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Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans

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Abstract

Background

Older patients often receive less guideline-concordant care for heart failure than younger patients.

Objective

To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chart-documented reasons for non-adherence to guidelines.

Design and Patients

Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program).

Main Measures

Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.

Results

Among 2,772 patients, mean age was 73 +/− 10 years, 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 inhibitors or ARBs and beta blockers.

Conclusions

A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.

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Acknowledgements

Contributors

The authors thank Sharon Goodman for her help procuring and interpreting data from VA’s EPRP system.

Funding Sources

This work was funded by the VA Health Services Research and Development Service (IIR 06-080-2, Dr. Steinman) and by the National Institute on Aging and American Federation for Aging Research (K23-AG030999, Dr. Steinman). The funding sources had no control over the analysis, writing, or decision to publish this manuscript.

Prior Presentation

This work was presented at the annual meeting of the Society for General Internal Medicine, Minneapolis, MN, May 2010.

Disclaimer

Any opinions expressed in this manuscript are those of the authors and do not reflect the official position of the Department of Veterans Affairs.

Conflicts of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Health Services Research Enhancement Award Program (REAP), San Francisco VA Medical Center, 4150 Clement St, VA Box 181 G, San Francisco, CA, 94121, USA

    Michael A. Steinman MD

  2. Division of Geriatrics, San Francisco VA Medical Center and the University of California San Francisco, San Francisco, CA, USA

    Michael A. Steinman MD, John B. Harlow BA & Kathy Z. Fung MS

  3. Division of Cardiology, San Francisco VA Medical Center and the University of California San Francisco, San Francisco, CA, USA

    Barry M. Massie MD

  4. Veterans Health Administration Congestive Heart Failure Quality Enhancement Research Initiative, Washington, DC, USA

    Barry M. Massie MD & Paul A. Heidenreich MD

  5. The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA

    Peter J. Kaboli MD

  6. Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA

    Peter J. Kaboli MD

  7. Division of Cardiology, Palo Alto VA Health Care System and Stanford University, Palo Alto, CA, USA

    Paul A. Heidenreich MD

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  1. Michael A. Steinman MD
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Corresponding author

Correspondence to Michael A. Steinman MD.

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Steinman, M.A., Harlow, J.B., Massie, B.M. et al. Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans. J GEN INTERN MED 26, 1152–1159 (2011). https://doi.org/10.1007/s11606-011-1745-2

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  • DOI: https://doi.org/10.1007/s11606-011-1745-2

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