenarios. Respondents (%) with treatment changes matching those of the panel. Scenario 1: Patient with newly-diagnosed heart failure; Scenario 2: Patient with uncontrolled CHF; Scenario 3: Patient with CHF and preserved left ventricular function.

 
3.5. Perceived barriers to implementation of guidelines
Poor patient compliance and complexity of guidelines were cited as the main barriers for adherence to guidelines (Fig. 4). Some differences between countries relating to external factors such as cost and time were observed, but respondents in all countries identified the complexity of the guidelines as an important barrier. Amongst a sub-group of 180 respondents who stated that they identified other barriers to implementation of guidelines, the reasons cited included the presence of comorbid conditions (18%), adverse effects or contraindications for medications (13%), and issues relating to polypharmacy (6%).


Figure 04
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  		Fig. 4 Cardiologists' perception of barriers for adherence to guidelines for CHF.

 
Respondents were also asked about ways to improve adherence to guidelines. Provision of guidelines in a user-friendly format (e.g. short summary), translation into local languages and delivery of updates by e-mail were suggested as ways to improve implementation (Fig. 5).


Figure 05
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  		Fig. 5 Possible strategies to improve implementation of guidelines.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 
The results of the ADDress your Heart study indicate that most cardiologists in Europe agreeing to take part in this on-line survey were aware of the existence of the ESC guidelines for the management of CHF, and generally perceived them as very relevant to their daily practice. In addition, the majority of those respondents who were aware of the ESC guidelines reported that they were very familiar with the latest updates to those guidelines, and also reported that they adhered to the guidelines closely. However, when their agreement with those guidelines was assessed by way of the three patient case scenarios, at best only 25% of the total sample made treatment recommendations that exactly matched those of an expert panel, based on the 2005 ESC guidelines. Furthermore, in spite of the positive attitudes towards guidelines, the respondents considered that the complexity of such guidelines is a barrier to their implementation in routine clinical practice.

This study has several limitations. Respondents were ‘self-selected’ and may be atypical of the total cardiologist population, a factor supported by the completion rate for such a survey being atypically high. However, the use of country-specific quotas for the inclusion of cardiologists from office-based, hospital-based and mixed practices ensured that they were representative of the overall cardiology population in their respective countries. Furthermore, the fact that the majority of respondents were male, with the highest proportion of female respondents in Finland, is consistent with the trend that the Nordic countries generally have a higher share of female cardiologists than countries in Central and Southern Europe.

In terms of the treatment of patients with CHF, only the respondents' knowledge of recommendations for pharmacotherapy was assessed in three fictitious case scenarios. In reality, the responses given in the survey may not be those elicited in the ‘real world’ where other factors, such as the presence of co-morbidities and patient attitude and compliance have to be considered. The way in which the scenarios were presented may also have been confusing for some respondents. It should also be noted that although the treatment recommendations for Scenario 3 (CHF with preserved left ventricular function) were valid at the time of the survey, opinions on the optimal treatment are continually changing, and we still lack proper clinical trials to give evidence-based advice on the optimal treatment of these patients. Nevertheless, the patient scenarios were a useful tool for investigating cardiologists' opinions on treatment choices and how closely they concur with the latest ESC guidelines for CHF. However, concordance with the opinions of an expert panel is not a measure of the implementation of those guidelines in clinical practice.

Notwithstanding these limitations, the findings of the survey are consistent with studies of actual treatment patterns in patients with CHF. For example, the EuroHeart Failure Survey screened discharge summaries of 11,304 heart failure patients from 115 hospitals in 24 countries over a 6-week period in 2000-2001, and found that beta-blockers and ACE inhibitors were under-used or given at insufficient doses to be optimally effective [15]. The survey also found that many factors influenced the rate of prescription of the recommended drugs including co-morbidities, aetiology of heart failure, medical setting (cardiology vs. internal medicine) and age. Poor adherence to guidelines was also reported in the management of octogenarian HF patients (mean age 85 years), with medications such as ACE inhibitors and beta-blockers that are known to improve the prognosis of CHF in younger patients being consistently under-used [19].

Surveys relating to other cardiovascular disease areas have also found that although physicians generally report a positive attitude towards and adherence to guidelines, their patients are not actually receiving optimal therapies. For example, the Lipid Treatment Assessment Program (L-TAP), which surveyed primary care physicians in the USA, found that although 95% of respondents reported awareness of the National Cholesterol Education Program guidelines, and 63% stated that they followed them "quite a bit", only 38% of their patients had achieved their LDL cholesterol target level [20]. Similarly, the From the Heart survey of physicians in 10 countries worldwide found that although 81% of physicians stated that they used guidelines to set cholesterol goals, only 47% of patients reached and maintained their goals. Nevertheless, 61% of physicians believed that a sufficient number of patients achieved their cholesterol goals [21].

Physicians are not the sole arbiters of guideline implementation. Patient compliance has a large part to play. As noted in the present survey, cardiologists considered patient compliance as one of the major barriers to full guideline implementation. This may be due in part to a lack of understanding of the potential ‘severity’ of CHF by patients and their families; for example, the SHAPE survey found that awareness of CHF among the general public in Europe is low [22]. In the management of CHF, Lainscak et al. reported that after hospitalisation for HF, many patients fail to remember non-pharmacological advice and of those that do, many do so incompletely [23].

Contra-indications to medications and the presence of co-morbidities were also cited as factors that can limit the full implementation of CHF guidelines. It is notable that the EuroHeart Failure Survey I observed that only a minority of patients would have been eligible for inclusion in the MERIT HF, SOLVD or RALES studies [24]. The need for careful up-titration of some medications is also a factor that may result in underdosage.

Notwithstanding the importance of patient-related factors in influencing the implementation of the ESC guidelines for management of CHF, almost half of the respondents stated that the length and/or complexity of the guidelines were also barriers to their implementation. To address this, many of the respondents stated that they would like to receive future versions of such guidelines in a more user-friendly format, such as a short summary of key recommendations, possibly delivered by e-mail and translated into local languages.

A recent report from a focus panel meeting that considered strategies for improving the implementation of guidelines for cardiovascular disease prevention, particularly with respect to lipids, also identified the provision of simplified guidelines as an important measure [25]. This observation is important since, in many ESC countries, heart failure management is provided by different categories of healthcare professionals, including general practitioners, internists and nurses. These professionals need to receive guidance in a condensed format, as they not only manage heart failure and other cardiovascular diseases, but also a range of other disease areas, including respiratory, rheumatic or metabolic disorders. In particular, the positive impact of guideline implementation on outcome in heart failure patients needs to be emphasised. In the MAHLER Survey, for example, it was observed that good adherence to guidelines was associated with a significant reduction in 6-month rehospitalisations for heart failure or cardiovascular reasons [16].

In summary, this survey found that although physicians consider the ESC guidelines on CHF useful in guiding their management of patients, they also find the guidelines complex and would welcome receiving future versions in a more accessible format. It may be that by providing both physicians and patients with valuable concise information about CHF and its appropriate treatment, we can begin to overcome some of the issues relating to compliance with therapy. Clearly, better education of both physicians and patients regarding CHF and the importance of effective treatments is necessary to improve its overall management.


   Conflict of interest
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conflict of interest
Appendix A. Supplementary data
 Acknowledgments
 References
 
Leif R. Erhardt has received grants, been an advisor and speaker for many pharmaceutical companies including Astra Zeneca.

M. Komajda, MD, PhD has received occasional research funding, sponsorship and fees from a variety of pharmaceutical companies, including AstraZeneca.

F.D.R. Hobbs has received occasional research funding, sponsorship and fees from a variety of pharmaceutical companies, including AstraZeneca.

J. Soler-Soler has received occasional research funding, sponsorship and fees from several pharmaceutical companies, including AstraZeneca.


   Appendix A. Supplementary data
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
Acknowledgments
 References
 
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejheart.2008.08.001.


   Acknowledgments
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
References
 
The members of the Expert Panel were: Chairman: Leif Erhardt, Malmö, Sweden; Michel Komajda, Paris, France; Richard Hobbs, Birmingham, UK; Jordi Soler-Soler, Barcelona, Spain; and Reiner Deitz, Berlin, Germany. Leif Erhardt was Treasurer of the Heart Failure Association at the time of the study, and has been involved in the development of Swedish guidelines for the management of heart disease, including heart failure. Michel Komajda was a Member of The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology and an Author of the 2005 update to the ESC guidelines for the diagnosis and treatment of CHF. Richard Hobbs was a Document Reviewer for the 2005 update to the ESC guidelines for the diagnosis and treatment of CHF.

The costs of conducting this study were met by an unrestricted grant from AstraZeneca.

Alison Taylor PhD, freelance writer, provided medical writing support funded by AstraZeneca.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conflict of interest
 Appendix A. Supplementary data
 Acknowledgments
 References
 

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