Both the applicability and the adherence to the heart failure guideline's recommended use of ACE-inhibitors (ACE-I) or angiotensin receptor blockers (ARB) and/or beta-blockers may vary by age, gender, race, and co-existing illnesses. Large scale studies that systematically evaluate pharmacotherapy in the elderly with heart failure and their outcomes are lacking.
1) To evaluate predictors of combined use of ACE-inhibitors (ACE-I) or angiotensin receptor blockers (ARB) and/or beta-blockers for veterans with heart failure diagnosis and ejection fraction <40%; and
2)To compare the effects of combination and individual therapies of ACE-I, ARB and/or beta-blocker use on mortality and subsequent risk of hospitalization.
We conducted a retrospective cohort study using the VA External Peer Reviewer Program (EPRP) dataset 2003-2007, which contains quality performance information of a randomly selected sample of veteran patients with heart failure and ejection fraction <40% within each VAMC, linked to files describing drug utilization, and Medicare use. After stratification into 3 treatment groups based on the discharge prescriptions of the combination of an ACE-I or ARB and a beta-blocker, ACE-I or ARB but no beta-blocker, and beta-blocker but no ACE-I or ARB, patients were followed for a year for heart failure rehospitalization and survival. Multinomial logistic regression and propensity matching techniques adjusted for potential confounding factors.
We identified 16,850 veterans with an ejection fraction <40% discharged with heart failure diagnosis during 2003-2007 at VAMC's nationwide. Approximately 70% of them were discharged with the combination of ACE-I or ARB and a beta-blocker, 15% received only ACE-I or ARB but no beta-blocker, another 15% received only beta-blocker but no ACE-I or ARB, and 10% of patients were discharged with neither medication. Predictors of receipt of the guideline-recommended combination therapy were younger age, being unmarried, coronary artery disease, concomitant use of other cardiac medications such as nitrates, digoxin and diuretics; having a higher blood pressure, pulse and a better kidney function; being hospitalized in the Northeast census region, and have the hospitalization during 2006-2007 as opposed to previous years. At 90-days, patients who were discharged with the combination therapy had a significantly lower risk-adjusted rehospitalization rates for heart failure at 30.5% when compared to patients discharged with beta-blocker but without ACEI/ARB at 35.2%, and comparable to patients discharged with ACE-I or ARB but without beta-blockers at 33%. The risk-adjusted heart failure rehospitalization rates among the 3 groups were not significantly different after 1-year from the index hospitalization at approximately 47%. Irrespective of the ACE-I or ARB and/or beta-blocker prescriptions at discharge, 90-day and 1-year mortality rates were similar among the study groups at approximately 11% and 30% respectively.
We were able to identify predictors of heterogeneity in heart failure treatment which were associated with 90-day rehospitalization rates. Some predictors were patient specific which would help clinician's identify patients most likely to benefit from guideline recommended pharmacotherapy. Other predictors showed temporal trends of improving adherence to guideline pharmacotherapy in heart failure in the recent years. However, we also identified geographic variations in care and suggest heterogeneity in guideline adherence which may help to explain regional outcome differences. These results provided a real-life rationale for adherence to pharmacotherapy guidelines in heart failure for clinicians. It also informed policy makers on the outcome validity of current performance measures in heart failure as well as areas in need of improvement.
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