2012 HSR&D/QUERI National Conference Abstract
3136 — Reasons for Not Prescribing Guideline-Recommended Medications to Veterans with Heart Failure
Steinman MA, and Peterson CA, San Francisco VAMC;
Performance measures for heart failure implicitly assume that higher rates of guideline-recommended treatment are better. However, little is known about whether patients not receiving guideline-concordant care have legitimate reasons for foregoing care, or about the distribution of reasons for non-treatment.
Chart review study of Veterans age 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a beta blocker and/or an ACE inhibitor or angiotensin receptor blocker (ARB). Reasons for non-treatment with these medications were identified from clinic notes based on explicit or strongly implicit statements by the treating clinician. We also interviewed subjects’ primary care clinicians about their reasons for non-prescribing to patients identified in the chart review.
Among 2846 patients screened, 301 met inclusion criteria, of whom 70% were not prescribed an ACE inhibitor or ARB, 18% were not prescribed a beta blocker, and 11% were not prescribed both drug classes. Mean age was 75 (+/-10) years, and 85% had seen a primary care clinician in the past 6 months. Chart review identified 235 reasons for non-prescribing in 195 patients (65%). The most common reason for non-prescribing was clinical contraindications to drug treatment (58%). In addition, 18% of patients had at least one non-biomedical reason for non-prescribing, including reasons related to patient attitudes, adherence, or drug misuse (10%) and comanagement with other clinicians (6%). We compared these results with interviews of 61 clinicians whose patients were the subject of chart review. The interviews identified nearly twice as many reasons for non-prescribing as the chart (mean 1.6 vs. 0.9 reasons per patient, P <.001). While clinical contraindications were often cited (70% of patients), one or more other reasons for non-prescribing were described for 66% of patients. These other reasons included patient attitudes, adherence, or misuse; comanagement with other clinicians; and believing that the drug is not indicated (21-27% of patients each).
Two-thirds of Veterans with heart failure who do not receive guideline-recommended medications have a reason for non-prescribing documented in the chart, mostly involving clinical contraindications. However, clinicians report that non-biomedical reasons for not prescribing are equally common.
Guidelines and performance measures should better account for non-biomedical reasons for not providing guideline-recommended care.