Drugs & Aging

, Volume 28, Issue 7, pp 561–573 | Cite as

Clinical, Demographic and Functional Characteristics Associated with Pharmacotherapy for Heart Failure in Older Home Care Clients

A Retrospective, Population-Level, Cross-Sectional Study
  • Andrea D. FoebelEmail author
  • George A. Heckman
  • John P. Hirdes
  • Suzanne L. Tyas
  • Erin Y. Tjam
  • Robert S. McKelvie
  • Colleen J. Maxwell
Original Research Article


Background: Use of combination pharmacotherapy, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and β-adrenoceptor antagonists (β-blockers) in the management of heart failure (HF) can reduce mortality, prevent functional decline and reduce health service use. However, these first-line therapies are underused in older populations. This article describes the use and predictors of use of first-line HF therapies in a population-based cohort of older home care clients in Ontario, Canada.

Objectives: To examine the use and correlates of first-line pharmacotherapy in older home care clients with HF.

Methods: This was a retrospective, cross-sectional study of Resident Assessment Instrument — Home Care (RAI-HC) data in individuals aged ≥65 years receiving home care services in the province of Ontario, Canada. Data collected were from all 14 health regions in Ontario. Home care clients with HF were identified from among those aged ≥65 years whose first RAI-HC assessment occurred between January 2004 and December 2007 (n = 176 866). Potential correlates of pharmacotherapy for HF were identified from the RAI-HC and examined using multivariable logistic regression.

Results: HF prevalence was 12.4%. Among clients with HF, 28.6% received no first-line pharmacotherapy; this proportion declined by 6% over the 4 years studied. Only 28.0% were receiving recommended combination therapy. First-line pharmacotherapy use was dependent on hypertension and diabetes mellitus status. Use of pharmacotherapy was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms.

Conclusions: Approximately 29% of older home care clients with HF received no first-line HF pharmacotherapy, while another 28% received optimal first-line HF pharmacotherapy. In addition to the expected clinical correlates, the increased likelihood of non-use associated with clients’ demographic and functional characteristics raises concerns about quality of care. A better understanding of how these factors affect prescribing practices, particularly for combination therapy, would help to optimize HF disease management. For clinicians, this work also serves as a potential reminder to follow guideline recommendations for HF management in older, vulnerable adults.


Heart Failure Candesartan Cilexetil Heart Failure Therapy Heart Failure Management Cognitive Performance Scale 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The Change Foundation, Toronto, Ontario, Canada, provided financial support for this research. The Change Foundation did not play a role in the design or conduct of the study; the collection, management, analysis or interpretation of data; or in the preparation, review or approval of the completed manuscript.

Dr Hirdes received the grant for this study from the Change Foundation and is supported as the Ontario Home Care Research and Knowledge Exchange Chair by the Ontario Ministry of Health and Long Term Care. Dr Heckman is a primary panelist of the Canadian Cardiovascular Society Consensus Conference on heart failure and receives salary support as the Schlegel Research Chair in Geriatric Medicine at the University of Waterloo. Dr McKelvie is Chair of the Canadian Cardiovascular Society Consensus Conference on heart failure. Dr Maxwell holds a Health Scholar Award from the Alberta Heritage Foundation for Medical Research and also received salary support from the CIHR Institute of Aging and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary. None of these roles were in conflict with this study or preparation of this manuscript. Dr Tyas, Dr Tjam and Dr Foebel also have no conflicts of interest that are directly relevant to the content of this study.

There were no other persons who made substantial contributions to this study or manuscript preparation.


  1. 1.
    Ross H, Howlett J, Arnold JM, et al. Treating the right patient at the right time: access to heart failure care. Can J Cardiol 2006 Jul; 22(9): 749–54PubMedCrossRefGoogle Scholar
  2. 2.
    Arnold JM, Liu P, Demers C, et al. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006 Jan; 22(1): 23–45PubMedCrossRefGoogle Scholar
  3. 3.
    Rouleau JL. Treatment of congestive heart failure: present and future. Can J Cardiol 2005 Oct; 21(12): 1084–8PubMedGoogle Scholar
  4. 4.
    Johansen H, Strauss B, Arnold JM, et al. On the rise: the current and projected future burden of congestive heart failure hospitalization in Canada. Can J Cardiol 2003 Mar 31; 19(4): 430–5PubMedGoogle Scholar
  5. 5.
    Smith ER. A special issue on chronic heart failure [letter]. Can J Cardiol 2003 Mar 31; 19(4): 345Google Scholar
  6. 6.
    Heckman GA, Rockwood K. The frail elderly patient with heart disease. In: Fillit HM, Rockwood K, Woodhouse K, editors. Brocklehurst’s textbook of geriatric medicine and gerontology, 7th ed. Philadelphia (PA): WB Saunders, 2010: 295–9CrossRefGoogle Scholar
  7. 7.
    Fitchett D, Rockwood K, Chan BT, et al. Canadian Cardiovascular Society consensus conference 2002. Management of heart disease in the elderly patient. Can J Cardiol 2004 May; 20Suppl. A: 7A–16APubMedGoogle Scholar
  8. 8.
    The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991 Aug 1; 325(5): 293–302CrossRefGoogle Scholar
  9. 9.
    CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomized trial. Lancet 1999 Jan 2; 353: 9–13CrossRefGoogle Scholar
  10. 10.
    Packer M, Coats AJS, Fowler MB, et al. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 2001 May 31; 344(22): 1651–8PubMedCrossRefGoogle Scholar
  11. 11.
    Arling ML. Management of heart failure in nursing facility residents according to AMDA guidelines. Nurs Home Med 1997; 5: 374–80Google Scholar
  12. 12.
    Gambassi G, Lapane KL, Sgadari A, et al. Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure. Arch Intern Med 2000 Jan 10; 160(1): 53–60PubMedCrossRefGoogle Scholar
  13. 13.
    Zuccala G, Onder G, Marzetti E, et al. Use of angiotensin-converting enzyme inhibitors and variations in cognitive performance among patients with heart failure. Eur Heart J 2005 Feb; 26(3): 226–33PubMedCrossRefGoogle Scholar
  14. 14.
    Chan JD, Read TD, Smith NL, et al. Association of β-blocker use with mortality among patients with congestive heart failure in the Cardiovascular Health Study. Am Heart J 2005; 150(3): 464–70PubMedCrossRefGoogle Scholar
  15. 15.
    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 Feb; 26(3): 215–25PubMedCrossRefGoogle Scholar
  16. 16.
    Tsuyuki RT, Ackman ML, Montague TJ. Effects of the 1994 Canadian Cardiovascular Society clinical practice guidelines for congestive heart failure. Can J Cardiol 2002 Feb; 18(2): 147–52PubMedGoogle Scholar
  17. 17.
    Fuat AN, Hungin APS, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 2003 Jan 25; 326: 196–201PubMedCrossRefGoogle Scholar
  18. 18.
    Cleland JGF, Cohen-Solal A, Aguilar JC, et al. Management of heart failure in primary care (the IMPROVEMENT of Heart failure Programme): an international survey. Lancet 2002 Nov 23; 360: 1631–9PubMedCrossRefGoogle Scholar
  19. 19.
    Komajda M, Follath F, Swedbuerg K, et al. The EuroHeart failure survey programme — a survey on the quality of care among patients with heat failure in Europe: part 2: treatment. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. Eur Heart J 2003 Mar; 24(5): 464–74PubMedCrossRefGoogle Scholar
  20. 20.
    Calvert MJ, Shankar A, McManus RJ, et al. Evaluation of the management of heart failure in primary care. Fam Pract 2009 Apr; 26(2): 145–53PubMedCrossRefGoogle Scholar
  21. 21.
    Heiat A, Gross CP, Krumholz HM. Representation of the elderly, women, and minorities in heart failure clinical trials. Arch Intern Med 2002 Aug; 162(15): 1682–8PubMedCrossRefGoogle Scholar
  22. 22.
    Erhardt L, Komajda M, Hobbs FDR, et al. Cardiologists’ awareness and perceptions of guidelines for chronic heart failure. The ADDress your heart survey. Eur J Heart Fail 2008 Oct; 10(10): 1020–5PubMedCrossRefGoogle Scholar
  23. 23.
    Foebel AD, Hirdes JP, Heckman GA, et al. A profile of older community-dwelling home care clients with heart failure in Ontario. Chronic Dis Can 2011; 31(2): 49–57PubMedGoogle Scholar
  24. 24.
    Feldman DE, Thivierge C, Guerard L, et al. Changing trends in mortality and admissions to hospital for elderly patients with congestive heart failure in Montreal. CMAJ 2001 Oct 16; 165(8): 1053–5Google Scholar
  25. 25.
    Bueno H, Ross JS, Wang Y, et al. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993–2006. JAMA 2010 June 2; 303(21): 2141–7PubMedCrossRefGoogle Scholar
  26. 26.
    Bernabei R, Gray L, Hirdes J, et al. International gerontology. In: Halter JB, Ouslander JG, Tinetti ME, et al., editors. Hazzard’s geriatric medicine and gerontology. 6th ed. New York: McGraw Medical, 2009: 69–96Google Scholar
  27. 27.
    Morris JN, Fries BE, Steel K, et al. Comprehensive clinical assessment in community setting: applicability of the MDS-HC. J Am Geriatr Soc 1997 Aug; 45(8): 1017–24PubMedGoogle Scholar
  28. 28.
    Landi F, Tua E, Onder G, et al. Minimum data set for home care: a valid instrument to assess frail older people living in the community. Med Care 2000 Dec; 38(12): 1184–90PubMedCrossRefGoogle Scholar
  29. 29.
    Landi F, Onder G, Tua E, et al. Impact of a new assessment system, the MDS-HC, on function and hospitalization of homebound older people: a controlled clinical trial. J Am Geriatr Soc 2001 Oct; 49(10): 1288–93PubMedCrossRefGoogle Scholar
  30. 30.
    Morris JN, Carpenter GI, Berg K, et al. Outcome measures for use with home care clients. Can J Aging 2000; 19Suppl. 2: 87–105CrossRefGoogle Scholar
  31. 31.
    Gambassi G, Landi F, Peng L, et al. Validity of diagnostic and drug data in standardized nursing home resident assessments: Potential for geriatric pharmacoepidemiology. Med Care 1998 Feb; 36(2): 167–79PubMedCrossRefGoogle Scholar
  32. 32.
    Wodchis WP, Naglie G, Teare GF. Validating diagnostic information on the minimum data set in Ontario hospital-based long-term care. Med Care 2008 Aug; 46(8): 882–7PubMedCrossRefGoogle Scholar
  33. 33.
    Litaker JR, Chou JY. Patterns of pharmacologic treatment of congestive heart failure in elderly nursing home residents and related issues: a review of the literature. Clin Ther 2003 Jul; 25(7); 1918–35PubMedCrossRefGoogle Scholar
  34. 34.
    Heckman GA, Misiaszek B, Merali F, et al. Management of heart failure in Canadian long-term care facilities. Can J Cardiol 2004 Aug; 20(10): 963–9PubMedGoogle Scholar
  35. 35.
    Zannad F. Evidence-based drug therapy for chronic heart failure. Eur Heart J 2002; 4Suppl. D: D66–72CrossRefGoogle Scholar
  36. 36.
    Hirdes JP, Frijters DH, Teare GF. The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people. J Am Geriatr Soc 2003 Jan; 51(1): 96–100PubMedCrossRefGoogle Scholar
  37. 37.
    Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive performance scale. J Gerontol 1994 Jul; 49(4): M174–82PubMedCrossRefGoogle Scholar
  38. 38.
    Liu P, Arnold JM, Belenkie I, et al. The 2002/3 Canadian Cardiovascular Society consensus guideline update for the diagnosis and management of heart failure. Can J Cardiol 2003 Mar 31; 19(4): 347–56PubMedGoogle Scholar
  39. 39.
    Heckman GA, Patterson CJ, Demers C, et al. Heart failure and cognitive impairment: challenges and opportunities. Clin Interv Aging 2007; 2(2): 209–18PubMedGoogle Scholar
  40. 40.
    Heckman GA, McKelvie RS, Turpie ID. Heart failure in the frail elderly. In: Turpie ID, Heckman GA, editors. Aging issues in cardiology. Boston (MA): Kluwer, 2003: 139–62Google Scholar
  41. 41.
    Chaudhry SI, Wang Y, Gill TM, et al. Geriatric conditions and subsequent mortality in older patients with heart failure. J Am Coll Cardiol 2010; 55: 309–16PubMedCrossRefGoogle Scholar
  42. 42.
    Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005; (4): CD003566Google Scholar
  43. 43.
    Lainscak M, Cleland JGF, Lenzen MJ, et al. International variations in the treatment and comorbidity of left ventricular systolic dysfunction: data from the EuroHeart failure Survey. Eur J Heart Fail 2007 Mar; 9(3): 292–9PubMedCrossRefGoogle Scholar
  44. 44.
    Nicol ED, Fittall B, Roughton M, et al. NHS heart failure survey: a survey of acute heart failure admissions in England, Wales and Northern Ireland. Heart 2008 Feb; 94(2): 172–7PubMedCrossRefGoogle Scholar
  45. 45.
    Mitnitski AB, Mogilner AJ, MacKnight C, et al. The mortality rate as a function of accumulated deficits in a frailty index. Mech Ageing Dev 2002 Sep; 123(11): 1457–60PubMedCrossRefGoogle Scholar
  46. 46.
    Hickling JA, Nazareth I, Rogers S. The barriers to effective management of heart failure in general practice. Br J Gen Pract 2001 Aug; 51(469): 615–8PubMedGoogle Scholar
  47. 47.
    Horne R, Coombes I, Davies G, et al. Barriers to optimum management of heart failure by general practitioners. Br J Gen Pract 1999 May; 49(442): 353–7PubMedGoogle Scholar
  48. 48.
    Tjam EY, Heckman GA, Smith S, et al. Predicting heart failure mortality in frail seniors: comparing the NYHA functional classification with the Resident Assessment Instrument (RAI) 2.0. Int J Cardiol. Epub 2011 Feb 1Google Scholar
  49. 49.
    Senni M, Rodeheffer RJ, Tribouilloy CM, et al. Use of echocardiography in management of congestive heart failure in the community. J Am Coll Cardiol 1999 Jan; 33(1): 164–70PubMedCrossRefGoogle Scholar
  50. 50.
    Quach S, Blais C, Quan H. Administrative data have high variation in validity for recording heart failure. Can J Cardiol 2010 Oct; 26(8): e306–12CrossRefGoogle Scholar
  51. 51.
    Powell H, Lim LLY, Heller RF. Accuracy of administrative data to assess comorbidity in patients with heart disease: an Australian perspective. J Clin Epidemiol 2001; 54: 687–93PubMedCrossRefGoogle Scholar
  52. 52.
    Brookhart MA, Patrick AR, Schneeweiss S, et al. Physician follow-up and provider continuity are associated with long-term medication adherence. Arch Intern Med 2007 Apr 23; 167(8): 847–52PubMedCrossRefGoogle Scholar
  53. 53.
    Canadian Home Care Association. Portraits of home care in Canada: executive summary [online]. Available from URL: [Accessed 2010 August 31]
  54. 54.
    Grimley Evans J. Evidence-based and evidence-biased medicine. Age Ageing 1995 Nov; 24(6): 461–3CrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2011

Authors and Affiliations

  • Andrea D. Foebel
    • 1
    Email author
  • George A. Heckman
    • 1
    • 2
  • John P. Hirdes
    • 1
    • 3
  • Suzanne L. Tyas
    • 1
    • 4
  • Erin Y. Tjam
    • 1
    • 5
  • Robert S. McKelvie
    • 6
  • Colleen J. Maxwell
    • 7
  1. 1.Department of Health Studies & GerontologyUniversity of WaterlooWaterlooCanada
  2. 2.Department of Medicine, Division of GeriatricsMcMaster UniversityHamiltonCanada
  3. 3.Homewood Research InstituteGuelphCanada
  4. 4.Department of PsychologyUniversity of WaterlooWaterlooCanada
  5. 5.St Mary’s General HospitalKitchenerCanada
  6. 6.Department of Medicine, Division of CardiologyMcMaster UniversityHamiltonCanada
  7. 7.Departments of Medicine and Community Health SciencesUniversity of CalgaryCalgaryCanada

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