A CHF OUTPATIENT POPULATION. B. Fenster 1 ; 1 Stanford University, Stanford, CA PURPOSE: Angiotensin Coverting Enzyme (ACE) inhibitors have been well established as first-line therapy in a wide spectrum of congestive heart failure (CHF) patients (1, 2) . ACE inhibition has been proven to ameliorate symptoms, decrease hospitalizations, and decrease mortality. In patients in whom ACE inhibitors cannot be used due to contraindications, intolerances, or allergies, angiotensin receptor blockers (ARB's) or isosorbide dinitrate and hydralazine, particularly in combination, have been shown to provide similar therapeutic benefits (3, 4) . Although the use of ACE inhibitors in treatment of CHF has become standard of care, previous studies have demonstrated wide variations in utilization patterns. Furthermore, few studies have directly assessed ACE inhibitor utilization among CHF outpatients (5,6). Finally, little is known about the usage of ACE inhibitor-alternatives in the setting of ACE inhibitor intolerance. The purpose of this study is to determine the utilization patterns of ACE inhibitors relative to established ACE inhibitor-alternatives in an outpatient CHF population. METHODS: The Palo Alto Medical Foundation (PAMF) is a large multi-specialty clinic located in Palo Alto, California. The PAMF CHF Registry consists of a database listing demographic and clinical data for 229 PAMF outpatients who currently carry the diagnosis of CHF. A retrospective electronic medical record audit of the PAMF CHF Registry population was performed to assess current utilization and dose administration of ACE inhibitors. Patients not receiving ACE inhibitors were assessed for ACE inhibitor-alternative usage, specifically ARB's, hydralazine, or isosorbide dinitrate. Reasons for ACE intolerance, contraindications, or allergies were also recorded. RESULTS: Review of all 229 patients in the PAMF CHF registry revealed that 87% of patients were receiving with either ACE inhibitors or established ACE inhibitor-alternative therapy. Sixty seven percent of all patients were receiving ACE inhibitor therapy, and 68% of these patients were treated with doses considered to be within the target range. An additional 20% of the population was being treated with either ARB's or hydralazine and/or isosorbide dinitrate. Many patients (13%) who were treated with ACE inhibitors experienced allergies or intolerances. CONCLUSION: The overwhelming majority of PAMF CHF outpatients are receiving either ACE inhibitor or ACE inhibitor-alternative therapy. In addition, the majority of patients receiving ACE inhibitors are receiving doses within target range. Although current practice patterns are better than predicted, a small but significant population exists that may benefit from ACE inhibitor initiation and/or more aggressive titration of existing ACE inhibitors. However, such efforts may be limited by a significant number of ACE inhibitor intolerances, allergies, and contraindications. Patients with alcohol problems are common in primary care and there may be advantages to treating these patients in this setting. However, there are few systematic reviews that focus on the efficacy of treatment for alcohol problems in primary care. Our goal was to evaluate the literature on treatment of alcohol problems in primary care according to alcohol consumption outcomes and methodological standards. METHODS: We searched the published literature for years 1966 ± 1999 to identify studies on treatment of alcohol problems in primary care. We included studies from English language peer reviewed journals that were (1) performed in a primary care setting; (2) had as the main focus the treatment of alcohol problems; (3) had two or more treatment arms; and (4) reported alcohol consumption outcomes. Two reviewers appraised all articles for methodological content and results according to pre-specified coding criteria. RESULTS: We identified eleven studies on treatment of alcohol problems in primary care. Seven described treatments for at risk drinking, while four described treatment for alcohol abuse and dependence. The studies were performed in a variety of primary care settings and all reported on the efficacy of brief interventions (BI). There was marked variability in these brief interventions with 4 (36%) using a single session, 6 (55%) using a drinking diary and 5 (45%) discussing a treatment plan. BI were effective in reducing alcohol consumption compared to control treatments in only three of the eleven studies (27%). This finding was only demonstrated in studies of at risk drinking. The studies inconsistently adhered to methodological standards with only 3 (27%) using a single step recruitment procedure and reporting the participation rate, none (0%) providing a full description of patient demographics and medical/psychiatric comorbidity, 1 (9%) assessing prognostic susceptibility, 10 (91%) performing randomization, 1 (9%) assessing ancillary treatments, 0 (0%) assessing discrimination between the treatments, and 5 (45%) providing follow-up on all enrolled subjects. CONCLUSION: This systematic review, restricted to studies performed in primary care found that, in contrast to expert recommendations, there is contradictory evidence on the efficacy of brief interventions for at risk drinkers in primary care. Based upon evidence from the medical literature, patients in primary care with alcohol abuse or dependence are unlikely to decrease their alcohol consumption as a result of brief interventions alone. Finally, studies of brief interventions in primary care inconsistently adhere to methodological standards.