Age and receipt of guideline-recommended medications for heart failure: a nationwide study of veterans

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.

Figure 1

Use of guideline-recommended interventions among veterans with heart failure. “Chart-documented reasons” for non-prescribing comprise reasons specifically cited by the treating clinician for not prescribing an ACE inhibitor or ARB and/or beta blocker. * Complete data on use of ACE inhibitors and ARBs were only available for the third and fourth quarters of the study year. In addition, six patients were participating in a clinical trial of heart failure therapy and were excluded from the analysis of ACE-inhibitor or ARB use. Data on beta blocker use were missing for 46 patients.