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International Journal for Quality in Health Care 14:313-319 (2002)
© 2002 International Society for Quality in Health Care

Paper

Use of echocardiography among patients with heart failure: practice variations in Hungarian hospitals

EDIT PAULIK1, ANNA MÜLLER1, ÉVA BELICZA2, KRISZTINA BODA3 and LÁSZLÓ NAGYMAJTÉNYI1

1Department of Public Health, Faculty of Medicine, University of Szeged, Szeged
2Health Care Management Center, Semmelweis University, Budapest
3Medical Informatics Department, Faculty of Medicine, University of Szeged, Szeged, Hungary

Objective. To evaluate some factors, such as demographic factors, disease severity, dissemination of practice guidelines, and hospitals providing medical care, influencing the use of echocardiography among patients with congestive heart failure.

Design. A ‘before–after’ controlled epidemiological study based on hospital documentation.

Setting and participants. A total of 1222 admitted patients with a diagnosis of chronic heart failure from six voluntarily participating hospitals representing each level of in-patient care in Hungary.

Interventions. Implementation of clinical practice guidelines about heart failure developed by the US Agency for Health Care Policy and Research.

Results. The echocardiography was performed in slightly more than 50% of all cases in the total. The use of echocardiography was different according to age, sex, and hospitals, but no significant difference was found in disease severity and between the two periods of time (before and after the dissemination of the guidelines).

Conclusions. This study reveals the existing differences in the use of echocardiography and the lack of essential changes after the dissemination of the guidelines. The distribution and implementation of guidelines needs further investigation.

Keywords: clinical practice guidelines, echocardiography, practice variations

There is a broad interest in clinical guidelines, stretching across Europe, North America, Australia, New Zealand, and Africa [1–6]. The principal expected benefit of guidelines is to improve the quality of care by the reduction of variations in service delivery among providers, hospitals, and geographical regions [6]. Clinically relevant guidelines determine how diseases, disorders, and health care conditions can most effectively and appropriately be prevented, diagnosed, treated, and clinically managed [7].

No evidence-based clinical guidelines have been developed in Hungary, although there is an emerging need for them in all fields of clinical practice. Potential areas for guidelines can emerge from an assessment of the major causes of morbidity and mortality for a given population, uncertainty about the appropriateness of health care processes or evidence that they are effective in improving patient outcomes, or the need to conserve resources in providing care [8].

Heart failure is a major cause of morbidity and mortality worldwide [7, 9, 10]. Because of the high prevalence of heart failure and the resulting high cost of caring for these patients, improvements in the quality of care—and in the practice of cost-effective care—could have a tremendous impact on costs and outcomes. Proper management of heart failure can reduce both morbidity and mortality from this condition [7]. The treatment modalities and management of congestive heart failure have undergone significant changes in the past few years [7, 9, 11]. It is highly important to recognize asymptomatic left-ventricular systolic dysfunction, which, depending on the prevalence of other cardiovascular risk factors, affects 1–5% of the population. Prior to pharmacological management of patients with heart failure, appropriate evaluation of their condition is needed, and other conditions mimicking the symptoms of heart failure (e.g. pulmonary, renal or hepatic diseases, anemia, hypothyroidism, and obesity) should be excluded [7, 9]. When the condition of patients is evaluated it is not appropriate to confirm only signs and symptoms of heart failure, and systolic and diastolic function; valvular function, and pericardial and pulmonary functions should also be examined [12].

The combined use of history, physical examination, chest X-ray, and electrocardiography cannot be relied upon to distinguish between the major etiologies of heart failure: left-ventricular systolic dysfunction, valvular heart failure, or a non-cardiac etiology [7]. Practically, it is impossible to distinguish between systolic and diastolic dysfunction on the basis of physical examination [12]. The electrocardiogram (ECG) has been reported to be valuable as a first line investigation for suspected heart failure, as left-ventricular systolic dysfunction is unlikely in the presence of a normal ECG [13, 14]. However, systolic and diastolic dysfunction can be distinguished accurately only on the basis of left-ventricular function testing. The most frequently used tests are two-dimensional echocardiography, Doppler echocardiography, and radionuclide ventriculography [15]. Currently, echocardiography combined with physical examination and ECG is one of the most important and effective diagnostic tests in non-invasive cardiology [12]. It has an exclusive diagnostic value in assessing the type (systolic or diastolic), the cause (valvular disorder, prior myocardial infarction, dilated cardiomyopathy, etc.), and severity of heart failure [16].

Echocardiography plays a prominent role in the early diagnosis of systolic dysfunction, but no data are available on the use and impact of echocardiography in management of congestive heart failure in Hungary. This paper examines the factors influencing the use of echocardiography, such as demographic factors, disease severity, the dissemination of the clinical practice guideline Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction [7], and some hospitals providing medical care.

Materials and methods

Background of guideline implementation
In 1996, the Ministry of Welfare initiated a project about the adaptation and implementation of practice guidelines developed by the US Agency for Health Care Policy and Research (AHCPR; since 1999 this agency has been known as AHRQ, Agency for Healthcare Research and Quality). The aim of this study was to examine the applicability and adaptability of the clinical practice guidelines Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction, issued by the AHCPR, to Hungarian conditions, and parallel with this to study the actual clinical practice in hospitals [7]. Studying the literature of the implementation of guidelines we have found that there is no single effective way to ensure the use of guidelines in practice [17, 18]. In this study, each activity was coordinated by the Ministry of Welfare. Firstly, the guidelines were translated into Hungarian, and then the suggestions of the guidelines were revised by Hungarian opinion-leader cardiologists to determine whether they contained recommendations that were not possible to implement in Hungary. A general agreement was reached about the applicability of the guidelines, and on the basis of the cardiologists’ opinion the guidelines were adapted to Hungarian conditions. After that, a scientific meeting was organized for the physician leaders of the hospital wards involved in the study. The main aspects of the guidelines were introduced to them by the above-mentioned opinion leaders. The adapted version of the guidelines were mutually accepted by the physician leaders of the hospitals during this meeting. It was the task of the physician leaders to disseminate the guidelines. During the dissemination of the guidelines, all physicians involved in the project received the Hungarian translation of the Quick Reference Guide for Clinicians, and the manual book for the guidelines—Clinical Practice Guidelines—was also available for all. The implementation of the guidelines was organized locally, and we checked the knowledge of the guidelines among physicians indirectly, by following the changes in their clinical practice.

Design, setting, and participants

A ‘before–after’ controlled epidemiological study was used to examine the health care practice before and after the dissemination of the guidelines (‘before’ period: 1 January 1997 to 28 February 1998—before the dissemination of the guidelines;, ‘after’ period: 15 March 1998 to 15 March 1999—after the dissemination of the guidelines).

Six voluntarily participating hospitals, chosen by the Ministry of Welfare, took part in our study (H1–H6), representing each level of in-patient health care in Hungary: three town hospitals (H1–H3), one county hospital (H4), one university teaching hospital (H5), and one central national hospital (H6).

A total of 1222 patients admitted with an initial diagnosis of chronic heart failure, or any primary causative factor of it (arteriosclerotic, hypertensive or valvular heart disease, and dilated cardiomyopathy), were involved in the study. Originally, 1385 patients were selected for the study, but 11.8% of them were excluded either because of inappropriate diagnosis or due to patient overlap between the two periods.

Data collection was based on hospital documentation, and demographic features, disease severity on the basis of the New York Heart Association (NYHA) functional classes of heart failure, and use of diagnostic procedures particularly echocardiography were examined during hospital stay. (NYHA classification is a four-level scheme for grading the functional incapacity of patients with cardiac disease: class I, cardiac disease without resulting limitations of physical activity; class II, slight limitation of physical activity—comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain; class III, marked limitation in physical activity: comfortable at rest, but ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain; class IV, inability to carry on any physical activity without discomfort, or symptoms at rest.)

A pilot study was carried out to examine the availability of data in the hospital documents that describe the actual clinical practice, which are needed to study the impact of the guidelines. We also evaluated the accuracy of data collection, and the reliability of record abstractors. We found that data were available in different measures to evaluate clinical practice (range 78–100%): e.g. sociodemographic data were fully available, and information on examinations was available in 90% of hospital patients’ records. Data collection was carried out by 12 record abstractors (two in each hospital); they were all health workers having received proper, continuous assistance from the physician leaders. Record abstractors were informed about the objective of the study and further data processing, and were given direction on filling out the questionnaires. Reliability of data collection ranged from 40 to 84% during the pilot study, and was increased by further training before the actual data collection and by continuous supervision of the record abstractors during the study [19].

Statistical analysis

The utilization of the guidelines was evaluated by the assessment of the following performance measure: ‘patients with a diagnosis of heart failure should have received an initial echocardiogram and the result should be documented in their chart’ [20]. The use of echocardiography was analyzed according to patients characteristics, guidelines dissemination periods, and hospitals.

Data processing was carried out using SPSS 9.0 for Windows. Distribution was calculated in categorical data, and the {chi}2 test was used to compare different groups and hospitals. For all comparisons, P < 0.05 was considered significant. Joint analysis of factors influencing the use of echocardiography was modeled by logistic regression. Logistic regression describes the relationship between one categorical dependent variable and several categorical or continuous independent variables. In our research, the use of echocardiography was the categorical dependent variable. Sex, disease severity on the basis of NYHA classification, period of time (before and after), and hospitals were the categorical independent variables, and age was the continuous independent variable.

Results

A total of 1222 patients (566 before and 656 after) were examined. Table 1 shows the main demographic features and the distribution of stages in the severity of heart failure according to the NYHA classification. No significant difference was found between the two periods of time according to sex, age group, and NYHA class of heart failure.


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  		Table 1 Patient characteristics

 

Echocardiography was found to be undertaken in 54.3% in the total period of time, 55.8% in the before period and 53.0% in the after period. No significant difference was found between the data from the two periods of time.

Echocardiography was also considered to be performed in patients who did not undergo this test at the point of admission, but who had an echocardiogram not longer than 1 year ago, the results of which were registered in the case history.

Patients who underwent echocardiography were studied according to age, sex, NYHA classification, doctors’ knowledge of the guidelines (comparing before with after period), and the admitting hospitals. Use of echocardiography during the before and after periods according to demographic features and disease severity is shown in Table 2.


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  		Table 2 Use of echocardiography (echocardiography performed/not performed) according to sex, age group, and New York Heart Association class

 

Studying age and sex we conclude that echocardiography was performed more frequently in men. However, the number of patients who underwent echocardiography reduced with age (60% of patients aged <65 years underwent echocardiography, compared with <50% of patients aged >75 years). No relation was found between NYHA class and the use of echocardiography; echocardiography was performed in each class at almost the same rate (50–55%), except for NYHA class I. In this NYHA class I, echocardiography was performed at a lower rate in both periods, with no significant difference between the two.

The use of echocardiography differed according to hospital. In both periods of time (before and after) it was the highest (>80%) in H2 and H4 (Figure 1). The use of echocardiography increased in four hospitals (H1, H3, H4, and H5) in the after period and decreased in two hospitals (H2 and H6). The only significant difference in the use of echocardiography between the before and after periods was found in H6, according to the {chi}2 test. The decrease in echocardiography use H2 does not indicate inappropriate health care, as in practice every patient with heart failure had undergone echocardiography before the introduction of the guidelines. The substantial decrease in the use of echocardiography in H6 [prior to the introduction of the guidelines it was relatively high (over 60%)] needs to be investigated further.



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  		Figure 1 Performance of echocardiography among patients with heart failure in some Hungarian hospitals. Before period: 1 January 1997 to 28 February 1998—before the dissemination of the guidelines. After period: 15 March 1998 to 15 March 1999—after the dissemination of the guidelines.

 

The results of the logistic regression model can be seen in Table 3. According to the model, the use of echocardiography is clearly influenced by age, sex, and the hospital providing medical care. Studying the disease severity the difference was significant only between NYHA classes I and IV. The research period (before and after) was not significant by itself, but was when examining interaction with the hospital providing care. The probability of echocardiography use is higher among males than females (odds ratio 1.6983; 95% confidence interval 1.3095–2.2025). There is a negative relationship between age and the use of the echocardiography: the younger the patient, the more likely it is that the test will be undertaken.


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  		Table 3 Logistic regression model comparing the use of echocardiography by sex, age, New York Heart Association class, time period, and hospitals

 

Except for H2, there is a significant difference in the use of echocardiography between all the hospitals and H4, which is the reference category. Examining the interaction between the periods of time and the hospitals we found a significant difference only in H6: the change in clinical practice in this hospital differed the most from the reference hospital.

Discussion

In our study, we found that echocardiography was performed in slightly more than 50% of all cases. The use of the test was influenced by several factors, the most important of which are age, sex, admitting hospital, and the dissemination of the AHCPR guidelines. Echocardiography was undertaken more frequently in males than in females. The probability of the test being used decreased with age. However, non-invasive cardiological tests including echocardiography are highly indicated in women, the aged, and the obese, because the assessment of their status based merely on their clinical signs is inappropriate [21, 22]. Echocardiography was rarely used in less severe cases, such as NYHA class I patients.

No fundamental changes were found in the use of echocardiography after the dissemination of the guidelines. There was a significant difference in the clinical practice of echocardiography between the various hospitals, and this difference did not even out after the dissemination of the guidelines.

After physical examination, each patient is referred to ECG and chest X-ray if there is a suspected heart failure, but these examinations are of dubious value in differential diagnosis [23, 24]. Systolic and diastolic dysfunction can be distinguished only after left-ventricular function testing. To receive the appropriate diagnosis of heart failure, routine echocardiography is warranted. This test is widely available, simple, and has no risks associated with it, and the functional intactness of valves, size of ventricles, ventricular hypertrophy, and systolic and diastolic ventricular functions can all be assessed [9]. It is essential that distinction between systolic and diastolic dysfunction be made, because optimal treatment of one dysfunction exacerbates the other [12].

The use of echocardiography has been studied in several countries; in the UK, half of patients, and in the US 63% of patients with suspected heart failure had undergone echocardiography [23–26]. US studies report that a significant difference was found in the frequency of echocardiography performed on the basis of the qualification of the attending physician: family doctors versus cardiologists, or cardiologists versus non-cardiologists. The clinical practice of cardiologists complies more closely with the published guidelines than does the clinical practice of other physicians [27–30].

Currently, quality and appropriateness of health care is the focus of interest in several countries, particularly in Hungary. Clinical practice guidelines are increasingly affecting the quality of health care, and have the potential to affect the availability of health care options for consumers [31]. The use of guidelines has become a popular, integral part of a reasoned approach to improving individual physician performance. However, efforts to implement guidelines using tools to affect an individual physician’s performance have often met with failure [32].

Our study reveals the existing differences in the use of echocardiography and the lack of essential changes after the dissemination of the guidelines. Guideline dissemination included meetings with opinion leader cardiologists; however, these meetings were too passive to affect behavior change without active implementation strategies. In practical implementations of physician performance improvement, multiple tools are likely to be necessary, and should be chosen carefully [32].

Evidence-based guideline development requires considerable time and effort, and the costs are high. Since no such guidelines have been developed in Hungary, we decided to adapt guidelines developed abroad to Hungarian conditions. The methodology used is very important when adapting foreign guidelines, because differences in use may not only be due to lack of knowledge, but also to differences in human and financial resources in different countries or hospitals. Thus, we believe that distribution and implementation of the guidelines needs further investigation. We should consider whether the local circumstances are appropriate for the introduction and adaptation of these guidelines.

Acknowledgements

Thanks are due to the hospitals for assistance with the research, and to the Ministry of Welfare for the financial support of data collection.

Address reprint requests to Edit Paulik, Department of Public Health, Faculty of Medicine, University of Szeged, 6720 Szeged, Dóm tér 10, Hungary. E-mail: paulik{at}puhe.szote.u-szeged.hu Back

Received for publication . Accepted for publication March 27, 2002.

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