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European Journal of Heart Failure 2003 5(3):355-361; doi:10.1016/S1388-9842(03)00047-3
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© 2003 European Society of Cardiology

Difficulties of introducing the National Service Framework for heart failure into general practice in the UK

Nigel Sparrowa,*, David Adlamb, Alan Cowleyb and John R. Hamptonb

a Newthorpe Medical Practice Chewton Street, Eastwood, Nottingham NG16 3HB, UK
b Department of Cardiovascular Medicine, Queen's Medical Centre Nottingham NG7 2UH, UK

* Corresponding author. Tel.: +44-1773-760202. E-mail address: nigelsparrow{at}aol.com


   Abstract
Top
 Notes
 Abstract
1. Introduction
 2. Method
 3. Results
 4. Discussion
 References
 
Background: The National Service Framework (NSF) sets standards for the management of heart failure in the UK. Loop diuretics are commonly first prescribed in primary care. Some patients taking these drugs have heart failure and may benefit from other treatments including ACE inhibitors. Accurate diagnosis in primary care is essential for the aims of the NSF to be realised.

Aims: To investigate loop diuretic prescribing in general practice, to analyse recorded clinical features, patient investigations and ACE inhibitor use in this population.

Method: One thousand three hundred and one patients taking loop diuretics were identified from prescription records of seven general practices. Demographic details, clinical features, investigations and drug treatments were extracted from patient records.

Results: The prevalence of loop diuretic prescribing increased with age. Twenty percent of patients were attributed a diagnosis of heart failure but relevant clinical features were recorded in less than 50% of patient records. Open access echocardiography was used in 8.9% of patients. ACE inhibitors were prescribed in 39.8% of patients considered to have heart failure. 18.2% of these were taking the recommended target dose.

Conclusion: Loop diuretics are prescribed commonly, particularly in the elderly. There is no clear pattern of documented clinical features that leads to prescription of these drugs. Open access echocardiography is rarely used to aid diagnosis. ACE inhibitors are under-prescribed and under-dosed in patients diagnosed with heart failure in this study population.

Key Words: Loop diuretics • Heart failure • General practice • ACE inhibitors

Received August 5, 2002; Revised January 8, 2003; Accepted January 21, 2003


   1. Introduction
Top
 Notes
 Abstract
 1. Introduction
2. Method
 3. Results
 4. Discussion
 References
 
The National Service Framework (NSF) for coronary heart disease is produced by the Department of Health in the UK [1]. The NSF sets standards for the prevention, diagnosis and treatment of heart disease. This includes patients with chronic heart failure. Most patients with heart failure present in general practice [2]. The diagnostic processes in primary care are therefore critical to fulfilling the aims of the NSF. There are no universally accepted diagnostic criteria and clinical diagnosis may be difficult, especially in the early stages of disease. Accurate diagnosis has become increasingly important with the identification of therapies that can improve both morbidity and mortality in heart failure. These include ACE inhibitors [3,4], B blockers [5,6] and spironolactone [7].

Loop diuretics are amongst the most commonly prescribed drugs [8,9]. These drugs are frequently first prescribed in a general practice setting and once started are often continued in the long term [10]. The proportion of patients receiving loop diuretic drugs increases markedly with age [11]. The use of long-term loop diuretics on a large scale in the elderly has been questioned. However, attempts to withdraw treatment in selected patients has been shown to lead to a recrudescence of the symptoms of heart failure in a significant proportion of patients [12]. A substantial subpopulation of patients prescribed loop diuretics have chronic heart failure [13]. It is not clear what clinical indications trigger the prescription of loop diuretics in primary care. It is also not clear which clinical features and investigations primary care physicians use to make a firm diagnosis of heart failure and if such patients are managed in accordance with NSF guidelines.

The purpose of this study was to investigate a population of patients prescribed loop diuretics in primary care. The aim was first to investigate the prevalence of loop diuretic prescribing in primary care amongst different age groups. Then by studying the general practice records of patients taking loop diuretics, to establish the clinical symptoms, signs and diagnoses which lead to the prescription of these drugs. Finally, we studied the investigation and management of this patient population and, in particular, the use of ACE inhibitors in patients on loop diuretics for heart failure.


   2. Method
Top
 Notes
 Abstract
 1. Introduction
 2. Method
3. Results
 4. Discussion
 References
 
Seven general practices in the Nottingham area of the United Kingdom were studied between January 1995 and December 1998. The study area included both urban and rural practices with list sizes ranging from 4 to 12 000. The total population covered by these practices was 60 728 patients. This practice population was under the care of an estimated 27 full time equivalent general practitioners. One thousand three hundred and sixty-six of these patients were found from practice prescribing records to be taking loop diuretics. A research nurse visited these practices and completed a data collection form using information from the general practice records of 1301 of these patients. The remaining patient records were unavailable at the time of data collection.

The following data were collected: basic demographic details of the age and sex of each patient, aspects of the past medical history and current drug prescriptions. In addition, the diagnosis or principle symptom recorded by the general practitioner that led to prescription of the loop diuretic was noted. It was found retrospectively that the indications recorded by general practitioners were heterogeneous. For analysis these data were sorted by one of the authors (N. Sparrow) into seven clinical indication categories; ‘definite heart failure’, ‘probable heart failure’, ‘shortness of breath’, ‘ankle swelling’, ‘hypertension’, ‘other’ and ‘no diagnosis recorded’. Details of any recorded clinical symptoms and signs documented in support of the main diagnosis were also obtained. Finally, any patient investigations performed in the 6 months prior to commencement of loop diuretics were recorded. These included the use of open access echocardiography, which was fully available in this district at the time of the study.

Ethical approval for this study was obtained from the Queens Medical Centre Ethics Committee.


   3. Results
Top
 Notes
 Abstract
 1. Introduction
 2. Method
 3. Results
4. Discussion
 References
 
The characteristics of the 1301 patients prescribed loop diuretics from whose general practice records the data were obtained are shown in Table 1. The type of loop diuretic prescribed is also shown. The majority of patients were prescribed either frusemide alone (38.7%) or frusemide in combination with amiloride (54.3%). Two patients were prescribed metolozone in combination with a loop diuretic, whilst four patients were taking spironolactone in addition to frusemide.


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  		Table 1 Patient characteristics

 
Dosing data were available in 610 patients taking loop diuretics. Four hundred and twelve (67.5%) patients were taking an equivalent of 40 mg frusemide daily (assumes 1 mg Bumetanide equivalent to 40 mg frusemide). Seventy-seven (12.6%) were taking an equivalent of 80 mg frusemide. Forty-nine (8%) were prescribed doses higher than 80 mg, whilst 70 (11.5%) were given doses of less than 40 mg daily.

The prevalence of patients prescribed loop diuretics increased with age reaching 25% of patients in the over 85-age group (Fig. 1).


Figure 1
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  		Fig. 1 Percentage of general practice patients taking loop diuretics by age.

 
In addition to the data on the prescription of other cardiac-acting medications shown in Table 1, the prescription of ACE inhibitors was analysed. ACE inhibitor prescription rates for each of the seven clinical indication categories are shown in Table 2. In those patients attributed a diagnosis of ‘definite heart failure’, 39.8% were prescribed ACE inhibitors in addition to loop diuretics. This compares with an overall 31.3% rate of ACE inhibitor prescription in all patients taking loop diuretics. Of those patients given a diagnosis of ‘definite heart failure’ for whom an ACE was prescribed (N=101), 19 (18.2%) of the 88 from whom dosage data is available, were prescribed the target dose recommended for heart failure in the European Society of Cardiology Guidelines [19]. The remainder were prescribed lower doses.


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  		Table 2 Diagnosis or symptom indication recorded in GP records at time of prescription of loop diuretic

 
The indications given in the general practice records that lead to loop diuretic prescription were grouped according to the diagnostic and symptom categories shown in Table 2. The relative frequency of each of the categories is also given. 20.3% of patients prescribed loop diuretics were given a diagnosis of definite heart failure. A similar proportion, 18.3% were prescribed loop diuretics for ankle swelling alone. No clear diagnosis or symptom indication was recorded in 31.7% of patient records.

Symptoms and clinical signs recorded by general practitioners at the time of prescription of loop diuretics are shown in Figs. 2 and 3, respectively. There is an increased recording of the clinical features associated with heart failure in the patients given this diagnosis. However, these symptoms and signs do not clearly distinguish between the diagnostic groups. Overall these symptoms and signs are documented in fewer than 50% of the general practice records of patients started on loop diuretic therapy.


Figure 2
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  		Fig. 2 Symptoms recorded in GP records at time of prescription of loop diuretic for each clinical indication. Note: HF=Heart Failure, SOB=Shortness of Breath, SOA=Swelling of Ankles, HTN=Hypertension.

 


Figure 3
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  		Fig. 3 Clinical signs recorded by GPs at the time of prescription of loop diuretics for each clinical indication. Note: HF=Heart Failure, SOB=Shortness of Breath, SOA=Swelling of Ankles, HTN=Hypertension.

 
Investigations requested in the 6 months prior to loop diuretic prescription are shown in Table 3. Open access echocardiography was used in the previous 6 months to aid diagnosis in 3.2% of patients started on loop diuretics. This rises to 8.9% of patients taking loop diuretics who had ever had an echo. Of those patients given a primary care diagnosis of ‘definite heart failure’, 6.4% had an echocardiogram, 21.2% had an ECG and 24.6% a chest X-ray in the last 6 months. Only 15.1% of patients given this diagnosis in primary care had ever had an echo. Of all patients taking loop diuretics, 20.4% had urea and electrolytes tested in the 6 months prior to starting treatment.


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  		Table 3 Clinical investigations ordered by clinical indication in the 6 months prior to loop diuretic prescription

 

   4. Discussion
Top
 Notes
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
References
 
These results confirm that prescription of loop diuretics is common in community practice. It increases with age with almost a quarter of patients over the age of 85 being prescribed a loop diuretic.

The vast majority of patients were prescribed frusemide, either alone or in combination with amiloride and usually a dose equivalent of 40 mg frusemide was prescribed.

The indications given on initiation of loop diuretic therapy were fairly heterogeneous. Approximately 20% were felt to have heart failure but an equivalent number were started on loop diuretics for ankle swelling alone. Almost a third of patients were started on these drugs without a clearly recorded diagnosis in their practice notes.

The symptoms recorded on initiation of loop diuretic therapy show an increased prevalence of both breathlessness on exertion and orthopnoea recorded in the heart failure group. This would be consistent with the syndrome of congestive cardiac failure. However, comments on the presence or absence of these symptoms were present in fewer than 50% of patient records. Furthermore, these symptoms did not differentiate between our clinical indication categories, with many patients with a recorded clinical indication other than heart failure reporting identical symptoms.

Features on clinical examination are also frequently not recorded in the patient records. More than two thirds of patients initiated on loop diuretics had no record in their notes of pulse character, jugular venous pressure, heart sounds, peripheral oedema or a chest examination. Reporting of absent signs was even more rare, occurring in less than 10% of patient records. Recording of clinical signs increases in patients attributed a diagnosis of heart failure. This may represent a genuine increase in clinical signs in this group but may also be the result of under-assessment or a lack of recording of clinical signs in patients assigned to other diagnostic groups.

It is not clear from this study exactly what combination of symptoms and signs are being used by GPs to reach the clinical diagnosis that leads to the initiation of loop diuretic treatment. There is a considerable lack of documentation of clinical findings that may help in both the diagnosis and future management of heart failure. This may, in part, be a reflection of the inevitable under-recording of clinical negatives that results from constraints on patient consultation time. It is impossible to be certain to what extent the absence of recorded clinical information reflects incomplete patient assessment. The contemporaneous record keeping of primary care physicians limits the results of any retrospective study of this nature into community practice. However, the lack of data recording of important clinical signs and symptoms relevant to the diagnosis of heart failure is in itself an indication of the difficulties faced in introducing national guidelines into community practice. The results of this study suggest that clinical heart failure may be significantly under-diagnosed in the patient population studied. This has been confirmed by further study of this patient population [18].

Despite the diagnostic difficulties open access echocardiography is rarely used to facilitate the community diagnosis of heart failure. 3.2% of patients were referred for echocardiography in the 6 months prior to starting loop diuretics with only 6.4% of patients given a diagnosis of ‘definite heart failure’ being referred for this investigation. Of all the patients prescribed loop diuretics 8.9% had ever had echocardiography whilst only 15.1% of those given a diagnosis of ‘definite heart failure’ had ever received this investigation. Echocardiography is now recommended in the NSF for all patients with suspected heart failure. The use of open access echo services is likely to increase with better awareness of the availability and uses of this investigation.

From this study the favoured diagnostic tool for heart failure seems to be chest radiography, with 24.6% of ‘definite heart failure’ patients being referred for this investigation. It is also interesting to note that more than two thirds of patients initiated on loop diuretics did not have a U&E or creatinine checked in the 6 months prior to starting treatment. There are no clear guidelines on electrolyte monitoring in patients taking loop diuretics, although this is recommended as part of the assessment of patients with suspected heart failure [1,14,19].

31.3% of patients taking loop diuretics were prescribed ACE inhibitors. Interestingly, the largest proportion per diagnosis was in the hypertension group in which 72.7% were co-prescribed an ACE inhibitor. In this study 39.8% of patients attributed a diagnosis of ‘definite heart failure’ were prescribed an ACE inhibitor. These findings compare with those of a recent cross-sectional survey of secondary prevention prescribing in primary care [15]. This suggested approximately 50% of patients with coronary heart disease and heart failure are prescribed an ACE inhibitor. The difference between these results may reflect differences in the patient populations studied, as well as regional differences in prescribing practice. Furthermore, in those heart failure patients in whom an ACE inhibitor was prescribed, the doses used were generally small, with only 18% achieving the recommended target dose. There is now evidence that higher doses of ACE inhibitors are well tolerated and improve clinical outcome [16].

The results from our study compare with those of the IMPROVEMENT study. This is a recently published multinational (European) investigation of current practice in the management of heart failure in primary care [20]. The IMPROVEMENT investigators studied the practice of primary care physicians from widely spread regions of 15 European countries. These general practitioners were asked to keep a log of patients they saw with heart failure or who had suffered a myocardial infarction with or without heart failure. The frequency of clinical symptoms recorded were breathlessness in 82% (68% in the UK population), orthopnoea in 37% (23% in the UK) and fatigue in 68%, (34% in the UK). These compare well with the results in our ‘definite heart failure’ group (Fig. 2). The problem of under-recording of clinical features demonstrated by our data is also suggested in the results of IMPROVEMENT with 36% of UK patients having no record of symptom severity. The patient population in IMPROVEMENT were much more comprehensively investigated than our patients. Ninety-five percent of patients had undergone an ECG, 84% a chest radiograph and 82% an echo. It is interesting to note, however, the apparent reluctance among primary care physicians to request echocardiography. Only 45% (32% in the UK) of general practitioners in IMPROVEMENT would ‘usually ask for’ echocardiography. The high rates of patient investigation may in part reflect the way patients were selected for this study. Only patients confidently identified by the primary care physician as having heart failure (or past MI) were included. This may also explain the higher rates of ACE inhibitor prescription in this study population. In total 60% of patients were prescribed an ACE inhibitor although only 50% of these were taking recommended doses. The population we have studied is different (only 51% of patients in IMPROVEMENT were taking loop diuretics). However, the results of our study taken with those of IMPROVEMENT begin to improve understanding of the processes involved in diagnosis and management of patients with heart failure in primary care and the challenge of applying national and international guidelines in this setting.

Acknowledged limitations of the methodology in our study include the potential for inter-observer variation in both the research nurse's acquisition of data from primary care records and in the assignment of clinical indication categories. We do not feel these limitations have significantly influenced the results presented.

If the UK NSF guidelines for investigation and management of heart failure in primary care are to be met, greater diagnostic accuracy will be required to identify those patients that may benefit from innovative treatments. The results of this study suggest heart failure may at present be under-treated in general practice. The accurate assessment and recording of clinical features in general practice together with the appropriate investigation and management of patients with suspected heart failure is essential if the aims of the NSF to ‘help people with heart failure to live longer and achieve a better quality of life’ are to be fulfilled.


   Acknowledgements
 
The study was funded by a grant from Trent Regional Health Authority and the Nottinghamshire Multi-disciplinary Audit Advisory Group.


   Notes
Top
 Notes
Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 References
 
{star} For relevant further reading, please refer to Ref. [17].


   References
Top
 Notes
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 References
 

  1. National Service Framework—Coronary Heart Disease. Department of Health, 2000.
  2. Wheeldon T.M., MacDonald T.M., Flucker C.J., et al. Echocardiography in chronic heart failure in the community. QJM (1993) 86:17–23.[Abstract/Free Full Text]
  3. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Co-operative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med (1987) 316:1429–1435.[Abstract]
  4. SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med (1991) 325:293–302.[Abstract]
  5. CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet (1999) 353:9–13.[CrossRef][Web of Science][Medline]
  6. MERIT-HF Study Group. 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.[CrossRef][Web of Science][Medline]
  7. Pitt B., Zannad F., Remmie W.J., et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med (1999) 341:709–717.[Abstract/Free Full Text]
  8. Stewart R.B., Moore M.T., May F.E., et al. A longitudinal evaluation of drug use in an ambulatory elderly population. J Clin Epidemiol (1991) 44:1353–1359.[CrossRef][Web of Science][Medline]
  9. Chrischillis E.A., Foley D.J., Wallace R., et al. Use of medications by persons 65 and over: data from the established populations for epidemiologic studies of the elderly. J Gerontol (1992) 47:M137–M144.[Abstract]
  10. Rhodes K.E. Prescription of diuretic drugs and monitoring of long-term use in one general practice. Br J Gen Pract (1992) 42(355):68–70.[Web of Science][Medline]
  11. Straand J., Rokstad K. Are prescribing patterns of diuretics in general practice good enough? Scand J Prim Health Care (1997) 15:10–15.[Web of Science][Medline]
  12. Walma E.P., Hoes A.W., van Dooren C., et al. Withdrawal of long-term diuretic medication in elderly patients: a double blind randomised trial. BMJ (1997) 315:464–468.[Abstract/Free Full Text]
  13. Clarke K.W., Grey D., Hampton J.R. How common is heart failure? Evidence from PACT (Prescribing analysis and cost data in Nottingham). J Pub Health Med (1995) 17:459–464.[Abstract/Free Full Text]
  14. Williams, et al. Evaluation and management of heart failure. JACC (1995) 26:1320–1398.
  15. Brady A.J.B., Oliver M.A., Pittard J.B. Secondary prevention in 24 431 patients with coronary heart disease: survey in primary care. BMJ (2001) 322:1463.[Free Full Text]
  16. Packer M., Poole-Wilson P.A., Armstrong P.W., et al. Comparative effects of low doses and high doses of the angiotensin converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation (1999) 100(23):2312–2318.[Abstract/Free Full Text]
  17. Hobbs F.D.R. Management of heart failure: evidence versus practice. Does current prescribing provide optimal treatment for heart failure patients? Br J Gen Pract (2000) 50:735–746.[Web of Science][Medline]
  18. Sparrow N, Adlam D, Cowley A, Hampton JR. The diagnosis of heart failure in general practice: implications for the UK National Service Framework. Eur J Heart Fail 2003;5:349–354.
  19. Remme W.J., Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J (2001) 22:1527–1560.[Free Full Text]
  20. Cleland J.G.F., Cohen-Solal A., Cosin A.J., et al. Management of heart failure in primary care (the IMPROVEMENT of heart failure programme): and international survey. Lancet (2002) 360:1631–1639.[CrossRef][Web of Science][Medline]

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