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Publication Briefs

Study Shows Only Marginal Improvements and Significant Variation in Optimal Treatment for Veterans with Heart Failure

More than one million US adults are diagnosed with heart failure annually, with a 1-year mortality rate between 13% and 20%. Mortality is higher among those with heart failure with reduced ejection fraction (HFrEF). Multiple medications are available to treat patients with HFrEF (e.g., β-blockers and angiotensin-converting enzyme inhibitors), as well as implantable cardioverter-defibrillators (ICDs). Optimal HFrEF medical treatment is estimated to reduce mortality by more than 70%. However, uptake of guideline-recommended therapies has historically been poor. Understanding how medical therapy rates and mortality have changed over time is critical for informing efforts to bridge the existing gaps in quality of care. This study sought to evaluate trends in guideline-directed medical therapy, ICD use, and risk-adjusted mortality among VA patients with recent-onset HFrEF. Using VA data, investigators identified 144,074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. They also evaluated guideline-recommended medical therapy and ICD use rates within six months of the index date, as well as all-cause mortality at 6 and 12 months. For each medication, they restricted the population to patients with at least one prescription filled in VA within 6 months before and after their index date. Further, they assessed patient characteristics (i.e., demographics and comorbidities) – and treatment rates for therapies across VA facilities with at least 20 eligible patients.


  • This study found only marginal improvements between 2013 and 2019 in guideline-recommended therapy and mortality rates among Veterans with recent-onset HFrEF.
  • Substantial variation in medical therapy rates across VA facilities was observed, e.g., for guideline-recommended β-blocker use, 8 facilities had rates less than 55%, and 19 facilities exceeded 75%.
  • Risk-adjusted mortality decreased over the study period from 20% in 2013 to 18% in 2019. Facility-level, 1-year risk-adjusted mortality rates ranged from 14% to 23%.
  • Among patients with an ICD indication, use rates were 41% at 6 months but decreased over time.


  • Despite the availability of multiple therapies that are associated with reduced mortality among VA patients with HFrEF, treatment rates remained suboptimal, suggesting the need for new approaches to increase the uptake of evidence-based treatment.


  • An HFrEF patient may not be an appropriate candidate for a medical therapy for multiple reasons, such as allergies, hypotension, or kidney dysfunction. Despite efforts to account for most of these factors, investigators may not have captured some factors (i.e., non-VA lab results).

Dr. Heidenreich led QUERI’s MedSafe QUERI Program; he and Dr. Turakhia are part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Sandhu A, Kohsaka S, Turakhia M, Lewis E, and Heidenreich P. Evaluation of Quality of Care for US Veterans with Recent-Onset Heart Failure with Reduced Ejection Fraction. JAMA Cardiology. November 10, 2021; online ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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