Clinical implications of an accurate problem list on heart failure treatment

CONTEXT: The premise of the problem-oriented medical record is that an accurately defined problem list will directly result in more thorough and efficient patient care. However, little empirical evidence exists demonstrating improved patient outcomes as a result of an adequately structured problem list. OBJECTIVE: To determine the impact of problem list documentation of heart failure on the likelihood that evidence-based pharmacotherapy has been prescribed. DESIGN: Cross-sectional study. SETTING: Community-based primary care clinics in Portland, Oregon. SUBJECTS: Active patients in the network with a left ventricular ejection fraction of 40% or less, with and without heart failure, in their structured problem list. MAIN OUTCOME MEASURES: The proportion of patients prescribed medications with known benefits for systolic dysfunction. RESULTS: In this group of patients with known systolic dysfunction, the likelihood of therapy with either an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker was higher in patients who had heart failure listed on their problem list compared to patients who did not (92.2% vs 76.7%; P<.05). This association remained after statistical adjustment for age, gender, and ejection fraction. Patients with accurate problem list entries were also more likely to receive digoxin (61.1% vs 36.7%; P=.001) and spironolactone (26.7% vs 13.3%; P=.025). There were no differences in the use of beta-blockers between the 2 groups. CONCLUSION: Accurate documentation of heart failure on the problem list of patients with known systolic dysfunction is associated with a significant increase in the likelihood of being prescribed medications with known clinical benefit.