Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans

  • Michael A. Steinman
  • John B. Harlow
  • Barry M. Massie
  • Peter J. Kaboli
  • Kathy Z. Fung
  • Paul A. Heidenreich
Original Research

DOI: 10.1007/s11606-011-1745-2

Cite this article as:
Steinman, M.A., Harlow, J.B., Massie, B.M. et al. J GEN INTERN MED (2011) 26: 1152. doi:10.1007/s11606-011-1745-2

Abstract

Background

Older patients often receive less guideline-concordant care for heart failure than younger patients.

Objective

To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chart-documented reasons for non-adherence to guidelines.

Design and Patients

Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program).

Main Measures

Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.

Results

Among 2,772 patients, mean age was 73 +/− 10 years, 87% received an ACE inhibitor or ARB, and 82% received a beta blocker. When patients with explicit chart-documented reasons for not receiving these drugs were excluded, 95% received an ACE inhibitor or ARB and 89% received a beta blocker. In multivariable analyses controlling for a variety of patient and health system characteristics, the adjusted odds ratio for ACE-inhibitor and ARB use was 0.43 (95% CI 0.24–0.78) for patients age 80 and over vs. those age 50–64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI 0.48–0.93) between the two age groups. The magnitude of these associations was similar but not statistically significant after excluding patients with chart-documented reasons for not prescribing ACE inhibitors or ARBs and beta blockers.

Conclusions

A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.

KEY WORDS

guideline adherence heart failure aging health services research quality of care 

Supplementary material

11606_2011_1745_MOESM1_ESM.doc (40 kb)
Online Appendix: Classification of reasons for not prescribing guideline-recommended drugs (DOC 40 kb).

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Michael A. Steinman
    • 1
    • 2
  • John B. Harlow
    • 2
  • Barry M. Massie
    • 3
    • 4
  • Peter J. Kaboli
    • 5
    • 6
  • Kathy Z. Fung
    • 2
  • Paul A. Heidenreich
    • 4
    • 7
  1. 1.Health Services Research Enhancement Award Program (REAP)San Francisco VA Medical CenterSan FranciscoUSA
  2. 2.Division of GeriatricsSan Francisco VA Medical Center and the University of California San FranciscoSan FranciscoUSA
  3. 3.Division of CardiologySan Francisco VA Medical Center and the University of California San FranciscoSan FranciscoUSA
  4. 4.Veterans Health Administration Congestive Heart Failure Quality Enhancement Research InitiativeWashingtonUSA
  5. 5.The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare SystemIowa CityUSA
  6. 6.Division of General Internal Medicine, Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityUSA
  7. 7.Division of CardiologyPalo Alto VA Health Care System and Stanford UniversityPalo AltoUSA

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