BACKGROUND/RATIONALE:
More than 4.8 million adults have heart failure in the U.S. and the incidence is increasing, with currently 550,000 new cases each year. In the VA, heart failure accounted for over 115,000 hospital discharges during FY99 with a total cost including outpatient visits of over $2.5 billion. In addition, heart failure is associated with 20 to 30 percent one-year mortality rates in the elderly and causes significant functional limitation. The primary treatment for heart failure is medications to improve signs and symptoms and decrease morbidity and mortality. It is not known what the overall patterns of use are for heart failure medications for patients in the VA. And though clinical trials provide evidence of which patterns should lead to improved clinical outcomes, there is no comprehensive study of the patterns of use of these therapies in a population of patients in real practice.

OBJECTIVE(S):
The purpose of this project was to examine medication use in a national cohort of patients with CHF, and examine the association between pharmacy use measures with clinical outcomes of hospitalization and mortality. In addition, the relationship of pharmacy costs with inpatient, ambulatory, and total costs of care was studied.

METHODS:
This was a retrospective study of over 400,000 total unique patients with CHF in the VA from FY99 to FY02. Descriptive measures of pharmacy use were created to examine overall patterns of use in the CHF Cohort, trends in patterns over time, and variation by demographic characteristics and VISN. Clinical outcomes of one-year all-cause hospitalization and CHF-related hospitalization and one-year mortality were also calculated for each FY of the Cohort. Measures of persistence of use and achievement of targeted dose, in both the national cohort and the EPRP outpatient CHF sample were examined for beta blockers, ACE inhibitors and ARBs. Multivariable logistic regression models were created to determine the unique effect of drug use variables, persistence of use and achievement of targeted dose on the association with outcomes. Cost measures were created based on inpatient use, outpatient use, and pharmacy care. These were sub-totaled, and summed into total costs of care. The average per patient cost was determined based on all patients at risk for inpatient or outpatient use (all patients). The relative share of costs for inpatient, outpatient and pharmacy were then determined and compared from FY00 to FY02.

FINDINGS/RESULTS:
Therapeutic classes where use increased included from FY99 to FY02: angiotensin-converting enzyme (ACE) or angiotensin II inhibitors (66.7% to 69.3%); beta-blockers (43.2% to 54.0%); statins (42.0% to 51.9%); and spironolactone (9.7% to 12.0%). Classes where use decreased included: digitalis (38.1% to 34.1%) and calcium channel blockers (35.7% to 32.4%). Diuretic use was relatively constant at 73%. All cause and CHF hospitalization decreased from 26.8% to 22.1% and 5.0% to 4.0%, respectively. One-year mortality decreased from 9.6% to 8.7%. The inpatient cost per patient decreased from $4,382 in FY00 to $3,914 in FY02 (all costs adjusted to $2002). The average cost per patient for outpatient use similarly decreased slightly from $3,438 to $3,350, and the average cost per patient for pharmacy increased slightly from $1,358 to $1,407. Total costs per patient decreased from $9,179 to $8,671.

IMPACT:
Findings suggest that provision of good pharmacological care is improving clinical outcomes and shifting the costs of care from inpatient to outpatient pharmacy and ambulatory care, resulting in a net decrease in total costs of care.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Johnson ML, El-Serag HB, Tran TT, Hartman C, Richardson P, Abraham NS. Adapting the Rx-Risk-V for mortality prediction in outpatient populations. Medical care. 2006 Aug 1; 44(8):793-7. [view]
2. Johnson ML, Pietz K, Battleman DS, Beyth RJ. Therapeutic goal attainment in patients with hypertension and dyslipidemia. Medical care. 2006 Jan 1; 44(1):39-46. [view]

Conference Presentations

1. Wei II, Johnson ML. Does Medicare-Related Pharmacy Coverage Affect VA Pharmacy Use? Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]
2. Johnson ML. Hospital Use and Survival Among Veterans Affairs Beneficiaries: A Policy Evaluation Study using Retrospective Databases in the US Veterans Health Administration. Paper presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2006 May 23; Philadelphia, PA. [view]
3. Johnson ML. Large Database Analysis in Health Services Research. Paper presented at: Baylor College of Medicine Health Services Research Module Clinical Scientist Training Annual Program; 2006 Mar 1; Houston, TX. [view]
4. Parikh N, Shah D, Deswal A, Ashton CM, Agarwal SJ, Chen H, Johnson ML. The association of Aspirin use on Risk of Hospitalization in CHF Patients taking Ace Inhibitors: A Retrospective Analysis of a National Cohort of Veterans. Poster session presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2009 May 16; Orlando, FL. [view]
5. Johnson ML. Use of Pharmacy Services by Medicare-enrolled Veterans. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]

DRA: Health Systems
DRE: none
Keywords: Risk adjustment, Chronic heart failure, Quality assessment
MeSH Terms: none