European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF)

Aims: To survey a random sample of primary care physicians across six European countries regarding their perceptions of diagnostic and prescribing issues in heart failure, and to consider factors that might be associated with physician under-performance.

Methods and results: Qualitative, postal questionnaire-based, validated survey in the native tongue of a random sample of 200 primary care physicians in each of five European countries (France, Germany, Italy, The Netherlands and Spain) and of 250 U.K. primary care physicians. Respondents provided: details of practice characteristics; the usual way a diagnosis of heart failure was established; access to investigations; names of drugs prescribed in heart failure, with estimates of the proportion of patients supplied with particular classes; and physician attitudes regarding the evidence base (in terms of benefits and risks) for treatments used. Outcomes were physician perceptions and attitudes about heart failure diagnosis and treatment. Adjusted response rates varied from 17% (France) to 56% (Britain). Primary care physicians underestimate the prevalence of heart failure. Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Although most primary care physicians stated they prescribe ACE inhibitors in heart failure, this was for only 47-62% of patients, and at doses below those identified as effective in trials. Most prescribing doctors (91%) believe there is strong evidence of reduced mortality in heart failure patients using ACE inhibitors, but 51% also consider ACE inhibitors have substantial risks with their use.

Conclusion: Limitations of the data include the general problem of questionnaires, whether responses accord with actual clinical practice, and, specific to these data, the low response rate in some countries (although the study does provide information from nearly 300 randomly selected primary care physicians across Europe). New preliminary insights include exposition of the 'low tech' approach to heart failure diagnosis across Europe: doctors report the use of symptoms and signs alone; the lack of direct (open) access to objective investigations, such as echocardiography, which almost guarantees that misdiagnoses will occur; and the under-utilization and under-dosing with ACE inhibitors. The main factor influencing under-use would appear to be the exaggerated perceptions of treatment risk amongst primary care physicians that dominate the widespread and accurate knowledge of treatment benefits.