Peters-Klimm F, Müller-Tasch T, Schellberg D, Remppis A, Barth A, Holzapfel N, Jünger J, Herzog W, Szecsenyi J
Department of General Practice and Health Services Research, University Hospital Heidelberg, Vossstrasse 2, Heidelberg 69115, Germany.
Clin Res Cardiol. 2008 Apr;97(4):244-52. doi: 10.1007/s00392-007-0617-6. Epub 2007 Nov 28.
There is robust evidence for effective pharmacotherapy of chronic (systolic) heart failure (CHF) which has led to the creation of guidelines, but many surveys evaluating CHF treatment show an under-utilisation of relevant drugs, while setting and patient population appear to be crucial for adequate appraisal of treatment patterns.
To evaluate the guideline adherence (GA) of general practitioners (GPs) in a well-defined patient population with CHF in primary care (PC).
A cross-sectional analysis was performed with the data of 167 patients enrolled in 37 GP practices (Germany) with documented left ventricular systolic dysfunction (LVEF: 33.3 +/- 6.9%). GA was assessed as usual (prescribing "yes" or "no"), through evaluation of target dosing, while adjusting for potential clinical contraindications, and through a modified Guideline Adherence Indicator-3 (mGAI-3), which assesses three relevant groups of substances according to New York Heart Association (NYHA) functional class: ACE-Inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone-antagonists (AA).
Prescription rates for ACE-I/ARB, BB or both were 80%, 75% and 62%, respectively. The proportion of target doses reached for ACE-I was 16%, for BB only 8%. When adjusted for potential (mainly relative) contraindications (COPD, heart rate <60/min, hypotension, hyperkalaemia and renal dysfunction), the percentage of target doses reached increased to 49% for ACE-I/ARBs and 46% for BB. Application of the mGAI-3 showed moderate to perfect GA for usual assessment, proportion of target dose reached and adjusted in 83%, 16% and 55% of the patients, respectively.
In the context of this patient and doctor setting, life-saving treatment was provided above average when assessed by usual criteria. The application of additional criteria showed further room for improvement. Future interventions aiming at optimisation should be tailored to the needs of doctors and patients likewise.
有充分证据表明慢性（收缩性）心力衰竭（CHF）的药物治疗有效，这促使了相关指南的制定，但许多评估CHF治疗的调查显示，相关药物的使用不足，而治疗环境和患者群体似乎对充分评估治疗模式至关重要。
评估初级保健（PC）中明确界定的CHF患者群体中全科医生（GPs）的指南依从性（GA）。
对德国37家全科医生诊所登记的167例患者的数据进行横断面分析，这些患者有记录的左心室收缩功能障碍（左心室射血分数：33.3±6.9%）。通过评估目标剂量，同时调整潜在的临床禁忌症，并通过改良的指南依从性指标-3（mGAI-3）来评估GA，mGAI-3根据纽约心脏协会（NYHA）功能分级评估三类相关药物：血管紧张素转换酶抑制剂（ACE-I）或血管紧张素受体阻滞剂（ARB）、β受体阻滞剂（BB）和醛固酮拮抗剂（AA）。
ACE-I/ARB、BB或两者的处方率分别为80%、75%和62%。达到ACE-I目标剂量的比例为16%，BB仅为8%。在调整潜在（主要是相对）禁忌症（慢性阻塞性肺疾病、心率<60次/分钟、低血压、高钾血症和肾功能不全）后，ACE-I/ARB达到目标剂量的百分比增加到49%，BB为46%。mGAI-3的应用显示，在常规评估、达到目标剂量的比例和调整方面，分别有83%、16%和55%的患者具有中度至完美的GA。
在该患者和医生环境中，按照常规标准评估时，提供了高于平均水平的挽救生命的治疗。额外标准的应用显示仍有进一步改进的空间。未来旨在优化治疗的干预措施应同样根据医生和患者的需求进行调整。
