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The first of four articles looking at the new contract and its effects one year on

How to overcome the QOF failings on chronic heart failure care

Dr Stephen Leslie and Dr Martin Denvir argue the new contract does not reflect the most recent evidence on heart failure care and offer tips for improving things

The new contract was a missed opportunity to improve the current sub-optimal care of patients with chronic heart failure. In short, it lags behind the recent best evidence in this area and the increasingly complex treatments that are available.

For example, the use of ACE inhibitors, angiotensin receptor blockers (ARBs), betablockers and aldosterone inhibitors (spironolactone) are now standard therapies and have been since the late 1990s ­ but this is not reflected in the new contract.

Furthermore, there are benefits to be gained from flu vaccination and symptomatic benefits to be gained from the use of digoxin and exercise training.

These treatments have been proven in patients with ischaemic and non-ischaemic left ventricular dysfunction. Their implementation has been shown to be improved by adopting a multidisciplinary approach involving heart failure nurses.

And advanced pacing modalities (cardiac resynchronisation therapy) and implantable cardiac defibrillators (ICDs) have been proven to have important mortality and morbidity benefits in selected patients with CHF.

While some of these therapies cannot be implemented in primary care, if GPs are to remain the gatekeepers to secondary care, there should be an awareness of which patients may benefit from these advanced therapies and should therefore be referred to specialists.

The new contract should have included points for the referral of all new diagnosis of heart failure to a cardiologist, in the same way as newly diagnosed angina.

Currently the contract specifies only one drug therapy and does little to ensure the appropriate use of other pharmacological therapies such as

?-blockers, spironolactone and the referral of patients in whom the cause of the heart failure may be uncertain.

The danger with the current GMS contract is that even patients who are sub-optimally treated may gain full points for GPs.

Stephen J Leslie, cardiology specialist registrar

Martin A Denvir, consultant cardiologist, cardiology department, Western General Hospital, Edinburgh

Why the QOF 'falls short'

· It only includes patients with chronic heart failure (CHF) and ischaemic heart disease (IHD) and does not include patients with CHF from another cause

· In these patients it has only three performance indicators

(i) identification of such patients and the creation of a register

(ii) confirmation of left ventricular systolic impairment by echocardiography

(iii) the use of ACE inhibitors or ARBs

While these are all worthwhile goals, there is a danger that instead of incentivising good care these limited performance indicators may actually inhibit the use of lifesaving therapies (such as betablockers and spironolactone) as GPs who have gained full points in patients with CHF may not see the need or importance of pursuing good care in keeping with current guidelines (NICE and SIGN).

GPs, the new contract and CHF care ­ what our study showed

In a study carried out within our cardiology department, we surveyed 380 GPs. Many reported dissatisfaction with the GMS contract. In particular there was concern that even the limited performance indicators would have to be met from within 'existing resources' and nGMS was seen as a 'paper exercise for no great benefit to patients'.

Many GPs reported that services performed by secondary care might be a limiting factor when addressing the performance indicators of the GMS contract. In particular they felt the delivery of echocardiography services and timely reporting of findings could be improved. In a separate audit of our direct access CHF echo service, less than 20 per cent of patients who were referred for an echocardiogram had significant left ventricular dysfunction.

GPs also believed that implementation of CHF treatments in the community was time-consuming and titration of betablocker therapy difficult, but that the presence of a community-based CHF nurse was helpful. GPs also gave general support for more open-access echocardiography and specialist hospital-based CHF clinics.

Source: Leslie, SJ et al. Management of CHF: perceived needs of GPs in light of the new GMS,

Postgraduate Medical Journal, 2005, 81: 321-6

Thirteen things GPs should know to improve CHF care

1Some patients have heart failure with preserved left ventricular function, while other patients with LVSD may be asymptomatic. In a recent population-based study, LVSD was found in 3.5 per cent of the general population, rising to 14 per cent in patients over the age of 80.

2The proportion of patients with suspected heart failure who actually have 'LVSD' confirmed by echocardiography is between 20 and 40 per cent, suggesting clinical findings alone are insufficient to make an accurate diagnosis.

3Patients with a normal ECG are unlikely to have LVSD and another cause for their symptoms should be sought.

4Studies suggest the use of a simple blood test for N-terminal B-type natriuretic peptide (NT-BNP) has a

97 per cent sensitivity for diagnosing heart failure when combined with a careful history and examination. Perhaps more importantly, this test has a 97 per cent negative predictive value (that is, if it is not elevated, a diagnosis of heart failure can be excluded). The test is not expensive.

5Angiotensin-converting enzyme (ACE) inhibitors should be considered in all patients with LVSD, even if asymptomatic. Small rises (~10 per cent) in creatinine are common and acceptable as long as renal function remains stable. Up to

10 per cent of patients will discontinue ACE inhibitors because of persistent dry cough. In these patients an angiotensin II receptor blocker (ARB) should be considered.

6In stable patients betablockers may be initiated and the dose increased in the community. Betablockers should be started at low doses and slowly titrated every two to four weeks. At present only bisoprolol and carvedilol are licensed for use in heart failure in the UK.

7Spironolactone has been shown to have important mortality and symptomatic benefits in patients with grade III/IV heart failure. Careful monitoring of renal function is important, especially when co-administered with ACE inhibitors.

8Digoxin can be useful in heart failure, even in patients in sinus rhythm. Its use is associated with reduced breathlessness and reduced hospitalisations in patients with severe symptomatic heart failure.

9Patients who weigh themselves daily can detect increasing fluid retention early and may prevent decompensation by judicious use of increased diuretic. Community-based heart failure nurses can help facilitate this process.

10Recent studies have demonstrated that implantable cardiac defibrillators (ICDs) reduce mortality in patients with CHF. Cardiac resynchronisation therapy (CRT) using a new generation of pacemakers has important morbidity and mortality benefits for selected patients with CHF.

11It is important to identify patients in whom palliative treatment for chronic heart failure is required. Many drugs designed to reduce mortality may, in some patients, worsen symptoms. Judicious withdrawal of ACE inhibitors and betablockers can improve the symptoms of fatigue and lethargy. Digoxin treatment may improve breathlessness and small doses of morphine can give relief from the symptom of breathlessness. Patients may become resistant to loop diuretics and the cautious concomitant use of oral thiazide diuretics can aid diuresis.The palliative care team can provide invaluable support.

12Patients who have chronic heart failure from a cause other than IHD (such as idiopathic dilated cardiomyopathy or alcoholic cardiomyopathy) can benefit from standard therapies even though these patients are currently excluded from the contract.

13Innovative ideas such as computerised decision support software (CDSS) can provide web-based support for GPs when making treatment decisions.

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