Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans
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Older patients often receive less guideline-concordant care for heart failure than younger patients.
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).
Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.
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.
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.
- Fonarow GC. Quality indicators for the management of heart failure in vulnerable elders. Ann Intern Med. 2001;135(8 Pt 2):694–702.
- Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):e154-235. CrossRef
- Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991;325(5):293–302.
- Foody JM, Farrell MH, Krumholz HM. beta-Blocker therapy in heart failure: scientific review. JAMA. 2002;287(7):883–889. CrossRef
- Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709–717. CrossRef
- Masoudi FA, Rathore SS, Wang Y, et al. National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction. Circulation. 2004;110(6):724–731. CrossRef
- Fonarow GC, Abraham WT, Albert NM, et al. Age- and gender-related differences in quality of care and outcomes of patients hospitalized with heart failure (from OPTIMIZE-HF). Am J Cardiol. 2009;104(1):107–115. CrossRef
- Forman DE, Cannon CP, Hernandez AF, Liang L, Yancy C, Fonarow GC. Influence of age on the management of heart failure: findings from Get With the Guidelines-Heart Failure (GWTG-HF). Am Heart J. 2009;157(6):1010–1017. CrossRef
- Chaudhry SI, Berlowitz DR, Concato J. Do age and comorbidity affect intensity of pharmacological therapy for poorly controlled diabetes mellitus? J Am Geriatr Soc. 2005;53(7):1214–1216. CrossRef
- Glynn RJ, Monane M, Gurwitz JH, Choodnovskiy I, Avorn J. Aging, comorbidity, and reduced rates of drug treatment for diabetes mellitus. J Clin Epidemiol. 1999;52(8):781–790. CrossRef
- Hood S, Taylor S, Roeves A, et al. Are there age and sex differences in the investigation and treatment of heart failure? A population-based study. Br J Gen Pract. 2000;50(456):559–563.
- Hulsmann M, Berger R, Mortl D, Pacher R. Influence of age and in-patient care on prescription rate and long-term outcome in chronic heart failure: a data-based substudy of the EuroHeart Failure Survey. Eur J Heart Fail. 2005;7(4):657–661. CrossRef
- Muntwyler J, Cohen-Solal A, Freemantle N, Eastaugh J, Cleland JG, Follath F. Relation of sex, age and concomitant diseases to drug prescription for heart failure in primary care in Europe. Eur J Heart Fail. 2004;6(5):663–668. CrossRef
- Lee DS, Tu JV, Juurlink DN, et al. Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA. 2005;294(10):1240–1247. CrossRef
- Bertoni AG, Duren-Winfield V, Ambrosius WT, et al. Quality of heart failure care in managed Medicare and Medicaid patients in North Carolina. Am J Cardiol. 2004;93(6):714–718. CrossRef
- Scott IA, Guyatt GH. Cautionary tales in the interpretation of clinical studies involving older persons. Arch Intern Med. 2010;170(7):587–595. CrossRef
- Dulin BR, Krum H. Drug therapy of chronic heart failure in the elderly: the current state of clinical-trial evidence. Curr Opin Cardiol. 2006;21(4):393–399. CrossRef
- Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J. 2005;26(3):215–225. CrossRef
- Erdmann E, Lechat P, Verkenne P, Wiemann H. Results from post-hoc analyses of the CIBIS II trial: effect of bisoprolol in high-risk patient groups with chronic heart failure. Eur J Heart Fail. 2001;3(4):469–479. CrossRef
- Packer M, Coats AJ, Fowler MB, et al. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001;344(22):1651–1658. CrossRef
- Deedwania PC, Gottlieb S, Ghali JK, Waagstein F, Wikstrand JC. Efficacy, safety and tolerability of beta-adrenergic blockade with metoprolol CR/XL in elderly patients with heart failure. Eur Heart J. 2004;25(15):1300–1309. CrossRef
- Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–724. CrossRef
- Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ. 2003;326(7382):196. CrossRef
- Masoudi FA, Havranek EP, Smith G, et al. Gender, age, and heart failure with preserved left ventricular systolic function. J Am Coll Cardiol. 2003;41(2):217–223. CrossRef
- Masoudi FA, Baillie CA, Wang Y, et al. The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998–2001. Arch Intern Med. 2005;165(18):2069–2076. CrossRef
- Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218–2227. CrossRef
- Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Identifying hypertension-related comorbidities from administrative data: what's the optimal approach? Am J Med Qual. 2004;19(5):201–206. CrossRef
- Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–619. CrossRef
- Fonarow GC, Yancy CW, Albert NM, et al. Heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Circ Heart Fail. 2008;1(2):98–106. CrossRef
- Matthews JC, Johnson ML, Koelling TM. The impact of patient-specific quality-of-care report cards on guideline adherence in heart failure. Am Heart J. 2007;154(6):1174–1183. CrossRef
- Goff DC, Jr., Massing MW, Bertoni AG, et al. Enhancing quality of heart failure care in managed Medicare and Medicaid in North Carolina: results of the North Carolina Achieving Cardiac Excellence (NC ACE) Project. Am Heart J. 2005;150(4):717–724. CrossRef
- Smith NL, Chan JD, Rea TD, et al. Time trends in the use of beta-blockers and other pharmacotherapies in older adults with congestive heart failure. Am Heart J. 2004;148(4):710–717. CrossRef
- Sinha S, Goldstein M, Penrod J, et al. Brief report: beta-blocker use among veterans with systolic heart failure. J Gen Intern Med. 2006;21(12):1306–1309. CrossRef
- de Groote P, Isnard R, Assyag P, et al. Is the gap between guidelines and clinical practice in heart failure treatment being filled? Insights from the IMPACT RECO survey. Eur J Heart Fail. 2007;9(12):1205–1211. CrossRef
- Shah SM, Carey IM, DeWilde S, Richards N, Cook DG. Trends and inequities in beta-blocker prescribing for heart failure. Br J Gen Pract. 2008;58(557):862–869. CrossRef
- Koschack J, Jung HH, Scherer M, Kochen MM. Prescriptions of recommended heart failure medications can be correlated with patient and physician characteristics. Int J Clin Pract. 2009;63(2):226–232. CrossRef
- Keeffe B, Subramanian U, Tierney WM, et al. Provider response to computer-based care suggestions for chronic heart failure. Med Care. 2005;43(5):461–465. CrossRef
- Baker DW, Persell SD, Thompson JA, et al. Automated review of electronic health records to assess quality of care for outpatients with heart failure. Ann Intern Med. 2007;146(4):270–277.
- Bart BA, Gattis WA, Diem SJ, O’Connor CM. Reasons for underuse of angiotensin-converting enzyme inhibitors in patients with heart failure and left ventricular dysfunction. Am J Cardiol. 1997;79(8):1118–1120. CrossRef
- Witham MD, Gillespie ND, Struthers AD. Age is not a significant risk factor for failed trial of beta-blocker therapy in older patients with chronic heart failure. Age Ageing. 2004;33(5):467–472. CrossRef
- Phillips SM, Marton RL, Tofler GH. Barriers to diagnosing and managing heart failure in primary care. Med J Aust. 2004;181(2):78–81.
- Steinman MA, Patil S, Kamat P, Peterson C, Knight SJ. A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure. Am J Geriatr Pharmacother. 2010;8(6):583–594. CrossRef
- Parameswaran AC, Tang WH, Francis GS, Gupta R, Young JB. Why do patients fail to receive beta-blockers for chronic heart failure over time? A "real-world" single-center, 2-year follow-up experience of beta-blocker therapy in patients with chronic heart failure. Am Heart J. 2005;149(5):921–926. CrossRef
- Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717–727.
- Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans
Journal of General Internal Medicine
Volume 26, Issue 10 , pp 1152-1159
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- guideline adherence
- heart failure
- health services research
- quality of care
- Industry Sectors
- Author Affiliations
- 1. Health Services Research Enhancement Award Program (REAP), San Francisco VA Medical Center, 4150 Clement St, VA Box 181 G, San Francisco, CA, 94121, USA
- 2. Division of Geriatrics, San Francisco VA Medical Center and the University of California San Francisco, San Francisco, CA, USA
- 3. Division of Cardiology, San Francisco VA Medical Center and the University of California San Francisco, San Francisco, CA, USA
- 4. Veterans Health Administration Congestive Heart Failure Quality Enhancement Research Initiative, Washington, DC, USA
- 5. The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA
- 6. Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- 7. Division of Cardiology, Palo Alto VA Health Care System and Stanford University, Palo Alto, CA, USA