James P A, Cowan T M, Graham R P, Jaén C R, Majeroni B A, Schwartz J S
Department of Family Medicine, State University of New York at Buffalo, USA.
J Fam Pract. 1999 Oct;48(10):790-8.
Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure.
We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status.
Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF (91%) than among those with a normal LVEF (62%). Among patients with systolic heart failure taking ACE inhibitors, 87% were at target doses. Adherence measures were low for laboratory evaluation and patient-education criteria.
Heart failure with normal LVEF was as prevalent as systolic heart failure in these primary care practices. Performance profiles for the physicians' prescriptions of ACE inhibitors exceeded those published in the literature. Patients who did not have a documented measure of LVEF, however, received lower quality of care as measured by this disease-specific guideline. This underscores the importance of measuring LVEF.
人们对初级保健医生为心力衰竭患者提供的护理质量存在担忧。我们使用基于证据的临床指南，评估了为收缩性心力衰竭患者提供的护理。
我们回顾性分析了纽约州北部25家初级保健机构中420例已被诊断为心力衰竭患者的病历。病历记录证实了诊断（n = 395）。我们排除了非心源性容量超负荷或可纠正瓣膜疾病患者（n = 338）。绩效概况衡量了诊断测试的使用、左心室射血分数（LVEF）测量、患者教育以及血管紧张素转换酶（ACE）抑制剂的处方情况。对于治疗建议，根据LVEF状态对患者进行分类。
在研究的患者中，只有82%的病历中有LVEF测试结果记录。其中，49%的患者LVEF≤40%。LVEF低的患者中ACE抑制剂的使用率（91%）高于LVEF正常的患者（62%）。在服用ACE抑制剂的收缩性心力衰竭患者中，87%达到了目标剂量。实验室评估和患者教育标准的依从性指标较低。
在这些初级保健机构中，LVEF正常的心力衰竭与收缩性心力衰竭一样普遍。医生开具ACE抑制剂的绩效概况超过了文献中公布的水平。然而，根据这一特定疾病指南衡量，未记录LVEF测量值的患者接受的护理质量较低。这突出了测量LVEF的重要性。
