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BACKGROUND/RATIONALE:
RATIONALE: Clinical practice guidelines have improved outcomes in patients with heart failure. However, there has been growing recognition of the difficulty of applying these guidelines to elders with multiple comorbid illnesses. In this setting, strict guideline adherence quickly leads to polypharmacy that can have unintended adverse effects and may be inconsistent with patient goals of care. Previous research has found that older patients are less likely to receive guideline-concordant care for a variety of diseases. However, much remains unknown about heart failure care for older patients in VA, including the prevalence of non-adherence to prescribing guidelines, the reasons that clinicians use for withholding guideline-recommended therapy, and how these reasons differ in younger vs. older patients.
OBJECTIVE(S):
RESEARCH OBJECTIVES: The proposed project has several inter-related goals. First, we will determine the association between patient age and use of guideline-recommended medications, and explore how patient, provider, and system factors mediate the relationship between age and prescribing. Next, we will use two complementary approaches to determine reasons for non-adherence to prescribing guidelines, Finally, we will compare these two data sources as measures of reasons for guideline non-adherence.
METHODS:
RESEARCH METHODS: For Aim (1), we will use VA's External Peer Review Program to identify a cohort of patients age 50 and older with heart failure and left ventricular ejection fraction <40%. After merging in data from other national VA datasets, we will evaluate the association between patient age and use of guideline-recommended medications. For Aim (2), we will assemble a cohort of 500 patients from four VA health care systems who have heart failure with impaired systolic function and were not prescribed a beta blocker and/or an ACE inhibitor or angiotensin-II receptor blocker (ARB). We will then conduct detailed chart review to determine reasons for non-use of guideline-recommended drugs in these patients. For Aim (3), we will further explore reasons for guideline non-adherence by surveying the clinicians of patients in our chart review cohort. Then, we will compare the chart review and clinician survey for their ability to identify reasons for non-adherence.
ANALYSES: For Aim (1), we will use mixed effects logistic regression models to evaluate the association of age with prescribing of ACE inhibitors, ARBs, and beta blockers, with sequential steps to evaluate and control for other patient, provider, and system characteristics. For Aims (2) and (3), we will use logistic regression to evaluate the association between age and reasons for medication non-use. In addition, for Aim (3) we will perform tests of concordance and inter-rater reliability to compare results from the chart review with results from the clinician survey
FINDINGS/RESULTS:
Focus groups conducted to improve the conceptual grounding of the research have demonstrated that physicians categorize reasons for non-prescribing of guidleline-recommended medications into four broad domains: clinical factors, patient factors, physician factors, and system factors, with many of the specific reasons for non-prescribing falling at the intersection of two or more of these domains. We are applying this conceptualization to our chart review and survey studies that will evaluate reasons for non-prescribing of guideline-recommended medications in heart failure.
IMPACT:
ANTICIPATED IMPACT ON VETERANS' HEALTHCARE: The research conducted under this protocol will provide important data about the reasons for non-adherence to heart failure prescribing guidelines in VA, and how these reasons differ in younger vs. older veterans. Data generated by these studies will help us better understand the strengths and limitations of guideline-based performance measures in VA, and to better understand the appropriateness of guideline non-adherence in elderly veterans.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases, Health Services and Systems
DRE:
Quality of Care, Resource Use and Cost
Keywords:
Chronic heart failure, Quality assessment, Adherence
MeSH Terms:
none
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