Description of the condition
Heart failure (HF) is a chronic, progressive and debilitating condition that occurs when damaged heart muscle is unable to pump blood efficiently to the body's tissues. It may manifest as symptoms of shortness of breath, fatigue and/or lower extremity edema. HF can develop from any condition that weakens the heart muscle (AHA 2012). The most common risk factors include hypertension, a previous myocardial infarction, coronary artery disease, valvular defects, congenital defects, cardiomyopathies, lung disease, diabetes, drugs and infection (AHA 2012). Approximately 1% to 3% of individuals have HF worldwide, including 10% of individuals over the age of 65 years (McMurray 2002). In 2010, more than 41 million individuals were living with HF globally, representing a 14% increase from 1990 (Roger 2012). The lifetime risk of developing HF in men and women 40 years of age is as high as one in five (Lloyd-Jones 2002; Roger 2012). A staggering 1 million new cases are diagnosed yearly worldwide, making it the fastest growing cardiovascular disorder. Although survival after a diagnosis of HF has improved over time, mortality remains high with roughly half of newly diagnosed individuals dying within five years (Levy 2002; Murphy 2012; Roger 2004; Roger 2012).
In the US alone, in 2009 HF was responsible for over 3 million annual physician office visits (NHLBI 2012). The economic burden attributed to HF is projected to rise 215% to $77.7 billion by 2030 (NHLBI 2012). Indirect costs, such as lost productivity, are projected to increase 80% from $9.7 billion in 2010 to $17.4 billion by 2030 (Heidenreich 2009). A report from the UK estimated that HF accounts for 2% of the national expenditure on health, mostly due to the cost of hospital admissions (Stewart 2002). A similar report from Poland estimated that HF accounts for more than 3% of the national healthcare budget (Czech 2013). Hospital-case fatalities for all age groups have generally declined, however, and interventions to decrease hospital admissions and length of hospital stay have led to substantial savings (Lee 2004; Liao 2008; O'Connell 2000).
Guidelines for the treatment of heart failure have been contributed by several organizations such as the American Heart Association, American College of Cardiology, International Society for Heart and Lung Transplantation, European Society of Cardiology and National Heart Foundation of Australia (Hunt 2009; McMurray 2012; Mosca 2007; NHF 2011; Tricoci 2009; Yancy 2013). Treatments that are supported by the strongest levels of evidence (often termed 'class I/level A') include angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (McMurray 2012). Many other treatments, for which efficacy is supported by moderate levels of evidence, are often used for HF management depending on the severity of the symptoms. These may include agents such as diuretics, ivabradine, digoxin (and other digitalis-related glycosides), and combination hydralazine and isosorbide dinitrate (McMurray 2012; Yancy 2013). Class I/level A-recommended treatments have been shown in randomized controlled trials (RCTs) to decrease mortality and hospitalization rates when combined with conventional treatments such as diuretics, digoxin and spironolactone (McMurray 2012).
Establishing guidelines, however, does not guarantee their use in actual clinical practice (Feder 1999). A review of international studies (Williamson 2012) suggests that there is still a significant number of individuals with HF not receiving evidence-based treatments or receiving subtherapeutic doses of medications. For example, a cross-sectional study of 451 general practitioners in the Netherlands demonstrated poor adherence to clinical practice guidelines in their decisions on the management of individuals with HF (Swennen 2013). A variety of studies have documented that adherence to evidence-based practice guidelines improves outcomes in HF. For example, in the Survey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR), a multicenter, retrospective, observational study of individuals with systolic HF (ejection fraction <45%) admitted to 23 university hospitals in Korea, adherence to guideline-recommended medications was associated with lower mortality (Yoo 2014). Therefore, it is imperative to identify appropriate and effective interventions to improve evidence-based prescribing in HF.
Description of the intervention
Interventions that have been used to improve evidence-based prescribing include educational outreach visits to health professionals and interactive educational activities for clinicians; electronic and manual reminders in the medical charts of individuals with HF; establishing standardized protocols within inpatient or outpatient settings; providing summaries of a clinician's prescribing behavior and feedback; and educational materials designed for clinicians such as lectures and pamphlets. All of these strategies are aimed directly at the clinician prescriber. Some interventions can be aimed at the individual with HF in order to change their interaction with the clinician prescriber. This type of intervention is termed patient-mediated because it works through the patient-prescriber relationship. For instance, strategies prompting individuals with HF to ask their provider about one or more guideline-recommended medication can serve as an impetus to change the prescribing behavior of the clinician.
Audit and feedback, together with educational outreach visits, have been the focus of a variety of interventions to change prescribing behavior (Ostini 2009). Often more than one strategy or approach is employed within a single intervention. For instance, a recent intervention trial aimed at improving adherence to evidence-based prescribing guidelines in HF, the IMPROVE-HF trial, included a guideline-based clinical decision support tool kit, educational materials, practice-specific data reports, benchmarked quality-of-care reports and structured educational outreach visits (Fonarow 2010; Walsh 2012). The clinical decision support tool kit consisted of evidence-based best practice algorithm charts, clinical pathway flow charts, standardized encounter forms, checklists, pocket cards, chart stickers and educational materials aimed at individuals with HF (Walsh 2012). In another trial, the intervention consisted of providing educational materials for physicians with a recommended protocol for multidisciplinary management and a template for care presented as a registration form, with an optional outreach visit from a practice consultant (van Lieshout 2011). Other interventions have consisted of facilitated group discussions about evidence-based prescribing of HF medications, with generalist physicians using audit and feedback about their management of individuals with HF extracted from clinical practice software (Williamson 2012). Clinical peer groups have also been used to change behavior (Kasje 2006).
How the intervention might work
These interventions might change prescribing behavior by addressing factors at the organizational or individual level that contribute to the prescribing behavior (Bero 1998; Feder 1999; Grimshaw 2002). These factors include the organizational culture and its resources, information management strategies (e.g., the presence of reminders or prompts in patient records or the electronic medical record system), local healthcare setting and resources, provider's knowledge, communication strategies and availability of feedback (McEntee 2009). Interventions to improve the prescribing of guideline-based medications in HF work by addressing one or more of these organizational or individual modifiable factors. Passive strategies of distributing evidence (e.g., mailing publications) have not been successful in changing prescribing behavior (Bero 1998; Feder 1999; Freemantle 1997; Grimshaw 2001; Grimshaw 2003).
In systematic reviews studying the effectiveness of various strategies to enhance the application of research findings (Bero 1998; Grimshaw 1998; Grimshaw 2003), it has been reported that interventions that were consistently effective included educational outreach visits, interactive educational activities and reminders (electronic or manual). Reminders may work by improving recognition of the opportunity to institute guideline-recommended care. Recent interventions in prescribing have focused on strategies such as provider education and outreach within the primary care setting (Kamarudin 2013; Williamson 2012). These may work by improving providers' knowledge and skills in communication or resource management to improve evidence-based prescribing behaviors. Other interventions have targeted those modifiable factors, such as the availability of feedback through individual reports, which provide clinicians with objective measures of their performance.
Why it is important to do this review
It is vitally important to identify effective interventions that maximize the prescribing of evidence-based medications shown to improve morbidity and mortality in individuals with HF (Heidenreich 2009; LaBresh 2007; Redberg 2009a; Redberg 2009b; Spertus 2005a; Spertus 2005b). Essential to this process will be identifying interventions that work and the characteristics that will predict a successful intervention. Identifying methods for improving and implementing appropriate prescribing will ensure the best therapeutic outcome for individuals with HF and save billions in annual healthcare costs. Previous reviews have succeeded in identifying different methods of altering prescribing behavior with varying degrees of success (Bero 1998; Grimshaw 1998; Grimshaw 2003; Kamarudin 2013). None of these reviews, however, explored prescribing in HF. By carefully reviewing and analyzing the data, we hope this systematic review will deliver a comprehensive overview and clinical guidance for improving prescribing trends in HF management.