BACKGROUND/RATIONALE:
Clinical practice guidelines have improved outcomes in patients with heart failure. However, there has been growing recognition of the difficulty of applying these guidelines to elders with multiple comorbid illnesses. In this setting, strict guideline adherence quickly leads to polypharmacy that can have unintended adverse effects and may be inconsistent with patient goals of care. Previous research has found that older patients are less likely to receive guideline concordant care for a variety of diseases. Much remains unknown about heart failure care for older patients in VA, including the prevalence of non-adherence to prescribing guidelines, the reasons that clinicians use for withholding guideline-recommended therapy, and how these reasons differ in younger vs. older patients.

OBJECTIVE(S):
This project had several inter-related goals. First, we determined the association between patient age and use of guideline-recommended medications, and explored how patient, provider, and system factors mediate the relationship between age and prescribing. Next, we developed an original taxonomy of reasons for not prescribing guideline-recommended medications to patients with heart failure. Finally, we used complementary approaches to determine reasons for non-adherence to prescribing guidelines.

METHODS:
(A) To evaluate predictors of prescribing guideline-recommended medications in VA, we analyzed data from VA's External Peer Review Program merged with other national VA datasets. (B) To develop a taxonomy of reasons for not prescribing guideline-recommended medications, we convened 7 focus groups and applied qualitative analytic methods. (C) To determine the epidemiology of reasons for non-prescribing, we identified 295 patients in 4 VA health care systems who were not receiving guideline-recommended medications for heart failure, and conducted both extensive chart review, and interviews with clinicians of these patients, to evaluate clinician reasons for not prescribing recommended medications to these patients.

FINDINGS/RESULTS:
(A) Among a nationwide cohort of 2772 veterans with systolic heart failure, 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-I/ARBs or beta blockers.

(B) In developing a taxonomy of reasons for not prescribing ACE-I/ARBs and beta blockes, two broad themes emerged. First, clinicians hinted at their own attitude-related barriers to prescribing. However, they framed their comments largely in terms of patient-centered reasons for non-prescribing that arose in individual patient encounters. Second, decision-making about heart failure drug therapy often involved a complex and overlapping series of considerations. Five categories of reasons for not prescribing ACE inhibitors or beta-blockers emerged: (1) adverse effects of drug therapy; (2) non-adherence to therapeutic and monitoring plan; (3) patients' preferences and beliefs; (4) co-management and transitions of care; and (5) prioritization and patient benefit.

(C) Among 295 patients in 4 VA health systems not taking an ACE-I/ARB or not taking a beta blocker, chart review identified clinical contraindications as a reason for non-prescribing in 42-58% of patients. Contextual reasons were documented in 11-17%. Clinician interviews identified twice as many reasons for non-prescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P < .001). In these interviews, clinical contraindications were cited as a reason for not prescribing ACE-I/ARBs and/or beta blockers in 50-70% of patients, and contextual reasons were described in 64-70% of patients. These contextual reasons included patient preferences and non-adherence (15-24% of patients), co-management with other clinicians (32-35%), clinician belief that the medication is not indicated in that patient (12-25%), and competing priorities (8-20%). In clinician interviews, clinicians felt that clinical practice guidelines were less useful in patients with advanced age and multiple comorbidity: on a 5-point scale assessing the usefulness of clinical practice guidelines for heart failure, the mean (SD) response ranged from 4.4 (0.7) for patients younger than 65 years with few comorbid conditions to 3.5 (1.2) for patients older than 80 years with multiple comorbid conditions (P<0.001). The difference in perceived usefulness varied more by patient age than by degree of comorbidity (P = 0.02).

IMPACT:
This study has provided valuable information to guide strategies for evaluating and measuring quality of care for patients with heart failure in VA and in other health care systems. In particular, our findings suggest that the strong majority of veterans with systolic heart failure are receiving guideline-recommended medications; that there are multiple reasons for not prescribing these medications to patients who are not receiving them; and that many of these reasons are "contextual" rather than biomedical in nature, and are poorly documented in the chart and thus not amenable to automated or chart review-based assessment methods. New strategies are needed to appropriately measure and incentivize performance in this area.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Steinman MA, Lee SJ, Peterson CA, Fung KZ, Goldstein MK. A clinically guided approach for improving performance measurement for hypertension. Medical care. 2012 May 1; 50(5):399-405. [view]
2. Steinman MA, Patil S, Kamat P, Peterson C, Knight SJ. A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure. The American journal of geriatric pharmacotherapy. 2010 Dec 1; 8(6):583-94. [view]
3. 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. [view]
4. Steinman MA, Hanlon JT, Sloane RJ, Boscardin WJ, Schmader KE. Do geriatric conditions increase risk of adverse drug reactions in ambulatory elders? Results from the VA GEM Drug Study. The journals of gerontology. Series A, Biological sciences and medical sciences. 2011 Apr 1; 66(4):444-51. [view]
5. Hellyer JA, Azarbal F, Than CT, Fan J, Schmitt SK, Yang F, Frayne SM, Phibbs CS, Yong C, Heidenreich PA, Turakhia MP. Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study). The American journal of cardiology. 2017 Jan 15; 119(2):268-274. [view]
6. Steinman MA, Sudore RL, Peterson CA, Harlow JB, Fried TR. Influence of patient age and comorbid burden on clinician attitudes toward heart failure guidelines. The American journal of geriatric pharmacotherapy. 2012 Jun 1; 10(3):211-8. [view]
7. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: "There's got to be a happy medium". JAMA. 2010 Oct 13; 304(14):1592-601. [view]
8. Steinman MA, Dimaano L, Peterson CA, Heidenreich PA, Knight SJ, Fung KZ, Kaboli PJ. Reasons for not prescribing guideline-recommended medications to adults with heart failure. Medical care. 2013 Oct 1; 51(10):901-7. [view]
9. Steinman MA, Goldstein MK. When tight blood pressure control is not for everyone: a new model for performance measurement in hypertension. Joint Commission Journal on Quality and Patient Safety. 2010 Apr 1; 36(4):164-72. [view]

Conference Presentations

1. Steinman MA, Goldstein MK. A new approach to performance measurement for hypertension: preliminary results. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
2. Steinman MA, Knight SJ. A Taxonomy of Reasons for Not Prescribing Guideline-Recommended Medications: Results from Physician Focus Groups. Poster session presented at: American Geriatrics Society Annual Meeting; 2009 May 2; Chicago, IL. [view]
3. Steinman MA, Knight SJ. A Taxonomy of Reasons for Not Prescribing Guideline-Recommended Medications: Results from Physician Focus Groups. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami, FL. [view]
4. Steinman MA, Goldstein MK. New Methods For Performance Measurement in Hypertension: Results from an expert panel. Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 30; Pittsburgh, PA. [view]
5. Steinman MA, Goldstein MK. New Methods For Performance Measurement in Hypertension: Results from an expert panel. Paper presented at: VA HSR&D National Meeting; 2008 Jan 15; Washington, DC. [view]
6. Steinman MA, Dimaano L, Peterson CA. Reasons for not prescribing guideline-recommended medications to veterans with heart failure. Paper presented at: Society of General Internal Medicine Annual Meeting; 2012 May 10; Orlando, FL. [view]
7. Dimaano L, Peterson CA, Steinman MA. Reasons for not prescribing guideline-recommended medications to Veterans with heart failure. Paper presented at: American Geriatrics Society Annual Meeting; 2012 May 3; Seattle, WA. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems Science, Cardiovascular Disease
DRE: Prognosis
Keywords: Adherence, Chronic heart failure, Quality assessment
MeSH Terms: none