© 2003 European Society of Cardiology
Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice
Utrecht Heart Failure Organisation (UHFO), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht P.O. Box 85500, Stratenum 6.101, 3508 AB Utrecht, The Netherlands
* Corresponding author. Tel.: +31-30-2538193; fax: +31-30-2539028; www.juliuscenter.nl E-mail address: f.h.rutten{at}med.uu.nl (F.H. Rutten).
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. DiscussionReferences |
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Background: Data on diagnosis and management of heart failure in every-day care are scarce.
Aims: To compare general practitioners’ and cardiologists’ diagnostic work-up and management of patients with (suspected) heart failure.
Methods: In a cross-sectional survey we studied a sample of 103 files of patients coded as heart failure in primary care (31 general practices), and 99 files of out-patients coded as heart failure from 9 hospitals in the Netherlands. We defined patients as heart failure ‘GP patients’, when they were managed by a general practitioner without co-treatment of a cardiologist.
Results: Patients managed in general practice were older (mean age 79 years (S.D. 8.5) and more often female than ‘cardiology patients’ (mean age 64 years (S.D. 11.7)). Ischaemic heart disease (31 vs. 57%) was more prevalent in ‘cardiology patients’. Additional investigations such as chest radiography (51% vs. 84%), electrocardiography (39% vs. 100%), and (Doppler-) echocardiography (12% vs. 97%) were performed more often in ‘cardiology patients’. Most patients received diuretics (85% vs.79%). Angiotensin converting enzyme inhibitors (40% vs. 76%), beta-blockers (9% vs. 30%), spironolactone (11% vs. 32%), and angiotensin-II-antagonists (6% vs. 13%) were prescribed much more often to ‘cardiology patients’.
Conclusion: General practitioners more often treat elderly, female patients with heart failure than cardiologists. General practitioners use less additional investigations and prescribe less potentially beneficial medication, compared to cardiologists. Population characteristics only partly explain these differences, suggesting that the physician's attitude has an important bearing on the uptake of treatment.
Key Words: Heart failure • Diagnosis • Management • Primary care • Secondary care
Received July 25, 2002; Revised December 12, 2002; Accepted January 21, 2003
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionReferences |
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Heart failure has gradually become one of the most prevalent cardiovascular disorders in Western societies, notably in the elderly [1,2]. A further increase in the prevalence of heart failure is expected in the near future due to the ageing population and more successful cardiovascular disease management. The last decade has produced important advances in chronic heart failure treatment and established the prognostic efficacy of some drugs, such as angiotensin converting enzyme inhibitors (ACE inhibitors), beta-blockers, spironolactone and angiotensin-II-antagonists in patients with heart failure due to left ventricular dysfunction. Less robust studies also show that patients with ‘diastolic heart failure’ are likely to benefit from the same type of drugs [3–6].
Heart failure is a prevalent disease in the elderly, with frequent co-morbidities, and a frequently unfavourable outcome. Notwithstanding the public health importance of heart failure, available data on heart failure management in clinical practice are sparse. We do know, however, that current diagnostic and therapeutic management of heart failure in clinical practice is still far from optimal [7–11]. General practitioners especially show hesitation in making use of (Doppler-) echocardiography as a diagnostic facility, resulting in diagnostic uncertainty [12]. Studies comparing every-day primary and secondary care, are rare.
We therefore, studied the diagnostic and therapeutic management of heart failure in current primary and secondary care.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionReferences |
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In a cross-sectional survey conducted in 2000, we visited 31 general practices (rural, urban, and suburban) and 9 hospitals in the Netherlands. We invited 19 general practices connected to the General Practice Network Utrecht (HNU); a computerised general practice network, co-ordinated by the Julius Center for Health Sciences and Primary Care, from the University Medical Center Utrecht, and 49 other general practices in the vicinity of Utrecht. All invited general practitioners routinely register their patient contacts in ELIAS (SMS Cendata Nieuwegein); a software package suitable for electronic registration of medical information [13,14]. The general practices consisted of both single-handed and group practices. All 19 general practices allied to the general practice network participated, together with 13 other general practices (overall response 63%). We included one academic, three middle size, and five smaller hospitals. The hospitals were selected at random. Only patients from the ‘general’ out-patient cardiology department were eligible for our study; patients from any specialised heart failure out-patient department were excluded.
For the purpose of this study, heart failure was defined pragmatically as a coded diagnosis of heart failure. The first inclusion criterion was a coded diagnosis of heart failure recorded more than once (single episodes were excluded) by a general practitioner or cardiologist. We required more than one registration of the heart failure code in the patient files, to minimise the number of false-positive diagnoses. The second inclusion criterion was a follow-up period of more than 3 months after initial registration of a coded heart failure diagnosis. This period was thought to be necessary for the physician to establish a complete diagnostic and therapeutic management regime. Finally, the third inclusion criterion was a period of 5 years or less between the initial diagnosis of heart failure and the date of the study.
We defined patients as ‘GP patients’ if they were never referred to a cardiologist or internist for (suspected) heart failure or if they were referred only once for diagnostic reasons. In general practice, we studied files from patients with the International Classification of Primary Care (ICPC) code K 77 (heart failure) [13] and in the cardiology out-patient department, files from patients with International Classification of Diseases, 9th edition (ICD-9) code 428 (heart failure).
Files of patients with an initial coded diagnosis of heart failure were scrutinised and all relevant information was extracted. In total 963 patients with an ICPC code K77 (heart failure) were identified in the 31 general practices. After application of inclusion and exclusion criteria, 103 patients remained. Of the excluded patients from general practice, 301 patients (31%) had been referred to a cardiologist and 9 (0.9%) to an internist for (suspected) heart failure. Another 135 patients (14%) had been referred to a cardiologist for other reasons. Also excluded were 308 patients for whom the ICPC code K 77 was only stated once in the patient files, and 32 patients for whom the initial ICPC code K77 was recorded more than 5 years before the date of our study. Another 75 patients were excluded because they had a follow-up period shorter than 3 months.
In addition, consecutive out-patient files of patients with ICD-9 code 428 (heart failure) from the ‘general’ out-patient cardiology department of nine different hospitals were scrutinised. After applying the previously mentioned inclusion and exclusion criteria, 11 patients with ICD-9 code 428 (heart failure) per hospital (in total 99 patients) were included in our study.
The following demographic, diagnostic, and treatment data were extracted from the patient notes: date of birth; sex; date of diagnosis of heart failure; referral to a cardiologist or internist; signs and symptoms in the days prior to the diagnosis; additional diagnostic investigations (such as echocardiography) performed 6 months prior to diagnosis and during the year since diagnosis; comorbidity (including coronary heart disease such as myocardial infarction, angina pectoris, and coronary revascularisation (percutaneous transluminal intervention (PTI)) or coronary artery bypass grafting (CABG); atrial fibrillation; valvular heart disease; chronic obstructive pulmonary disease (COPD); diabetes mellitus; stroke or transient ischaemic attack (TIA); physician contacts; prescriptions; counselling advice; co-treatment by other health care workers.
Approval of the study was obtained from the Ethics Committee of the University Medical Center Utrecht, the Netherlands.
Data analysis: Differences in proportions were assessed by 
2-tests and differences between means by t-tests. All analyses were undertaken using SPSS for Windows version 9.0 (SPSS, Chicago, IL).
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionReferences |
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3.1. Patient characteristics
The mean age of the general practice and cardiology patients was 79 (S.D. 8.5) and 64 (S.D. 11.7) years (P<0.001), respectively, and 42% vs. 78% (P<0.001) were male (Table 1). Patients with coded heart failure were seen by a physician approximately 4 times a year in both primary and secondary care. Ischaemic heart disease was more prevalent in ‘cardiology’ patients (31 vs. 57%, P<0.001). Hypertension (53 vs. 41%, P=0.09) and atrial fibrillation (23 vs. 16%, P=0.20) were somewhat more common in ‘GP patients’, although these differences were not statistically significant.
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3.2. Diagnosis
Dyspnoea was the most frequently recorded complaint in both primary and secondary care patients at the time of diagnosis (Table 2). Paroxysmal nocturnal dyspnoea (32 vs. 14%, P=0.003), nocturnal cough (36 vs. 13%, P<0.001), and pulmonary crepitations (77 vs. 46%, P<0.001) were more often recorded in ‘GP patients’. Anginal complaints (11 vs. 41%, P<0.001), heart murmurs (12 vs. 43%, P<0.001), a third heart sound (1 vs. 14%, P<0.001), and hepatomegaly (2 vs. 11%, P=0.007) were more often recorded in ‘cardiology patients’ (Table 2).
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Chest radiography (51 vs. 84%, P<0.001), electrocardiography (ECG) (39% vs. 100%, P<0.001), and (Doppler-) echocardiography (12% vs. 97%, P<0.001) were performed more often in ‘cardiology patients’, as were other additional investigations, with the exception of laboratory tests and pulmonary function tests (Table 3). None of the patients in either the primary or secondary care setting underwent measurement of neuropeptide (atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP)) levels.
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3.3. Laboratory, chest X-ray, electrocardiographic, and echocardiographic abnormalities
Except for anaemia, laboratory tests seldom showed any abnormalities. Chest X-rays showed abnormalities in a substantial proportion of the investigated patients (85 vs. 90%, P=0.32), in particular a cor-thorax ratio >0.50 (40 vs. 70%, P=0.001) (Table 4). Electrocardiographic abnormalities were often observed, especially ST-T abnormalities (68 vs. 91%, P=0.001), prior myocardial infarction (5 vs. 9%, P=0.42), left ventricular hypertrophy (13 vs. 20%, P=0.28), and atrial fibrillation (28 vs. 13%, P=0.04) (Table 4). During (Doppler) echocardiography heart valve dysfunction was often seen (50 vs. 64%, P=0.36), while signs of diastolic dysfunction (0 vs. 3%, P=0.54) and left ventricular hypertrophy (0 vs. 3%, P=0.54) were reported in a few cases only. A left ventricular ejection fraction (LVEF) <40% was recorded more often in ‘cardiology patients’ (17% vs. 48%, P=0.04) (Table 4).
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3.4. Pharmaceutical and non-pharmaceutical treatment
At the time of the assessment of the patient files, the vast majority of patients received diuretics, especially loop diuretics, both in primary (85%) and secondary care (79%) (Table 5). ACE inhibitors (40 vs. 76%, P<0.001), beta-blockers (9 vs. 30%, P<0.001), spironolactone (11 vs. 32%, P<0.001), and angiotensin II receptor antagonists (6 vs. 13%, P=0.08) were prescribed more often in ‘cardiology patients’. Only a minority of all patients using ACE inhibitors received the (high) dosages used in trials (32 vs. 44%, P=0.20). In both the GP's and cardiologist's population, age differences (age<70 years or
70 years) did not appear to play an important role in the prescription preferences (Table 6), nor in the rates of additional diagnostic investigations used (data not shown).
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In patient files of both ‘cardiology patients’ and ‘GP patients’ there was little information about non-pharmaceutical treatment and advice (Table 7) or co-treatment by other health care workers. A (heart failure) nurse (in 16% of the ‘cardiology patients’ and 3% of the ‘GP patients’) was most frequently mentioned as a co-treating health care worker (Table 8).
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4. Discussion |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionReferences |
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Our study shows that there are major differences in the population coded as heart failure by general practitioners and cardiologists. The GP more often manages elderly and female patients, while cardiologists more often treat relatively young male patients with a history of ischaemic heart disease. The GP uses fewer additional diagnostic investigations, and less often prescribes ‘evidence-based’ morbidity and mortality reducing medication.
The differences in diagnostic and therapeutic management between the GP and cardiologist can only partly be explained by the large difference in age of the coded heart failure patients: patients aged <70 years or 70 years are investigated and treated in a similar way by both health care providers. This suggests that the physician's attitude could have an important bearing on the uptake of treatment.
In our study we aimed to compare the management of patients with (suspected) heart failure in primary and secondary care. For this reason, patients with ICPC code K77 (heart failure) in general practice, who were referred to a cardiologist (except those patients referred for a single diagnostic assessment) (in total 31%) were excluded, since in practice these patients are primarily treated by cardiologists and not general practitioners. This is a major difference compared with other recent practice studies [8,11], and is an important reason for the relatively low number of additional diagnostic investigations such as echocardiographic assessment, and for lower prescription rates of potentially beneficial medication in ‘GP patients’. Fewer additional investigations in GP patients compared to those managed by the cardiologist, illustrates that the GPs’ diagnosis of heart failure is based primarily on clinical judgement [9,10]. However, diagnosing heart failure based on clinical judgement alone, is notoriously difficult and leads to considerable proportions of false-negative and false-positive diagnoses [7,15].
A limitation of our study is that we studied patients who had heart failure according to their physician, without confirming the diagnosis. We were, however, interested in current management in patients with (suspected) heart failure according to the GP or cardiologist, and our aim was not to study the incidence or prevalence of heart failure or the effects of interventions. Evidently, some patients, more often those in primary care, without heart failure will receive medication. We are convinced that this pragmatic choice does not bias our results. Since we only included patients in whom a diagnosis of heart failure was coded at least twice, we thus limited the number of false positives.
Since we performed a cross-sectional survey, using available patient files, data should be interpreted with the understanding that recording of investigations performed and their results may be incomplete. Because physicians are more likely to record abnormalities than normal findings, under-recording of normal findings is likely. We could only observe the prevalence of recording of clinical signs such as heart murmurs, a third heart sound and hepatomegaly in patients. Therefore, we do not know whether these clinical signs were less prevalent or less often assessed in GP patients. For similar reasons, participation rates for other health care workers and provision of life style advice are also likely to be underestimated. On the other hand, prospective surveys or questionnaires are likely to induce ‘desirable’ answers and this produces inflated estimates.
Our study confirms earlier observations that GPs treat those patients (elderly and women), who are underrepresented in trials [10]. This is important in the interpretation of the differences observed with ‘cardiology patients’. For example, the prevalence of ‘diastolic heart failure’ is higher in elderly female patients [16,17]. With ‘diastolic heart failure’ we mean both (symptoms of) heart failure with preserved left ventricular function and ‘pure’ diastolic heart failure, which implies the demonstration of left ventricular diastolic dysfunction [6]. However, the exact contribution of ‘diastolic heart failure’ in the overall picture of heart failure is still not clear. Non-invasive assessment of diastolic dysfunction remains difficult and a consensus regarding diagnostic criteria has not been agreed [18]. Moreover, tissue Doppler imaging has revealed that systolic abnormalities are present in about half of the patients with a LVEF50% with diastolic abnormalities on Doppler echocardiography [19]. One other study clearly showed that many patients suspected of having diastolic heart failure, had other explanations for their symptoms such as obesity or COPD [20].
Moreover, at the time our study was performed, available heart failure guidelines in the Netherlands provided diagnostic and therapeutic advice for (suspected) heart failure, without making a clear distinction between ‘systolic’ and ‘diastolic’ heart failure. Although, there are only a few small clinical trials of the pharmacological treatment of patients with ‘diastolic heart failure’, treatment with ACE inhibitors and beta-blockers seems to be of prognostic benefit [21,22]. Apart from this, treatment of the possible causes of ‘diastolic heart failure’, i.e. myocardial ischaemia, hypertension, myocardial hypertrophy and myocardial/pericardial constriction, also means that the physician could prescribe ACE inhibitors, beta-blockers and (low dose) diuretics [6].
There is robust evidence, that ACE inhibitors, beta-blockers, spironolactone, and angiotensin-II-antagonists reduce morbidity and mortality when prescribed in combination with diuretics, in patients with heart failure due to left ventricular dysfunction [23–29]. An important reason for under-use of prognostically beneficial medication by the GP in patients with heart failure due to left ventricular dysfunction, could be diagnostic uncertainty [8]. Under-use of ACE inhibitors in primary care was also observed in earlier studies from Great Britain [9,10]. Fear of the side effects of ACE inhibitors seems to be of more importance for under-prescription by the GP, than lack of knowledge of the possible beneficial effects [30]. Less than half of the patients in both primary and secondary care were prescribed high dosages of ACE inhibitor, similar to those used in the major trials [31], although high dosages are more effective in systolic heart failure, without an important increase in side effects [32]. Beta-blockers were prescribed in only a minority of patients coded as heart failure in our study. This is partly attributable to the fact that beta-blockers were contra-indicated in heart failure in the past, and the necessity to start with a low dosage and up-titrate very slowly; a process which takes several weeks and leads to a short period of increased complaints in some patients [26,27]. A possible explanation for the under-use of spironolactone in our study, is the under-representation of patients in NYHA class III or IV with a LVEF<40% in our study; the population in which spironolactone, added to diuretics and an ACE inhibitor, was proven to be effective [29]. Potentially harmful medication, such as first generation calcium antagonists and NSAIDs, [33] was prescribed in only 6–8% of the patients. In our study, patients of different ages were treated similarly by both health care providers. This is somewhat in contrast with a recently performed practice study, which showed that patients in general practice with (suspected) heart failure, aged over 75 years, were treated less with ACE inhibitors and beta-blockers [11].
Initially, we also intended to include patients from the internal medicine department in our survey. In the Netherlands, however, nearly all patients with (suspected) heart failure who are referred to the hospital or outpatient department are (co)treated by a cardiologist.
We conclude that heart failure patients managed by the general practitioner alone, are more often elderly, female patients, compared to heart failure patients managed by the cardiologist. Fewer additional investigations, and lower prescription rates of potentially beneficial medication in primary care are only partly explained by differences in population characteristics, suggesting that the physician's attitude has an important bearing on the uptake of treatment. In both primary and secondary care diagnostic and therapeutic management of heart failure does not reflect current scientific evidence.
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Acknowledgements |
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We thank the participating general practitioners, internists and cardiologists. In addition, we want to thank Diana Balk, Renate Siebes and Peter Zuithoff for administrative assistance and statistical help, and Geert van der Heijden, Ph.D., for critical comments on earlier versions of the manuscript. Financial support for this study was obtained from the Dutch Heart Foundation, grant number 48006.
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