A notable finding of the present study was that the surveyed physicians in Beijing had only a moderate level of knowledge of GDMT for HFrEF. Furthermore, having a higher degree, working as a cardiologist, having a senior professional title and having more than 5 years of professional experience were associated with a higher knowledge score. Additionally, the responses to the practice dimension highlighted deficiencies regarding the use of quadruple therapy in patients with HFrEF. Our results provide new insights into the knowledge and practices of physicians in Beijing with regard to GDMT for HFrEF, and the findings may facilitate the design and implementation of training interventions to raise awareness about GDMT for HFrEF and thereby increase the use of management strategies that are recommended by the current guidelines.
The average knowledge score was 28.23 ± 9.03 points (maximum of 43 points), suggesting that the surveyed physicians had deficiencies in their knowledge about the use of GDMT for HFrEF. This finding is consistent with those of studies published in 2013 and 2017, which concluded that there is a considerable knowledge gap among physicians in China regarding the guidelines for the diagnosis and treatment of HF [20]. Around one-third of the respondents indicated that they were not familiar with the definition of HFrEF or the classes of medication used as quadruple therapy for HFrEF, and more than 40% of the participants were not familiar with the principles of HFrEF pharmacotherapy as recommended by current guidelines. These findings suggest that a substantial minority of physicians in Beijing lack sufficient awareness of HFrEF and the guideline-based recommendations regarding its treatment with quadruple therapy. Consistent with this, only around half of the physicians correctly identified ARNIs as the first-line RAS inhibitors for HFrEF, ACEIs as the second-line agents and ARBs as the last-line drugs. Additionally, less than half of the respondents were aware of the indications for CRT or ICD use in patients with HFrEF, in agreement with a previous study [21], implying that these treatments may be underused in eligible patients in China. Indeed, the China Heart Failure study showed that ACEIs/ARBs, beta-blockers and MRAs were utilized in only 27%, 25.6% and 26.6%, respectively, of patients with HF at admission to hospital, while ICDs, CRT and other devices were utilized in only 0.3% of patients hospitalized for HF [22]. Taken together, the above results highlight important knowledge gaps regarding the management strategies for HFrEF recommended by current guidelines, and particularly quadruple therapy. Various factors can act as obstacles to the adoption of GDMT for HF including clinician knowledge gaps, lack of patient/caregiver awareness, patients in clinical trials not being representative of those in the real-world setting, high treatment costs, and a lack of evidence of the benefits of implementation strategies [23]. Among these factors, clinician knowledge gaps are recognized as particularly important barriers to the implementation of GDMT in patients with HFrEF [23]. Interventions such as guideline dissemination and education have been shown to improve adherence to cardiovascular disease guidelines [24]. We suggest that the provision of suitable training might improve physicians’ knowledge of GDMT for HFrEF, in agreement with a previous report that recommended training programs focusing on the use of medications such as RAS inhibitors and beta-blockers, dosing principles, and the indications for ICD placement [21]. The provision of training programs is particularly important given that nearly half of the physicians surveyed in this study reported not taking a proactive approach to learning about GDMT for HFrEF and given that more than half of the respondents saw only a small number of patients with HFrEF each month, limiting their clinical experience.
The present analysis also found that having a higher degree, specializing as a cardiologist, having a senior professional title and having more than 5 years of professional experience were associated with a higher knowledge score. These results are consistent with previously reported data. For example, a questionnaire-based study by Wei et al. found that physicians specialized in cardiovascular disease had a higher rate of correct answers than physicians who were not specialized in cardiovascular disease. Additionally, Gan et al. observed that a higher level of qualifications was associated with greater awareness of HF guidelines [20]. Thus, clinical experience in managing patients with HF exerts an important influence on knowledge level.
The responses to the practice dimension of the questionnaire revealed that the majority of physicians (54.37–78.16%) indicated that RAS inhibitors, beta-blockers, MRAs and SGLT2 inhibitors were prescribed to less than half of their patients with HFrEF. Furthermore, the vast majority of physicians (83.01%) stated that quadruple therapy was prescribed in less than half of their patients, while 79.13% of the respondents stated that less than half of their patients received guideline-based dose adjustments. These findings demonstrate that there is substantial room for improvement in the practices of physicians in Beijing with regard to the management of HFrEF, and our data agree well with previous studies reporting suboptimal adherence to GDMT [25]. Analysis of data from the CHAMP-HF (Change the Management of Patients with Heart Failure) registry in the USA revealed that 27%, 33% and 67% of eligible outpatients with chronic HFrEF were not prescribed RAS inhibitor (ACEI, ARB or ARNI), beta-blocker and MRA therapy, respectively [26]. Furthermore, the target doses of the ACEI/ARB, ARNI and beta-blocker were attained in 17%, 14% and 28% of patients, respectively, and only 1% of eligible patients were receiving the target doses of ACE/ARB, ARNI, beta-blocker and MRA [26]. Data from the PINNACLE (Practice Innovation and Clinical Excellence) registry in the USA indicated that 74.6% of patients with HFrEF were prescribed a beta-blocker, 78% of patients were prescribed an ACEI, ARB or ARNI, 72.8% were prescribed both a beta-blocker and an ACEI/ARB/ARNI, but only 8.5% were receiving an ARNI [27]. A more recent study of patients with HF in Sweden, the UK and the USA established that the target dose of ACEI, ARB, beta-blocker and ARNI was achieved in only 15%, 10%, 12% and 30% of cases, respectively, and the drug discontinuation rates were high [28]. Somewhat higher rates of treatment with recommended medications (81% for loop diuretics, 84% for RAS inhibitors, 86% for beta-blockers and 56% for MRAs) were reported for outpatients in The Netherlands, although the average doses were lower than those recommended by the guidelines [29]. Therefore, there remains substantial room for improvement in the clinical application of GDMT for HFrEF in China and other countries. The implementation of targeted training programs and other interventions, such as automated electronic health record alerts [30], may help improve physicians’ adherence to guideline recommendations.
This study has some limitations. First, the sample size was reasonably small, so it is possible that the analysis lacked sufficient statistical power to detect some real differences in knowledge score between subgroups. Second, although this was a multi-center study, the generalizability of the findings remains to be established because all respondents worked in hospitals in one region of China (Beijing). Third, although the questionnaire was developed according to previously reported tools, it may have limitations regarding its ability to evaluate perceptions regarding GDMT for HFrEF. Fourth, this study did not assess whether education/training programs or other interventions would improve the questionnaire scores.