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.
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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.
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