Quality of heart failure care in managed Medicare and Medicaid patients in North Carolina*,

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Abstract

Use of angiotensin-converting enzyme (ACE) inhibitors and β-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, β-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than β-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for β-blocker use.

Section snippets

Methods

Managed care plans serving the Medicare (n = 3) or Medicaid (n = 2) populations were invited to collaborate in this quality improvement project with Medical Review of North Carolina, the state quality improvement organization, and Wake Forest University School of Medicine. Plans were asked to identify via claims all patients with HF in the year 2000. On-site medical record abstraction was then performed at the office of the primary care provider of each identified HF patient. The inclusion

Results

We identified 3,299 patients with HF who were enrolled in managed care plans and who met the inclusion criteria. Chart abstraction was performed on 971 Medicare and 642 Medicaid patients with a confirmed diagnosis of HF. Medicare and Medicaid patients differed with respect to age, gender, and race (Table 1). Hypertension, diabetes, and cardiovascular disease were frequent comorbidities in both patient populations.

Overall, 88% of patients with HF underwent left ventricular function assessment (

Discussion

These data demonstrate high compliance with HF quality indicators in North Carolina–managed Medicare/Medicaid plans. We found a high rate of ventricular function assessment, and among the patients with systolic dysfunction, a high rate of ACE inhibitor prescription. Use of β blockers lagged behind the use of ACE inhibitors and represents an opportunity for improvement. We found no evidence for differential drug treatment by insurance, gender, or race; despite a high rate of ventricular function

References (27)

  • R.S. Stafford et al.

    The underutilization of cardiac medications of proven benefit, 1990 to 2002

    J Am Coll Cardiol

    (2003)
  • A.B. Luzier et al.

    Containment of heart failure hospitalizations and cost by angiotensin-converting enzyme inhibitor dosage optimization

    Am J Cardiol

    (2000)
  • M. Senni et al.

    Congestive heart failure in the communitytrends in incidence and survival in a 10-year period

    Arch Intern Med

    (1999)
  • American Heart Association. Heart disease and stroke statistics— 2003 update. Dallas, TX: American Heart Association,...
  • J.N. Cohn et al.

    Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study

    N Engl J Med

    (1986)
  • Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

    N Engl J Med

    (1991)
  • M. Packer et al.

    The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group

    N Engl J Med

    (1996)
  • A. Hjalmarson et al.

    Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failurethe Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group

    JAMA

    (2000)
  • P. Lechat et al.

    Clinical effects of beta-adrenergic blockade in chronic heart failurea meta-analysis of double-blind, placebo-controlled, randomized trials

    Circulation

    (1998)
  • R. Garg et al.

    Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials

    JAMA

    (1995)
  • S.A. Hunt et al.

    ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the AdultExecutive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): developed in Collaboration With the International Society for Heart and Lung Transplantation, endorsed by the Heart Failure Society of America

    Circulation

    (2001)
  • Heart Failure Society of America. HFSA guidelines for the management of patients with heart failure due to left...
  • D.W. Baker et al.

    Quality of care for Medicare patients hospitalized with heart failure in rural Georgia

    South Med J

    (1999)
  • Cited by (0)

    This study was suported by Contract 500-02-NC03 from the Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention, Atlanta, Georgia, and by a grant from the Association of Teachers of Preventive Medicine, Washington, DC.

    *

    The analyses upon which this publication is based were performed under Contract 500-02-NC03, entitled “Utilization and Quality Control Peer Review Organization for the State of North Carolina,” sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does the mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The investigator assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the investigator concerning experience in engaging with issues presented are welcomed.

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