Hobbs F D, Jones M I, Allan T F, Wilson S, Tobias R
Department of Primary Care and General Practice, Medical School, University of Birmingham, U.K.
Eur Heart J. 2000 Nov;21(22):1877-87. doi: 10.1053/euhj.2000.2170.
To survey a random sample of primary care physicians across six European countries regarding their perceptions of diagnostic and prescribing issues in heart failure, and to consider factors that might be associated with physician under-performance.
Qualitative, postal questionnaire-based, validated survey in the native tongue of a random sample of 200 primary care physicians in each of five European countries (France, Germany, Italy, The Netherlands and Spain) and of 250 U.K. primary care physicians. Respondents provided: details of practice characteristics; the usual way a diagnosis of heart failure was established; access to investigations; names of drugs prescribed in heart failure, with estimates of the proportion of patients supplied with particular classes; and physician attitudes regarding the evidence base (in terms of benefits and risks) for treatments used. Outcomes were physician perceptions and attitudes about heart failure diagnosis and treatment. Adjusted response rates varied from 17% (France) to 56% (Britain). Primary care physicians underestimate the prevalence of heart failure. Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Although most primary care physicians stated they prescribe ACE inhibitors in heart failure, this was for only 47-62% of patients, and at doses below those identified as effective in trials. Most prescribing doctors (91%) believe there is strong evidence of reduced mortality in heart failure patients using ACE inhibitors, but 51% also consider ACE inhibitors have substantial risks with their use.
Limitations of the data include the general problem of questionnaires, whether responses accord with actual clinical practice, and, specific to these data, the low response rate in some countries (although the study does provide information from nearly 300 randomly selected primary care physicians across Europe). New preliminary insights include exposition of the 'low tech' approach to heart failure diagnosis across Europe: doctors report the use of symptoms and signs alone; the lack of direct (open) access to objective investigations, such as echocardiography, which almost guarantees that misdiagnoses will occur; and the under-utilization and under-dosing with ACE inhibitors. The main factor influencing under-use would appear to be the exaggerated perceptions of treatment risk amongst primary care physicians that dominate the widespread and accurate knowledge of treatment benefits.
对六个欧洲国家的初级保健医生进行随机抽样调查，了解他们对心力衰竭诊断和处方问题的看法，并探讨可能与医生表现不佳相关的因素。
采用基于邮寄问卷的定性验证式调查，以每个欧洲国家（法国、德国、意大利、荷兰和西班牙）200名初级保健医生以及250名英国初级保健医生的母语进行。受访者提供了：执业特征细节；确诊心力衰竭的常用方法；进行检查的途径；心力衰竭所开药物的名称，以及使用特定类别药物的患者比例估计；医生对所用治疗方法的证据基础（益处和风险方面）的态度。结果是医生对心力衰竭诊断和治疗的看法及态度。调整后的回复率从17%（法国）到56%（英国）不等。初级保健医生低估了心力衰竭的患病率。大多数患者仅根据症状和体征被诊断，只有32%的患者进行了进一步检查或转诊。尽管大多数初级保健医生表示他们在心力衰竭治疗中会开具ACE抑制剂，但只有47 - 62%的患者使用，且剂量低于试验中确定的有效剂量。大多数开处方的医生（91%）认为有充分证据表明使用ACE抑制剂可降低心力衰竭患者的死亡率，但51%的医生也认为ACE抑制剂使用存在重大风险。
数据的局限性包括问卷的普遍问题，即回复是否符合实际临床实践，以及就这些数据而言，一些国家的低回复率（尽管该研究确实提供了来自欧洲近300名随机选择的初级保健医生的信息）。新的初步见解包括揭示欧洲心力衰竭诊断的“低技术”方法：医生报告仅使用症状和体征；缺乏直接（开放）获取客观检查（如超声心动图）的途径，这几乎必然会导致误诊；以及ACE抑制剂的使用不足和剂量不足。影响使用不足的主要因素似乎是初级保健医生对治疗风险的夸大认知，这种认知超过了对治疗益处的广泛且准确的了解。
