Age and receipt of guideline-recommended medications for heart failure: a nationwide study of veterans.

Steinman MA, Harlow JB, Massie BM, Kaboli PJ, Fung KZ, Heidenreich PA. Age and receipt of guideline-recommended medications for heart failure: a nationwide study of veterans. Journal of general internal medicine. 2011 Oct 1; 26(10):1152-9.

Related HSR&D Project(s)

• IIR 04-046 – Optimal Use and Cost-Effectiveness of ICDS in the VA Health Care System
• IAF 06-080 – Guideline Adherence in Elders with Heart Failure and Multiple Comorbidities

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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.