Heart Failure Care in General Practice

Abstract

Heart failure (HF) is an increasing health care problem worldwide, and a multidisciplinary approach with a general practitioner (GP) in the health care team is considered optimal. HF management has improved substantially over the last two decades, mainly for patients with HF with a reduced ejection fraction. Earlier studies have shown that HF management in primary care is far from optimal, with under prescription of guideline recommended drug treatment. Secondly, most of these studies performed in primary care included patients with a GP’s diagnosis of HF, and thus in a substantial number without a confirmatory echocardiogram, thus more likely including many false-positive HF cases. Thirdly HF and chronic obstructive pulmonary disease (COPD) are both common in the elderly, and often coexist. Thirty primary-care practices (PCPs), including urban, suburban, and rural practices, located in the vicinity of Utrecht in the central part of the Netherlands participated in cluster randomized trial. The study was executed between November 2010 and March 2013. The 30 PCPs were allocated randomly to the intervention group or the care-as-usual (control) group. The GPs from the 15 PCPs allocated to the intervention group underwent a half-day group-training session on the diagnosis and drug treatment of HF based on recommendations of the most recent ESC HF guidelines. The primary outcome was the use of guideline-recommended HF medication in patients with HF at 6 months. Secondary outcomes were health status at 12 months and mortality and hospitalizations at 28 months. An expert panel composed of two cardiologists and a GP with expertise in HF determined the presence or absence of HF (definite HF, possibly HF, or no HF) of the 683 eligible patients. In total 17.3% patients had no HF according to the panel, and 19.2% persons possibly HF, leaving 434 with definite HF. A half-day training program of GPs does not improve HF drug prescriptions in patients with established HF. Around one out of six patients with a GP’s diagnosis of HF is misclassified, and such overdiagnosis brings the risk of inappropriate patient management. Two-hundredandthirty-sixpatients out of the 434 withestablishedHFwereinvitedforspirometry.And 106participantswere able to undergo spirometry. Prescription of evidence-based HF drugs in patients with HFrEF did not change significantly between baseline and T1 comparing the intervention and control group. There was no statistically significant or clinically important differences in the eight domains of the SF-36 scale (Quality of life) between the intervention and control groups for patients with either HFrEF or HFpEF. Survival during 28 months did not significantly differ between the intervention and control groups for either HFrEF or HFpEF. A half-day training program of GPs does not improve HF drug prescriptions in patients with established HF. Around one out of six patients with a GP’s diagnosis of HF is misclassified, and such overdiagnosis brings the risk of inappropriate patient management. COPD is common inpatients with HF, both HFrEF and HFpEF, and remains undetected in the majority of patients.