How can cardiologists and primary care physicians be encouraged to practice evidence-based management in heart failure?

I vidence-based medicine is a cultural and methodological approach to clinical Hbbh practice that bases decisions on cumulative clinical expertise and an intimate knowledge of the individual patient’s global situation, and that then feeds those decisions back into a database for the advancement of clinical research. As such, it is the art of medicine raised to a scientific status, a science-based system of clinical care. It deemphasizes intuition and unsystematic clinical experience as grounds for medical decision-making, stressing instead the rigorous and formal analysis of evidence from clinical research. Evidence-based medicine converts the abstract exercise of reading and appraising the literature into the pragmatic implementation of the literature for individual patient benefit, while simultaneously expanding the clinician’s own knowledge base.

Despite the publication of evidence-based guidelines, the current care of patients with heart failure remains suboptimal. Numerous studies document underutilization of key care procedures, such as giving angiotensin-converting enzyme inhibitors to patients with decreased systolic function or monitoring left ventricular systolic function. Guideline dissemination must clearly be accompanied by more intensive educational and practice-changing initiatives if we are to maximize performance in the office and on the ward. The disease management approach views heart failure as a chronic illness spanning the domiciliary, outpatient, and inpatient settings, requiring multidisciplinary team care. Observational and randomized controlled trials have shown that disease-management programs reduce hospitalization and improve quality of life and functional

status. Unfortunately, there is insufficient evidence as yet to establish uniform recommendations about the most appropriate roles for primary care physicians and cardiologists in the management of heart failure patients. However, a collaborative model is likely to prove most fruitful. Evidence-based guidelines could then be implemented along such lines as the following:

Develop management guidelines for implementing evidence-based medicine, either locally, eg, in an academic institution, or through professional organizations such as the European Society of Cardiology.

Present international European and American guidelines, with their relative differences and applicability to local clinical practice.

Encourage cardiologists and primary care physicians to take an active part in international scientific meetings and congresses.

Involve cardiologists and primary care physicians in clinical trials and observational studies.

American guidelines for the evaluation and management of chronic heart failure offer the following recommendations for implementing practice guidelines: Class I

Multifactorial interventions that attack different barriers to behavioral change (level of evidence A).

Multidisciplinary disease-management programs for patients at high risk of hospital admission or clinical deterioration (level of evidence B).

Academic detailing or educational outreach visits (level of evidence A).

Chart audit and feedback of results (level of evidence A).

Reminder systems (level of evidence A).

Local opinion leaders (level of evidence A).

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