Improving ACE inhibitor use in patients hospitalized with systolic heart failure: a cluster randomized controlled trial of clinical practice guideline development and use

RATIONALE, AIMS AND OBJECTIVES

The efficacy of angiotensin-converting enzyme (ACE) inhibitors in treating heart failure is well established, but there is concern that these agents are underutilized. This study aimed to evaluate the effect of developing and implementing Clinical Practice Guidelines (CPGs) on the quality of care given to patients receiving ACE inhibitors for systolic heart failure.

METHODS

Twenty cardiology units in Lorraine (France) were randomized to an experimental (n = 10) or a control group (n = 10). In each experimental unit, doctors were involved in drafting and implementing CPGs; those at control units were not. Practice surveys were conducted in all units before and after the intervention; 723 patients with heart failure and less than 75 years old were included. The main outcome was compliance with the CPGs.

RESULTS

Before intervention, clinicians in both groups were already compliant with CPGs relating to indications and contra-indications, adverse effects management, concomitant therapy and monitoring of biologic factors. After intervention, adherence to others CPGs was generally better in the experimental group. Compliance with the CPG relating to ACE inhibitor dose on discharge was higher in the experimental group (P = 0.003). Compliance with CPGs relating to increasing ACE inhibitors doses (P < 0.0001) and the contents of the discharge letter (P = 0.02) improved in all units between the two periods.

CONCLUSIONS

These results suggest that doctors involved in drafting and implementing CPGs are more likely to comply with them.

[Angiotensin-converting enzyme inhibitors in congestive heart failure: clinical practice guidelines]

Angiotensin-converting enzyme (ACE) inhibitors are, at present, the cornerstone of therapy for congestive heart failure. Nevertheless, international literature and regional data have reported their underutilisation in the practice of cardiology. Despite the abundance of consensus conferences, none deal specifically with a therapeutic strategy using ACE inhibitors. In this context, clinical practice guidelines on the management of systolic heart failure with ACE inhibitors have been drafted in Lorraine by hospital cardiologists. The guidelines were formulated using a standardised procedure, combining a literature analysis and the opinions of experts. Seventeen guidelines were finally adopted, under four headings: indications and contraindications for ACE inhibitors; dosages and approaches to treatment monitoring; the management of adverse effects; and contraindications for concomitant therapy. The drafting of the clinical practice guidelines is the first step in a quality improvement programme, initiated in 1999 in the cardiology wards of the region.