Commentary

So-called treatment “gaps” related to physician lapses in following evidence-based clinical guidelines are the result of specific physician or system shortcomings.1 Efforts to identify and validate uncomplicated, inexpensive procedures that improve physician adherence are welcome, especially when the disease in question, congestive heart failure (CHF), contributes immensely to morbidity, mortality, and healthcare expense, and treatment (β blockers) is low-cost and readily available. The value of β blockade in heart failure is well established,2 but many eligible patients do not receive this or other scientifically confirmed treatments.3 Fear of aggravating a patient’s precarious cardiac status is a common concern. Certainly β blocker treatment in CHF demands very low initial doses and carefully monitored titration, but when used properly, the risk of adverse events is low.

The simple reminder on the echocardiography reports of patients qualifying for treatment in the study by Heidenreich et al is readily reproducible. Including specific prescribing details for guideline-recommended β blockers, metoprolol and carvedilol, was useful. Even with the encouraging baseline status of patients (51% using β blockers) and improved utilisation of β blockers, particularly after the reminder, 1 in 4 patients did not receive a proven intervention. Thus, much remains to be done to accomplish the ideal.

The problem of eliminating treatment gaps will likely require as many solutions as there are apparent causes. Antipathy to “cookbook” medicine is clearly unhelpful. Neither is the threat of litigation for neglecting a proven treatment likely to improve implementation. Rewarding physician behaviour that most benefits most patients is an attractive option.