Is Heart Failure Guideline Adherence Being Underestimated?
Is Heart Failure Guideline Adherence Being Underestimated?
Background Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear.
Methods We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies.
Results Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P < .001).
Conclusions Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.
Heart failure (HF) currently affects 5.2 million Americans (2.5% of the total population) with 550,000 new cases diagnosed each year. The number of hospitalizations in the United States with any mention of HF tripled from almost 1.3 million in 1979 to approximately 3.9 million in 2004. Angiotensin-converting enzyme (ACE) inhibitors, β-blockers, aldosterone antagonists, anticoagulation for atrial fibrillation, and therapy with implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy (CRT) devices reduce all-cause mortality by 20% to 40% when used appropriately in patients with HF. Both medical and device-based HF therapies have demonstrated cost-effectiveness in numerous studies, and their use has been included in American College of Cardiology/American Heart Association (ACC/AHA) guidelines for diagnosis and treatment of HF in adults. Despite this overwhelming volume of evidence, HF therapies remain underutilized. Analyses of trial registries and hospital claims data suggest that only 18% to 33% of eligible patients receive aldosterone antagonists and only 20% to 50% of eligible patients receive ICD or CRT. It remains unclear if at least some of the reported underutilization of recommended therapies can be explained by unrecognized therapeutic contraindications.
The purpose of this study was to determine the frequency of therapeutic contraindications among patients with HF who do not receive guideline-recommended therapies using a detailed chart review. After accounting for contraindications, we assessed the frequency of use of HF guideline-recommended therapies and patient and provider characteristics associated with adherence to HF guideline recommendations.
Abstract and Introduction
Abstract
Background Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear.
Methods We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies.
Results Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P < .001).
Conclusions Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.
Introduction
Heart failure (HF) currently affects 5.2 million Americans (2.5% of the total population) with 550,000 new cases diagnosed each year. The number of hospitalizations in the United States with any mention of HF tripled from almost 1.3 million in 1979 to approximately 3.9 million in 2004. Angiotensin-converting enzyme (ACE) inhibitors, β-blockers, aldosterone antagonists, anticoagulation for atrial fibrillation, and therapy with implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy (CRT) devices reduce all-cause mortality by 20% to 40% when used appropriately in patients with HF. Both medical and device-based HF therapies have demonstrated cost-effectiveness in numerous studies, and their use has been included in American College of Cardiology/American Heart Association (ACC/AHA) guidelines for diagnosis and treatment of HF in adults. Despite this overwhelming volume of evidence, HF therapies remain underutilized. Analyses of trial registries and hospital claims data suggest that only 18% to 33% of eligible patients receive aldosterone antagonists and only 20% to 50% of eligible patients receive ICD or CRT. It remains unclear if at least some of the reported underutilization of recommended therapies can be explained by unrecognized therapeutic contraindications.
The purpose of this study was to determine the frequency of therapeutic contraindications among patients with HF who do not receive guideline-recommended therapies using a detailed chart review. After accounting for contraindications, we assessed the frequency of use of HF guideline-recommended therapies and patient and provider characteristics associated with adherence to HF guideline recommendations.
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