Federico Vancheri

Is clinical diagnosis of heart failure reliable?—Clinical judgement of cardiologists versus internists

BACKGROUND: Heart failure is a major cause of morbidity and mortality. Its diagnosis is mainly clinical. Most patients are seen by cardiologists and internists. However, it is not known whether clinical practices vary by specialty. We sought to evaluate the concordance in the clinical judgement of heart failure between cardiologists and internists. METHODS: Clinical judgement was investigated in 17 cardiologists and 25 internists from four district hospitals using the probability assessment of heart failure diagnosis in 30 case histories based on real patients. Use of clinical information in the diagnostic assessment was defined by the regression coefficients of multiple regression analysis, in which the diagnostic probability was the dependent variable and the clinical criteria the independent variables. The importance attributed to clinical variables, as reported by doctors in a questionnaire, and that of clinical practice, as expressed by the magnitude of the regression coefficients, were compared. RESULTS: We found no significant difference between cardiologists and internists. However, within each group of specialists, there was a wide inter-observer variation in the probability assessment of heart failure in the same case histories. The probability ranged from 25.6 to 83%. The relative importance of clinical variables actually used in diagnostic assessment was different from that reported by doctors. CONCLUSIONS: Cardiologists and internists do not differ in their clinical judgement of heart failure. However, within each group there can be wide discrepancies in the evaluation of the same case histories. This may be related to the different use of clinical information, as indicated by the wide confidence intervals of regression coefficients for clinical criteria. The way doctors use clinical information in practice differs from how they think they use it.

Hyperlipidaemia: Differences in management practices and attitudes in two regions in Europe - Sicily and the Stockholm area

In order to compare attitudes and management concerning hyperlipidaemia and risk factors for coronary heart disease among doctors in northern and in southern Europe, a questionnaire study was undertaken among doctors in primary health care and departments of internal medicine in Sicily and Stockholm. The regions differed in culture and health-care structure. Guidelines were similar, but screening of healthy individuals was recommended in Sicily, and not in Sweden. One hundred and fifty-three general practitioners in Sicily and 120 in Stockholm, 211 internists in Sicily and 83 in Stockholm participated. Main outcome measures were management policies for investigation and treatment and also attitudes. Routine lipid checks at first visits were done by few doctors in Stockholm but by a majority in Sicily (p < 0.001); in the presence of general cardiovascular risk factors (other than heredity, diabetes, cardiovascular disease and hypertension), routine checks were carried out more often by both general practitioners (p < 0.001) and internists (p < 0.005) in Stockholm. Drug treatment was initiated at lower cholesterol levels for secondary and primary intervention, cardiovascular disease, cardiovascular risk factors and hereditary hyperlipidaemia by both groups in Sicily (p < 0.001), as was dietary treatment. Secondary prevention was considered important by all groups, but primary prevention only by Sicilian doctors. We concluded that there were differences in views and management practice between doctors in Sicily and in Stockholm on the investigation and treatment of patients with hyperlipidaemia. Doctors tested lipids at first visits in Sicily but not in Stockholm. Treatment was initiated at lower levels of cholesterol in Sicily.

General practitioners’ coronary risk assessments and lipid-lowering treatment decisions in primary prevention : Comparison between two European areas with different cardiovascular risk levels

Aim: To investigate whether general practitioners (GPs) in countries with different levels of cardiovascular risk would make different risk estimates and choices about lipid-lowering treatment when ...

General Practitioners’ coronary risk estimates, decisions to start lipid-lowering treatment, gender and length of clinical experience: their interactions in primary prevention

AIM We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patients risk, such as the gender and length in clinical practice, interact. BACKGROUND The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD. METHODS Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R1D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment. RESULTS Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R1D group (difference not statistically significant). R1D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P50.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19-2.61, P50.004) and by less experienced doctors (OR 0.97, 95% CI 0.95-0.99, P50.016). CONCLUSIONS The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.