Integrating heart failure guidelines into clinical practice

Abstract

Chronic heart failure is a complex syndrome that is associated with increasing prevalence due to the ageing of the global population. Effective pharmacological treatments and evidence-based diagnostic and treatment guidelines are available for the optimum management of patients with this condition; however, many patients do not receive the medications they require or are given suboptimal doses of appropriate treatments. Underutilization of effective therapies continues to present a challenge in heart failure management and results in considerable human and financial consequences. Widespread undertreatment stems from a range of factors including diagnostic challenges, physicians' prescribing patterns, poor patient adherence to prescribed medications, a lack of effective screening programmes or specialized heart failure units, and the absence of national registries in many countries, which enable the incidence of heart failure to be monitored accurately. Global adoption of a range of strategies including the education of healthcare workers and patients, the dedication of hospital and outpatient facilities to heart failure management, and adequate discharge planning may enable adherence to guidelines to be improved and the benefits of effective treatments to be maximized.

Introduction

Chronic heart failure (CHF) is a complex syndrome that affects predominantly elderly patients and is associated with increasing prevalence due to the ageing of the global population and our increasing ability to save more patients with acute coronary syndromes.^1–4 It has been predicted that CHF will exert a significant impact on the western world, conferring considerable mortality, morbidity, and financial burdens on the affected societies.^1,3–5

The European Society of Cardiology (ESC) Guidelines for the Diagnosis and Treatment of Chronic Heart Failure (2005)⁴ were developed to provide clinicians with guidance in the diagnosis, treatment, and management of CHF patients using evidence-based approaches in order to provide optimum high-quality, cost-effective care. The guidelines strongly recommend the prescription of diuretics, angiotensin-converting enzyme inhibitors, and beta-adrenergic antagonists (beta-blockers) as a result of the wealth of evidence available from clinical trials and meta-analyses supporting their efficacy.^6–10

However, numerous factors act as barriers to the effective adoption and implementation of treatment guidelines, because of which many CHF patients do not receive the medications they require.^3,11,12 The underutilization of beta-blockers in CHF provides a good illustration of this challenge.

Data from a number of randomized clinical trials have indicated that beta-blockers are effective in the management of CHF, enabling substantial reductions in mortality, morbidity, and hospitalizations to be achieved. However, primary care physicians (PCPs) and hospital-based physicians mistrust these agents because of concerns over adverse effects on initial titration and fears of worsening this condition in elderly patients.^11,13 As a result, many CHF patients either do not receive beta-blockers or receive suboptimal doses of these agents.^11,14 The EuroHeart Failure Survey indicated that only 37% of hospitalized CHF patients surveyed in 2000–2001 were receiving beta-blocker therapy,¹³ whereas only one-third of PCPs questioned in the IMPROVEMENT programme administered beta-blockers to their patients, and doses were ∼50% lower than recommended.¹¹ Recognition of the efficacy of beta-blockers in CHF has increased considerably in recent years; however, implementation of the guidelines lags far behind awareness, and these agents remain largely underutilized in CHF.¹¹

There are many factors that act as barriers to the adoption of international management guidelines and the successful implementation of effective treatment strategies in CHF. These barriers stem from a range of sources including relationships between healthcare professionals and patients, physicians' prescription strategies, professional societies, healthcare authorities, governments, and the pharmaceutical industry.^11,15–18 In this article, these factors will be discussed and strategies by which their impact may be minimized will be presented.

Diagnostic challenges

The complexity of CHF presents considerable diagnostic challenges to healthcare professionals.^12,19 Furthermore, symptoms of CHF may be less prominent in stable patients receiving effective medications.²⁰ There is currently no gold standard for the diagnosis of CHF and it is not known whether diagnostic recommendations are commonly followed.^4,12,19 In addition, effective diagnostic tools may be unavailable to many PCPs. Echocardiography, for example, is recommended as an essential tool for the detection of left ventricular systolic dysfunction, but is a costly and time-consuming procedure associated with considerable intra-observer variability and a requirement for expertise on the part of the user.²⁰

Strategies to educate medical staff in primary care and long-term care facilities, in conjunction with the establishment of regular contact between patients and healthcare workers, may facilitate the timely diagnosis of CHF and enable faster recognition of deteriorating symptoms.²¹ Furthermore, the dissemination of international diagnostic and treatment guidelines and the involvement of professional societies in research into diagnostic techniques may assist clinicians in meeting these challenges.

Physicians' prescribing patterns

PCPs are not always aware of the recommendations presented in the national and international treatment guidelines. In a US study of hypertension management, a considerable 41% of surveyed PCPs were unaware of the US Joint National Committee guidelines for hypertension or were not familiar with their recommendations, whereas 45% disagreed with their guidance.¹⁷ Such data indicate that physicians' prescribing patterns do not always reflect the current treatment guidelines or evidence-based medicine and may contribute to poor patient outcomes.^17,22,23

Among those who are aware of current guidelines, practitioners may be unconvinced of the efficacy of new treatments or may prefer to prescribe less effective treatments with which they or their patients are more familiar.¹¹ Beta-blockers, for example, can impair performance on initial administration because of abrupt withdrawal of homeostatic support from the sympathetic nervous system.²⁴ Gradual uptitration of initial doses, as recommended in the guidelines, minimizes these side effects but presents certain management challenges.⁴ Such challenges can have considerable influences on physicians' treatment decisions.

Most PCPs consider that the chief factors influencing their prescribing patterns include their training and clinical experience and peer-reviewed scientific literature. However, a US study performed in the 1980s to assess clinicians' prescribing behaviour revealed that 60% of participating PCPs prescribed treatments without consulting supportive clinical trial data.¹⁵ Whilst it is hoped that improvements in modern communications systems have provided clinicians with greater access to trial data, ensuring that evidence-based guidelines are available to all prescribers is important.

How to improve prescribing patterns?

Evidence-based medicine represents the most effective way of providing high-quality, cost-effective care to CHF patients. The development of diagnostic and treatment guidelines by professional societies, such as the ESC, and their involvement in healthcare research are vital for ensuring the availability of effective evidence-based treatment approaches to all clinicians. Widespread dissemination of international treatment guidelines and clinical trial data may improve prescribing patterns, and a number of methods can be applied to overcome barriers to the dissemination of such guidelines.

The Italian BRING-UP study (beta-blockers in patients with congestive heart failure: guided use in clinical practice) was a collaborative investigation involving 197 Italian cardiology centres, which was instigated to provide epidemiological data on the use of beta-blockers and accelerate the country-wide adoption of beta-blockers in CHF.¹⁴ The study included the establishment of a helpline service to provide information on initial drug titration. Data from the study revealed a doubling of the use of beta-blockers within 1 year from 25 to 50%, illustrating the speed and extent to which prescribing patterns may be altered with organized management programmes and education.

In addition, the provision of detailed discharge summaries on return to community care, enables the needs of the patient to be communicated more effectively between the treating cardiologist and the general practitioner. The use of comprehensive discharge summaries that provide sufficient follow-up instructions for PCPs can improve outpatient management, enhance patient satisfaction and the doctor–patient relationship, and reduce the likelihood of hospital re-admission.^12,25

Patient compliance

Many patients present considerable challenges to effective treatment administration; many decline treatment or do not collect their prescriptions, and of those who do, a considerable number do not take or stop taking their medications.^26,27

Data suggest that as many as 50% of medicines prescribed for the treatment of chronic conditions are not taken as they are prescribed, resulting in inadequate disease management, more frequent hospital admissions, wastage of expensive medications, and even premature death;²⁶ an estimated 54% of CHF-related hospitalizations are thought to be preventable.²⁸ Even where patients consider that they are adhering to treatment and self-care guidelines, many fall short because of misconceptions in communication between patients and healthcare providers.²⁹ The caregiver's objective risk assessment and the patient's subjective risk perception are seldom identical. The latter varies between individuals and also within an individual, depending on psychological and social factors that require careful assessment and communication between caregiver and patient. This problem was illustrated by Ni et al.,³⁰ who evaluated CHF patients' perceptions of self-care information. They found that 36% of surveyed patients believed they should drink lots of fluid instead of restricting their fluid intake, whereas, of 53% who thought daily weighing important, 42% did not weigh themselves daily. A subsequent US behavioural study found that 69% of CHF patients were overweight, 61% did not get regular exercise, and 94% had eaten high-sodium foods shortly before completing the survey.³¹

Research indicates that what appears as non-compliant behaviour from the physician's viewpoint may be an attempt by the patients to gain control over their situation.³² Non-adherence is often not about patients disobeying or forgetting and cannot be solved solely with pharmacological information but has to be approached by trying to reach the patients' way of thinking and adapt to their way of understanding.

The multidrug therapy approach associated with CHF management also presents a challenge to physicians in terms of the reduced likelihood that patients will comply with prescriptions.³³ A Spanish survey revealed that only 32% of CHF patients knew the names of the medications they were receiving and only 23% understood their pharmacological actions.³⁴ However, combination therapies continue to be underutilized despite their potential benefits.³⁵

Concordance

Failure to comply with prescriptions results from a multitude of psychosocial, behavioural, and financial factors that prevent optimal management.³⁶ Non-compliance may be intentional because of patient concerns over drug potency, overuse, and long-term adverse effects or may result from a lack of understanding of therapeutic benefits.²⁶ Cost may also play a role, with many patients being unable to afford the multidrug treatment strategies recommended by their physicians. Owing to the preponderance of elderly individuals, cognitive impairment is common, occurring in 30–80% of CHF sufferers and conferring a reduced likelihood of treatment compliance.³⁷

The concept of compliance, with its paternalistic associations of obedience, places the onus solely on the patient. To avoid this association, the alternative term ‘concordance’ has been proposed. Evidence suggests that concordance—in which the patient is a valued and knowledgeable participant in treatment decisions—is associated with improved health outcomes, fewer medication-related problems, and greater patient satisfaction.³⁸ Concordance is defined as a state of agreement or harmony and it creates a partnership in medical treatment. This state of agreement is achieved through a therapeutic alliance reached by clinical negotiation, in which nurses are encouraged to play an active role.

By consciously working to promote concordance between patients and healthcare professionals, multidisciplinary management systems improve patient knowledge of HF and its treatment, leading to prolonged survival and improved quality of life (QoL).^39,40–42 Evidence suggests that patients who develop a good rapport with their clinician and those who are followed up in heart failure clinics or through nurse-based management programmes are more likely to maintain a sufficient level of motivation to adhere to treatment guidelines.^42,43 Regular contact between patients and caregivers may also confer cost savings and simplify the management of patients living in remote areas.^21,40 The efficacy of disease management programmes in improving adherence to guidelines has been likened to that observed in clinical trials.⁴⁴

Managing the elderly patient

The elderly represent a substantial proportion of CHF patients and present considerable challenges to healthcare providers.^45,46 Diagnostic methods for elderly patients are lacking and drug trials have consistently excluded the elderly, so insufficient data are available concerning their effective management.^19,45 Furthermore, many physicians are reluctant to prescribe certain pharmacological agents to their elderly patients because of concerns over increased toxicity in this patient group⁴⁶ or perceptions that they will derive little or no benefit from treatment.^3,14 As a result, failure to prescribe indicated medications, monitor and educate patients, and maintain treatment continuity—particularly in those admitted to geriatric wards or long-term care facilities—persists as a management challenge in this patient population.^23,45–47

Elderly patients show an increased incidence of concomitant disease (renal failure, obstructive lung disease, diabetes, stroke); those who do receive appropriate CHF medications are also likely to be receiving treatments for other conditions and therefore face a higher risk of drug–drug interactions and non-compliance.^4,12 Combination therapies and slow-release agents may be helpful in this regard and in maintaining constant plasma levels of therapeutic agents.³⁵ Careful multidisciplinary management strategies and initiation of treatment in hospital are also beneficial for enhancing QoL in elderly patients.^21,48,49 Multidisciplinary management systems significantly improve pharmacological treatment in severely ill elderly patients with CHF.^50,51

Healthcare systems

Epidemiological studies have shown that the incidence of CHF is rising and it is now associated with a worse prognosis than some of the most common malignancies.³ Most European countries have screening programmes and regulated management strategies to ensure optimal diagnosis, treatment, and care for cancer sufferers. In contrast, there is a lack of resources, screening programmes, and co-ordinated healthcare services in CHF, and available therapeutic strategies are underutilized.³ Furthermore, few regions have specialized units dedicated to the treatment of CHF, and management varies considerably between institutions and countries.^12,52

Accurate identification of patients and recording of clinical information through disease registers facilitate the investigation, treatment, and allocation of resources for CHF management.⁵³ Registries also provide data concerning the management of patients in the community setting and can complement clinical trials through the transfer of information and technology and the generation of increased awareness of CHF in primary care.⁵⁴

The Swedish CHF registry is an ongoing registry established to provide continuous information on patient characteristics, treatments, and outcomes in CHF patients throughout Sweden. The first of its kind in Europe, it is to be hoped that the establishment of similar registries in other European countries will improve our understanding of this condition and encourage the development of integrated CHF management programmes throughout Europe. Designed on the same platform as the established RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) registry (http://www.riks-hia.se/Information/information.html), it will promote internet-based communication concerning CHF.

Summary

Underutilization of available therapies is a problem that occurs commonly in the management of CHF. The barriers to optimal treatment are numerous, stemming from patients, physicians, and healthcare systems, and result in considerable human and financial consequences. However, the development of comprehensive guidelines, the education of healthcare providers and patients, the introduction of outpatient management programmes, and the establishment of national registries represent potential solutions to these challenges. Global adoption of such strategies may enable adherence to guidelines to be improved and the benefits of effective treatments to be maximized. Healthcare providers need to reconsider the allocation of hospital space, so that more facilities are dedicated to the proper care of CHF patients and adequate discharge planning is instigated to reduce the numbers of hospital re-admissions.

Acknowledgements

This work was supported by an unrestricted educational grant from Takeda Pharmaceutical Company Limited.

Conflict of interest: none declared.

References