Time trends in the use of β-blockers and other pharmacotherapies in older adults with congestive heart failure

doi:10.1016/j.ahj.2004.04.002

American Heart Journal

Volume 148, Issue 4, October 2004, Pages 710-717

https://doi.org/10.1016/j.ahj.2004.04.002 Get rights and content

Abstract

Background

Evidence supporting pharmacotherapy of congestive heart failure (CHF) has grown substantially over the past decade and includes large, placebo-controlled trials with mortality end points. We describe β-blocker and other medication temporal treatment trends of CHF in the Cardiovascular Health Study, a community-based cohort study of 5888 adults ≥65 years of age.

Methods

Prescription medication data were collected from hospital discharge summaries for incident CHF events and at in-study annual clinic visits for prevalent CHF cases from 1989 to 2000. Change in use of agents over time was estimated by using generalized estimating equations while adjusting for potential confounding factors of age, sex, race, and cardiovascular and pulmonary comorbidities.

Results

Among 1033 incident CHF events, β-blocker use after diagnosis increased an average of 2.4 percentage points annually (95% CI, 1.5 to 3.4 points) from 1989 to 2000. The increasing trend was consistent throughout follow-up. Among participants with coronary disease and/or hypertension and among those with low ejection fractions (<45%), β-blocker use remained flat from 1989 to 1994 and increased 4.7 points annually (2.5 to 6.9) and 10.0 points annually (6.1 to 13.8), respectively, from 1995 to 2000. Among participants without coronary disease or hypertension, there was no overall increase in use. Use of renin-angiotensin system inhibitors increased 2.3 points annually (1.0 to 3.5), digoxin use decreased 2.4 points annually (−3.6 to −1.1), and loop diuretic use remained flat between 1989 and 2000. In general, treatment trends were similar for prevalent CHF.

Conclusions

Treatment of CHF has changed gradually in the 1990s and may in part reflect the influence of CHF clinical trial evidence.

Section snippets

Setting

The Cardiovascular Health Study is a community-based, prospective cohort study of risk factors for cardiovascular disease in the elderly. Participants were recruited from 1989 to 1990 from 4 US communities (Washington County, Md; Pittsburgh [Allegheny County], Pa; Forsyth County, NC; and Sacramento County, Calif), based on a randomly generated sampling frame from Health Care Financing Administration files.9, 10

Design

The study protocol consisted of a baseline clinic visit followed by semiannual

Results

Two hundred seventy-three participants had CHF at study entry, leaving 5615 participants, 84% white and 58% female, at risk for new-onset CHF. After 10 years of follow-up, 1033 incident CHF cases were diagnosed. Eight hundred eighty-nine (86%) were diagnosed in the inpatient setting, 141 (14%) in the outpatient setting, and 3 (<1%) had unclear or missing information on diagnosis setting. Characteristics of the 1033 participants at the visit immediately before the onset of CHF are listed in

Discussion

The findings of this study suggest that the pharmacologic treatment of incident and prevalent CHF in the community has shifted gradually over the past decade. Among incident cases, β-blocker use has increased steadily after 1989, with larger increases in use after 1995 among those with low ejection fraction or with coronary disease and/or hypertension. Renin-angiotensin inhibition in participants with incident CHF, especially those with hypertension, increased in prevalence throughout

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Trends in heart failure hospitalizations, patient characteristics, in-hospital and 1-year mortality: A population study, from 2000 to 2012 in Lombardy
2017, International Journal of Cardiology
Citation Excerpt :
Data from residents in Lombardy (about 10 million people) depict a two-faced reality: first, the actual, overall burden of HFHs, and inherent mortality, appear to be stable over more than a decade; and second, the incidence of new cases is decreasing, with a growing proportion of very old patients (aged ≥ 85 years) and a trend for reduction of in-hospital and 1-year mortality in the “youngest” patient cohort, i.e. in those aged < 75 years. These findings suggest that current strategies for prevention and treatment of cardiovascular conditions are effective in delaying the onset of HF and in improving outcomes in symptomatic patients, except for those aged 75 year and more [24–28]. So far, these changes did not impact significantly on the prevalence and mortality of acute, hospitalized HF.
This study was undertaken to evaluate trends in heat failure hospitalizations (HFHs) and 1-year mortality of HFH in Lombardy, the largest Italian region, from 2000 to 2012.
Hospital discharge forms with HF-related ICD-9 CM codes collected from 2000 to 2012 by the regional healthcare service (n = 699797 in 370538 adult patients), were analyzed with respect to in-hospital and 1-year mortality; Group (G) 1 included most acute HF episodes with primary cardiac diagnosis (70%); G2 included cardiomyopathies without acute HF codes (17%); and G3 included non-cardiac conditions with HF as secondary diagnosis (13%). Patients experiencing their first HFH since 2005 were analyzed as incident cases (n = 216782).
Annual HFHs number (mean 53830) and in-hospital mortality (9.4%) did not change over the years, the latter being associated with increasing age (p < 0.0001) and diagnosis Group (G1 9.1%, G2 5.6%, G3 15.9%, p < 0.0001). Incidence of new cases decreased over the years (3.62 [CI 3.58–3.67] in 2005 to 3.13 [CI 3.09–3.17] in 2012, per 1000 adult inhabitants/year, p < 0.0001), with an increasing proportion of patients aged ≥ 85 y (22.3% to 31.4%, p < 0.0001). Mortality lowered over time in < 75 y incident cases, both in-hospital (5.15% to 4.36%, p < 0.0001) and at 1-year (14.8% to 12.9%, p = 0.0006).
The overall burden and mortality of HFH appear stable for more than a decade. However, from 2005 to 2012, there was a reduction of new, incident cases, with increasing age at first hospitalization. Meanwhile, both in-hospital and 1-year mortality decreased in patients aged < 75 y, possibly due to improved prevention and treatment.
Divergent trends in survival and readmission following a hospitalization for heart failure in the veterans affairs health care system 2002 to 2006
2010, Journal of the American College of Cardiology
Citation Excerpt :
Other studies of VA populations have noted increased use of beta-blockers and ACE inhibitors over time (6,7), and similar improvements in heart failure care have been seen in the general population. The CHS (Cardiovascular Health Study) of older Americans with heart failure found that use of ACE inhibitors increased 2.3% per year and beta-blocker use increased 2.4% per year from 1989 to 2000 (8). Additional studies are needed to determine how much of the decline in observed mortality rates can be explained by increased use of guideline-recommended medications.
This study sought to determine recent trends over time in heart failure hospitalization, patient characteristics, treatment, rehospitalization, and mortality within the Veterans Affairs health care system.
Use of recommended therapies for heart failure has increased in the U.S. However, it is unclear to what extent hospitalization rates and the associated mortality have improved.
We compared rates of hospitalization for heart failure, 30-day rehospitalization for heart failure, and 30-day mortality following discharge from 2002 to 2006 in the Veterans Affairs Health Care System. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and for clustering of patients within hospitals.
We identified 50,125 patients with a first hospitalization for heart failure from 2002 to 2006. Mean age did not change (70 years), but increases were noted for most comorbidities (mean Charlson score increased from 1.72 to 1.89, p < 0.0001). Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11). After adjustment for patient characteristics, the odds ratio for rehospitalization in 2006 (vs. 2002) was 0.54 (95% confidence interval [CI]: 0.47 to 0.61) for mortality, but 1.21 (95% CI: 1.04 to 1.41) for heart failure rehospitalization at 30 days.
Recent mortality and rehospitalization rates in the Veterans Affairs Health Care System have trended in opposite directions. These results have implications for using rehospitalization as a measure of quality of care.
The Medicare drug benefit (Part D) and treatment of heart failure in older adults
2010, American Heart Journal
Citation Excerpt :
Previous studies have shown that, before Part D, rates of prescribing of and adherence to pharmacotherapy regimens for heart failure were suboptimal.19,20 For example, only 43.6% of incident heart failure patients in the Cardiovascular Health Study were taking a β-blocker.20 We report a significant increase in β-blocker use among those without coverage in 2004-2005 who obtained Part D benefits (from 45% to 59%).
Adherence to pharmacotherapy for heart failure is poor among older adults in part because of high prescription drug costs. We examined the impact of improvements in drug coverage under Medicare Part D on utilization of, and adherence to, medications for heart failure in older adults.
We used a quasi-experimental approach to analyze pharmacy claims for 6,950 individuals aged ≥65 years with heart failure enrolled in a Medicare managed care organization 2 years before and after Part D's implementation. We compared prescription fill patterns among individuals who moved from limited (quarterly benefits caps of $150 or $350) or no drug coverage to Part D in 2006 with those who had generous employer-sponsored coverage throughout the study period.
Individuals who previously lacked drug coverage filled approximately 6 more heart failure prescriptions annually after Part D (adjusted ratio of prescription counts = 1.36, 95% CI 1.29-1.44, P < .0001 relative to the comparison group). Those previously lacking drug coverage were more likely to fill prescriptions for an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker plus a β-blocker after Part D (adjusted ratio of odds ratios = 1.73, 95% CI 1.42-2.10, P < .0001) and more likely to be adherent to such pharmacotherapy (adjusted ratio of odds ratios = 2.95, 95% CI 1.85-4.69, P < .0001) relative to the comparison group.
Medicare Part D was associated with improved access to medications and adherence to pharmacotherapy in older adults with heart failure.
Retrospective claims database analysis to determine relationship between renin-angiotensin system agents, rehospitalization, and health care costs in patients with heart failure or myocardial infarction
2008, Clinical Therapeutics
Background: Heart failure (HF) and myocardial infarction (MI) cause considerable morbidity and mortality, but the outcomes and health care costs related to adherence to treatment guidelines for HF and MI are not fully understood.
Objectives: The aims of this study were as follows: (1) to determine the proportion of patients discharged from the hospital with a primary diagnosis of HF or MI who subsequently received prescriptions for American Heart Association/American College of Cardiology-recommended angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), also referred to as renin-angiotensin system agents; (2) to investigate the relationship between adherence to and persistence with ACEIs/ARBs and risk of rehospitalization; and (3) to assess the relationship between adherence to and persistence with ACEIs or ARBs, cardiovascular-related health care costs, and total health care costs.
Methods: Using the prescription and medical service records of a large national pharmacy-benefit database, we conducted a retrospective analysis of patients discharged from the hospital with a primary diagnosis of HF or MI between July 1, 2003, and June 30, 2006. Medication adherence, persistence, rehospitalization risk, and health care costs during 1-year follow-up were measured. Logistic regression models were used to estimate the likelihood of rehospitalization for different levels of adherence and persistence. Generalized linear models were used to investigate the impact of adherence and persistence on total health care costs and cardiovascular-related health care costs.
Results: A total of 799 HF and 696 MI patients were included in the analysis; 57.20% of HF patients and 59.20% of MI patients were prescribed an ACEI or an ARB after discharge from the hospital. The mean (SD) age was 65.7 (13.7) years in the HF group and 60.6 (10.7) years in the MI group. In both groups, men accounted for a greater proportion of the patients than women. In the HF group, adherence and persistence were associated with a lower likelihood of rehospitalization compared with nonadherence and nonpersistence (P < 0.042 and P < 0.005, respectively). In the MI group, there was no significant difference in rehospitalization risk between those who were adherent and those who were not. However, among these patients, persistence was associated with a lower risk of rehospitalization than nonpersistence (P < 0.036). Adherence and persistence were associated with lower health care costs (HF: P < 0.001 for all comparisons; MI: P < 0.019 for adherence and total cost, P = NS for persistence and total cost, P < 0.012 for adherence and cardiovascular cost, P < 0.031 for persistence and cardiovascular cost).
Conclusion: Adherence to and persistence with ACEIs or ARBs may reduce the risk of rehospitalization in patients with HF or MI, thereby potentially reducing health care costs.
Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE)
2007, American Heart Journal
The purpose of this study was to assess temporal trends in clinical characteristics, treatments, quality indicators, and outcomes for heart failure (HF) hospitalizations.
Characteristics, treatments, quality measures, and inhospital outcomes were measured over 12 consecutive quarters (January 2002 to December 2004) using data from 159 168 enrollments from 285 ADHERE hospitals.
Baseline characteristics were similar or showed only modest changes, and severity of illness by logistic regression was unchanged over all 12 quarters. Inhospital treatment changed significantly over time with inotrope use decreasing from 14.7% to 7.9% (P < .0001). Discharge instructions increased 133%; smoking counseling, 132%; left ventricular function measurement, 8%; and β-blocker use, 29% (all P < .0001). Clinical outcomes improved over time, including need for mechanical ventilation, which decreased 5.3% to 3.4% (relative risk 0.64, P < .0001); length of stay (mean), 6.3 to 5.5 days; and mortality, 4.5% to 3.2% (relative risk 0.71, P < .0001).
Over a 3-year period, demographics and clinical characteristics were relatively similar, but significant changes in intravenous therapy, enhancements in conformity to quality-of-care measures, increased administration of evidence-based HF medications, and substantial improvements in inhospital morbidity and mortality were observed during hospitalization for HF.
Translation of clinical trial results into practice: Temporal patterns of β-blocker utilization for heart failure at hospital discharge and during ambulatory follow-up
2007, American Heart Journal
Underutilization of β-blockers in heart failure (HF) has been widely reported at hospital discharge and in the ambulatory setting. We examined recent temporal patterns of β-blocker utilization in HF with systolic dysfunction at hospital discharge and over 2-year follow-up.
Annual trends of β-blocker use were examined in a clinical database of patients with ejection fraction ≤40% discharged after HF hospitalization in 1998-2004 (n = 735). More detailed data on β-blocker use at discharge and over 2-year follow-up were abstracted for 200 consecutive patients each in 1999-2001 and 2003-2004.
Annual rates of β-blocker use at discharge increased steadily by 10% per year from 1998-2004 (P < .001), with no sharp increase noted in any single year after publication of clinical trials or guidelines. Use among patients without contraindications increased markedly from 1999-2001 to 2003-2004 at hospital discharge (38.7% vs 82.6%, P < .001) and 2-year follow-up (53.0% vs 84.5%, P < .001). The increase was significant in all examined subgroups. Although >50% of patients remained on low doses of β-blockers, a greater proportion trended to reach target doses at 2 years in the later period (25.6% vs 12.5%, P = .13).
Substantial increase in β-blocker utilization in HF with systolic dysfunction occurred from 1998 to 2004, demonstrating that high rates of β-blocker use are being achieved at hospital discharge and maintained in the ambulatory setting after discharge. However, the time lag in translation of scientific evidence into maximal use of beneficial therapy in practice remains a target for quality improvement.

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^☆: Supported by contracts N01-HC-85079, N01-HC-85080, N01-HC-85081, N01-HC-85082, N01-HC-85083, N01-HC-85084, N01-HC-85085, N01-HC-85086, N01-HL-35129, and N01-HL-15103 from the National Heart, Lung, and Blood Institute and grant R01-AG-09556 from the National Institute on Aging.

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Clinical investigation: congestive heart failureTime trends in the use of β-blockers and other pharmacotherapies in older adults with congestive heart failure☆

Abstract

Background

Methods

Results

Conclusions

Section snippets

Setting

Design

Results

Discussion

J Am Coll Cardiol

Ann Epidemiol

Ann Epidemiol

J Am Soc Echocardiogr

J Clin Epidemiol

Ann Epidemiol

Ann Epidemiol

Lancet

Effect of vasodilator therapy on mortality in chronic congestive heart failureresults of a Veterans Administration Cooperative Study

N Engl J Med

Clinical investigation: congestive heart failure
Time trends in the use of β-blockers and other pharmacotherapies in older adults with congestive heart failure☆