Skip to main content

Advertisement

SpringerLink
Log in

Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Objective

To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.

Design

Survey of a national systematic sample of physicians.

Participants

Five hundred family practitioners, 500 general internists, and 500 cardiologists.

Measurements and main results

Physicians’ choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p≤.01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%); and asymptomatic, post-myocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely (p≤.05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less (43% vs 15%).

Conclusions

Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasize the dosages demonstrated to lower mortality and morbidity in the trials.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Franks P, Nutting PA, Clancy CM. Health care reform, primary care, and the need for research. JAMA. 1993;270:1449–53.

    Article  PubMed  CAS  Google Scholar 

  2. Kassirer JP. Access to specialty care. N Engl J Med. 1994;331: 1151–3.

    Article  PubMed  CAS  Google Scholar 

  3. Stevenson WG, Stevenson L, Middlekauff HR, et al. Improving survival for patients with advanced heart failure: a study of 737 consecutive patients. J Am Coll Cardiol. 1995;26:1417–23.

    Article  PubMed  CAS  Google Scholar 

  4. Garg R, Yusuf S, Collaborative Group on ACE Inhibitor Trials. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA. 1995;273:1450–6.

    Article  PubMed  CAS  Google Scholar 

  5. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293–302.

    Article  Google Scholar 

  6. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med. 1992; 327:685–91.

    Article  Google Scholar 

  7. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327:669–77.

    Article  PubMed  CAS  Google Scholar 

  8. Konstam M, Dracup K, Baker D, et al. Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction. Clinical Practice Guideline No. 11. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; June 1994. AHCPR publication no. 94-0612.

    Google Scholar 

  9. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Guidelines for the evaluation and management of heart failure. J Am Coll Cardiol. 1995;26:1376–98.

    Article  Google Scholar 

  10. Young JB, Weiner DH, Yusuf S, et al. Patterns of medication use in patients with heart failure: a report from the Registry of Studies of Left Ventricular Dysfunction (SOLVD). South Med J. 1995; 88:514–23.

    PubMed  CAS  Google Scholar 

  11. Bourassa MG, Gurne O, Bangdiwala SI, et al. Natural history and patterns of current practice in heart failure. J Am Coll Cardiol. 1993;22(suppl A):14–9A.

    Google Scholar 

  12. McDermott MM, Feinglass J, Sy J, Gheorghiade M. Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function: clinical characteristics and drug therapy. Am J Med. 1995;99:629–35.

    Article  PubMed  CAS  Google Scholar 

  13. Chin MH, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health. 1997;87:643–8.

    Article  PubMed  CAS  Google Scholar 

  14. Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J. 1994;71:584–7.

    Article  PubMed  CAS  Google Scholar 

  15. Rajfer SI. Perspective of the pharmaceutical industry on the development of new drugs for heart failure. J Am Coll Cardiol. 1993; 22(suppl A):198–200A.

    Google Scholar 

  16. Chin MH, Wang JC, Žhang JX, Lang RM. Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure: effect of physician specialty and patient characteristics. J Gen Intern Med. 1997;12:563–6.

    Article  PubMed  CAS  Google Scholar 

  17. Aday LA. Designing and Conducting Health Surveys. San Francisco, Calif: Jossey-Bass Publishers; 1989:121–4.

    Google Scholar 

  18. Stross JK, Harlan WR. The dissemination of new medical information. JAMA. 1979;241:2622–4.

    Article  PubMed  CAS  Google Scholar 

  19. Packer M. Do angiotensin-converting enzyme inhibitors prolong life in patients with heart failure treated in clinical practice? J Am Coll Cardiol. 1996;28:1323–7.

    Article  Google Scholar 

  20. Massie BM, Kramer BL, Topic N. Lack of relationship between short-term hemodynamic effects of captopril and subsequent clinical responses. Circulation. 1984;69:1135–41.

    PubMed  CAS  Google Scholar 

  21. Swedberg K, Eneroth P, Kjekshus J, Snapinn S, and the CONSENSUS Trial Study Group. Effects of enalapril and neuroendocrine activation on prognosis in severe congestive heart failure (follow-up of the CONSENSUS Trial). Am J Cardiol. 1990;66:40–5D.

    Article  Google Scholar 

  22. Jones TV, Gerrity MS, Earp J. Written case simulations: do they predict physicians' behavior? J Clin Epidemiol. 1990;43:805–15.

    Article  PubMed  CAS  Google Scholar 

  23. Ayanian JŽ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994;331:1136–42.

    Article  PubMed  CAS  Google Scholar 

  24. Friedmann PD, Brett AS, Mayo-Smith MF. Differences in generalists' and cardiologists' perceptions of cardiovascular risk and the outcomes of preventive therapy in cardiovascular disease. Ann Intern Med. 1996;124:414–21.

    Google Scholar 

  25. Hlatky MA, Fleg JL, Hinton PC, et al. Physician practice in the management of congestive heart failure. J Am Coll Cardiol. 1986; 8:966–70.

    Article  PubMed  CAS  Google Scholar 

  26. Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q. 1989;67:268–317.

    Article  PubMed  CAS  Google Scholar 

  27. Leape LL. Practice guidelines and standards: an overview. Qual Rev Bull. 1990;16:42–9.

    CAS  Google Scholar 

  28. Hillman AL, Pauly MV, Kerman K, Martinek CR. HMO managers' views on financial incentives and quality. Health Affairs. 1991; 10:207–219.

    Article  PubMed  CAS  Google Scholar 

  29. Kerr EA, Mittman BS, Hays RD, Siu AL, Leake B, Brook RH. Managed care and capitation in California: how do physicians at financial risk control their own utilization? Ann Intern Med. 1995;123:500–4.

    PubMed  CAS  Google Scholar 

  30. Greco PJ, Eisenberg JM. Changing physicians' practices. N Engl J Med. 1993;329:1271–3.

    Article  PubMed  CAS  Google Scholar 

  31. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the read-mission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–5.

    Article  PubMed  CAS  Google Scholar 

  32. West JA, Miller NH, Parker KM, et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol. 1997;79:58–63.

    Article  PubMed  CAS  Google Scholar 

  33. Health Care Financing Review, Statistical Supplement, Baltimore, Md: U.S. Department of Health and Human Services: 1995:56.

Download references

Author information

Author notes

  1. Christine K. Cassel MD

    Present address: Mount Sinai Medical Center in New York, New York, USA

Authors and Affiliations

  1. Section of General Internal Medicine, Department of Medicine, University of Chicago (Ill.) Medical Center, 5841 S. Maryland Ave., MC 6098, 60637, Chicago, IL

    Marshall H. Chin MD, MPH, Peter D. Friedmann MD, MPH & Christine K. Cassel MD

  2. Section of Cardiology, Department of Medicine, University of Chicago (Ill.) Medical Center, 5841 S. Maryland Ave., MC 6098, 60637, Chicago, IL

    Roberto M. Lang MD

Authors
  1. Marshall H. Chin MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter D. Friedmann MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christine K. Cassel MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Roberto M. Lang MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Funded by a grant-in-aid from the American Heart Association of Metropolitan Chicago. Dr. Chin is supported by National Institutes of Health/National Institute on Aging Geriatric Academic Program Award 5-K12-AG-00488.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Chin, M.H., Friedmann, P.D., Cassel, C.K. et al. Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J GEN INTERN MED 12, 523–530 (1997). https://doi.org/10.1046/j.1525-1497.1997.07105.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.1997.07105.x

Key words

Search

Navigation