Department of General Practice and Health Services Research, University Hospital Heidelberg, Baden-Wuerttemberg, Germany.
PLoS One. 2012;7(2):e31082. doi: 10.1371/journal.pone.0031082. Epub 2012 Feb 21.
The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence.
To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models.
Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92-0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02-1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38-1.05, p = 0.08).
A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.
心力衰竭（HF）患者的管理需要考虑到多变且复杂的个体临床特征。指南建议使用肾素-血管紧张素系统抑制剂（RAAS-I）进行靶向剂量治疗。但医生似乎并没有充分遵循这一建议，而对于医生和患者的依从性预测因素知之甚少。
本研究旨在检查初级保健（PC）医生的知识和自我感知能力与RAAS-I的相关性，以及这些知识和自我感知能力与患者相关障碍之间的关系。这是一项在随机医学教育干预试验后的横断面随访研究，观察期为 7 个月。研究对象为巴登-符腾堡州实践中的 37 名 PC 医生和 168 名收缩性 HF 患者。测量指标包括知识（基于蓝图的多项选择测试）、自我感知能力（关于治疗整体信心和 RAAS-I 使用频率的问卷）和患者变量（年龄、性别、NYHA 功能状态、血压、钾水平、肾功能）。处方由试验记录收集。目标变量是调查≥50%的推荐 RAAS-I 剂量，采用二水平逻辑回归模型进行分析。
患者（69%为男性，平均年龄 68.8 岁）存在有症状和客观的左心室（NYHA II 与 III/IV：51%与 49%和平均 LVEF 为 33.3%）和肾功能损害（GFR<50%：22%）。RAAS-I 目标剂量的平均百分比为 47%，59%的患者接受≥50%的剂量。改善 RAAS-I 处方的决定因素是患者年龄（OR 0.95，95%CI 0.92-0.99，p=0.01）、医生随访时的整体自我信心（OR 1.09，95%CI 1.02-1.05，p=0.01）和 NYHA 分级（II 与 III/IV）（OR 0.63，95%CI 0.38-1.05，p=0.08）。
作为 RAAS-I 剂量增加预测因素的医生信心变化是一个新发现，可能反映了干预对医生意图的改善效果，并可能为改善安全循证处方提供新的策略。这些策略应包括针对知识、态度和技能。
