A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure

Polypharmacy and Guideline-Directed Medical Therapy Initiation Among Adults Hospitalized With Heart Failure

Background

Underprescribing of guideline-directed medical therapy (GDMT) for heart failure (HF) persists.

Objectives

The purpose of this study was to assess polypharmacy as a barrier to GDMT.

Methods

We examined participants hospitalized for HF with reduced ejection fraction and HF with mildly reduced ejection fraction between 2003 and 2017 from the Reasons for Geographic and Racial Differences in Stroke study. Participants were stratified by admission medication count-0 to 4, 5 to 9, and ≥10 medications. We examined GDMT use at admission, GDMT contraindications, and initiation of eligible indicated GDMT by medication count. We conducted a multivariable Poisson regression with robust standard errors to examine the association between medication count and GDMT initiation. GDMT included agents for HF with reduced ejection fraction/HF with mildly reduced ejection fraction, antiplatelet agents and statins for coronary artery disease, and anticoagulants for atrial fibrillation.

Results

Among 545 participants with HF, 34% were not taking a beta-blocker, 39% were not taking an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, or hydralazine-isosorbide dinitrate, and 90% were not taking a mineralocorticoid receptor antagonist at admission; among participants with coronary artery disease, 36% were not taking an antiplatelet agent, and 38% were not taking a statin; and among participants with atrial fibrillation, 49% were not taking an anticoagulant. Polypharmacy was inversely associated with initiation of at least one indicated medication (5-9 medications: relative risk [RR]: 0.67; 95% CI: 0.56-0.82; P < 0.001; ≥10 medications: RR: 0.50; 95% CI: 0.39-0.64; P < 0.001) and initiation of at least half of indicated medications (5-9 medications: RR: 0.64; 95% CI: 0.51-0.81; P < 0.001; ≥10 medications: RR: 0.50; 95% CI: 0.38-0.67; P < 0.001).

Conclusions

Polypharmacy is an important barrier to GDMT.

Clinician challenges to evidence-based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

BACKGROUND

Reasons for suboptimal prescribing for heart failure with reduced ejection fraction (HFrEF) have been identified, but it is unclear if they remain relevant with recent advances in healthcare delivery and technologies. This study aimed to identify and understand current clinician-perceived challenges to prescribing guideline-directed HFrEF medications.

METHODS

We conducted content analysis methodology, including interviews and member-checking focus groups with primary care and cardiology clinicians. Interview guides were informed by the Cabana Framework.

RESULTS

We conducted interviews with 33 clinicians (13 cardiology specialists, 22 physicians) and member checking with 10 of these. We identified four levels of challenges from the clinician perspective. Clinician level challenges included misconceptions about guideline recommendations, clinician assumptions (e.g., drug cost or affordability), and clinical inertia. Patient-clinician level challenges included misalignment of priorities and insufficient communication. Clinician-clinician level challenges were primarily between generalists and specialists, including lack of role clarity, competing priorities of providing focused versus holistic care, and contrasting confidence regarding safety of newer drugs. Policy and system/organisation level challenges included insufficient access to timely/reliable patient data, and unintended care gaps for medications without financially incentivized metrics.

CONCLUSION

This study presents current challenges faced by cardiology and primary care which can be used to strategically design interventions to improve guideline-directed care for HFrEF. The findings support the persistence of many challenges and also sheds light on new challenges. New challenges identified include conflicting perspectives between generalists and specialists, hesitancy to prescribe newer medications due to safety concerns, and unintended consequences related to value-based reimbursement metrics for select medications.

Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial

BACKGROUND

The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear.

OBJECTIVES

This study examined reasons for GDMT nonintensification and characterized clinical inertia.

METHODS

In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase.

RESULTS

Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification.

CONCLUSIONS

In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.

A machine learning evaluation of patient characteristics associated with prescribing of guideline-directed medical therapy for heart failure

Introduction/background

Patients with heart failure and reduced ejection fraction (HFrEF) are consistently underprescribed guideline-directed medications. Although many barriers to prescribing are known, identification of these barriers has relied on traditional a priori hypotheses or qualitative methods. Machine learning can overcome many limitations of traditional methods to capture complex relationships in data and lead to a more comprehensive understanding of the underpinnings driving underprescribing. Here, we used machine learning methods and routinely available electronic health record data to identify predictors of prescribing.

Methods

We evaluated the predictive performance of machine learning algorithms to predict prescription of four types of medications for adults with HFrEF: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). The models with the best predictive performance were used to identify the top 20 characteristics associated with prescribing each medication type. Shapley values were used to provide insight into the importance and direction of the predictor relationships with medication prescribing.

Results

For 3,832 patients meeting the inclusion criteria, 70% were prescribed an ACE/ARB, 8% an ARNI, 75% a BB, and 40% an MRA. The best-predicting model for each medication type was a random forest (area under the curve: 0.788-0.821; Brier score: 0.063-0.185). Across all medications, top predictors of prescribing included prescription of other evidence-based medications and younger age. Unique to prescribing an ARNI, the top predictors included lack of diagnoses of chronic kidney disease, chronic obstructive pulmonary disease, or hypotension, as well as being in a relationship, nontobacco use, and alcohol use.

Discussion/conclusions

We identified multiple predictors of prescribing for HFrEF medications that are being used to strategically design interventions to address barriers to prescribing and to inform further investigations. The machine learning approach used in this study to identify predictors of suboptimal prescribing can also be used by other health systems to identify and address locally relevant gaps and solutions to prescribing.

Factors Associated With Access to and Receipt of Liver Transplantation in Veterans With End-stage Liver Disease

IMPORTANCE

Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy.

OBJECTIVE

To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021.

EXPOSURES

Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated.

MAIN OUTCOMES AND MEASURES

Referral, wait-listing, and liver transplantation.

RESULTS

Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral.

CONCLUSIONS AND RELEVANCE

In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.

Mixed Methods Evaluation of Reasons Why Care Deviates From Clinical Guidelines Among Patients With Multimorbidity

Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients' specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.

National survey on the management of heart failure in individuals over 80 years of age in French geriatric care units

BACKGROUND

To evaluate the prevalence and management of heart failure (HF) in very old patients in geriatric settings.

METHODS

Members of the French Society of Geriatrics and Gerontology throughout France were invited to participate in a point prevalence survey and to include all patients ≥80 years old, hospitalized in geriatric settings, with HF (stable or decompensated) on June 18, 2012. General characteristics, presence of comorbidities, blood tests and medications were recorded.

RESULTS

Among 7,197 patients in geriatric institution, prevalence of HF was 20.5% (n = 1,478): (27% in acute care, 24.2% in rehabilitation care and 18% in nursing home). Mean age was 88.2 (SD = 5.2) and Charlson co morbidity score was high (8.49 (SD = 2.21)). Left ventricular ejection fraction (LVEF) was available in 770 (52%) patients: 536 (69.6%) had a preserved LVEF (≥ 50%), 120 (15.6%) a reduced LVEF (< 40%), and 114 (14.8%) a midrange LVEF (40-49%). Prescription of recommended HF drugs was low: 42.6% (629) used Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARBs), 48.0% (709) β-blockers, and 21.9% (324) ACEI or ARB with β-blockers, even in reduced LVEF. In multivariate analysis ACEI or ARBs were more often used in patients with myocardial infarction (1.36 (1.04-1.78)), stroke (1.42 (1.06-1.91)), and diabetes (1.54 (1.14-2.06)). β blockers were more likely used in patients with myocardial infarction (2.06 (1.54-2.76)) and atrial fibrillation (1.70 (1.28-2.28)).

CONCLUSION

In this large very old population, prevalence of HF was high. Recommended HF drugs were underused even in reduced LVEF. These results indicate that management of HF in geriatric settings can still be improved.

Admissions to intensive cardiac care units in France in 2014: A cross-sectional, nationwide population-based study

Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.

Impact of a nurse-based intervention on medication outcomes in vulnerable older adults

Background

Medication-related problems are common in older adults with multiple chronic conditions. We evaluated the impact of a nurse-based primary care intervention, based on the Guided Care model of care, on patient-centered aspects of medication use.

Methods

Controlled clinical trial of the Comprehensive Care for Multimorbid Adults Project (CC-MAP), conducted among 1218 participants in 7 intervention clinics and 6 control (usual care) clinics. Inclusion criteria included age 45–94, presence of ≥3 chronic conditions, and Adjusted Clinical Groups (ACG) score > 0.19. The co-primary outcomes were number of changes to the medication regimen between baseline and 9 month followup, and number of changes to symptom-focused medications, markers of attentiveness to medication-related issues.

Results

Mean age in the intervention group was 72 years, 59% were women, and participants used a mean of 6.6 medications at baseline. The control group was slightly older (73 years) and used more medications (mean 7.1). Between baseline and 9 months, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, p = 0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, p = 0.003). The total number of medications in use remained stable between baseline and follow-up in both groups (p > 0.18).

Conclusion

This nurse-based, primary care intervention resulted in substantially more changes to patients’ medication regimens than usual care, without increasing the total number of medications used. This enhanced rate of change likely reflects greater attentiveness to the medication-related needs of patients.

Trial registration

This trial is registered at https://clinicaltrials.gov, trial number NCT01811173.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0905-1) contains supplementary material, which is available to authorized users.

Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents

BACKGROUND/OBJECTIVES

Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission.

MEASUREMENTS

The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission.

RESULTS

Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR) = 0.48, 95% confidence interval (CI)  = 0.40-0.57 for ≥95 vs 65-74); women (POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89).

CONCLUSION

More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.

Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study

OBJECTIVES

To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission.

MEASUREMENTS

The outcome was beta-blocker initiation within 30 days of NH readmission.

RESULTS

Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership.

CONCLUSION

Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

Organising medication discontinuation: a qualitative study exploring the views of general practitioners toward discontinuing statins

BACKGROUND

Discontinuing medications is a complex decision making process and an important medical practice. It is a tool in reducing polypharmacy, reducing health system expenditure and improving patient quality of life. Few studies have looked at how general practitioners (GPs) discontinue a medication, in agreement with the patients, from a professional perspective. Three research questions were examined in this study: when does medication discontinuation occur in general practice, how is discontinuing medication handled in the GP's practice and how do GPs make decisions about discontinuing medication?

METHODS

Twenty four GPs were interviewed using a maximum variation sample strategy. Participant observations were done in three general practices, for one day each, totalling approximately 30 consultations.

RESULTS

The results show that different discontinuation cues (related to the type of consultation, medical records and the patient) create situations of dissonance that can lead to the GP considering the option of discontinuation. We also show that there is a lot of ambiguity in situations of discontinuing and that some GPs trialled discontinuing as means of generating more information that could be used to deal with the ambiguity.

CONCLUSIONS

We conclude that the practice of discontinuation should be conceptualised as a continually evaluative process and one that requires sustained reflection through a culture of systematically scheduled check-ups, routinely eliciting the patient's experience of taking drugs and trialling discontinuation. Some policy recommendations are offered including supporting GPs with lists or handbooks that directly address discontinuation and by developing more person centred clinical guidelines that discuss discontinuation more explicitly.

Therapy modifications during hospitalization in patients with chronic heart failure

BACKGROUND

Guidelines on suggested pharmacological treatments for heart failure (HF) are not optimally implemented in clinical practice and whether pharmacotherapy adjustment actually happens in daily practice is largely unknown. We aimed to investigate pharmacotherapy modifications during hospitalization.

METHODS

This was a prospective observational survey where all admissions were screened for HF; 210 patients were included. The guideline adherence index (GAI) and modified GAI (mGAI, if ≥50% of target dose) were used to grade the pharmacotherapy.

RESULTS

Among 198 patients discharged alive (mean age 77years, 51% male), 49% had preserved left ventricular ejection fraction (PLVEF) and 30% had left ventricular systolic dysfunction (LVSD); the echocardiography report was unavailable for 21%. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists were prescribed to 78%, 58% and 20% of patients on admission and 72%, 65% and 23% at discharge, respectively. Overall, 14% of patients met GAI-3, but at discharge only 7% met mGAI-3. One of the key drugs was stopped or down-titrated in 27%. During follow-up, 21% of patients died (25% with LVSD). Patients with LVSD discharged with at least one HF drug had a lower risk of death than patients with none (HR=0.142, 95% CI=0.029-0.683, p=0.015). Patients with PLVEF had better prognosis than LVSD patients when no HF drugs were prescribed at discharge (HR=0.075, 95% CI=0.009-0.627, p=0.017).

CONCLUSIONS

The pharmacotherapy of HF patients did not improve significantly during hospitalization, remaining suboptimal. Treatment with key drugs was terminated or reduced in a significant proportion of patients, mostly without specific written justification.

Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure: A Mixed-Methods Study

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are the most underutilized pharmacotherapy for heart failure. Minimal data are available on the barriers to MRA adoption from the perspective of prescribing clinicians.

METHODS AND RESULTS

A mixed-methods study consisting of a survey (n=50), focus groups (n=39), interviews (n=6) with clinicians at a single US Department of Veterans Affairs medical center served to ascertain barriers to optimal use of MRAs. Participants were drawn from 6 groups: cardiology providers, cardiology fellows, hospitalists, clinical pharmacists, internal medicine residents, and primary care providers. Qualitative data were iteratively coded with qualitative data analysis software. The survey response rate was 17.3%. Overall, 51% of survey respondents were unfamiliar with eplerenone, and 6% were unfamiliar with spironolactone. In addition, 30% of respondents reported that they would order a laboratory test >2 weeks after a new MRA prescription, although that is beyond the guideline recommendation. Most providers correctly identified New York Heart Association class 3 and 4 patients as MRA eligible, but only 42% identified class 2 patients as MRA eligible. Through analysis of focus groups, we identified 8 barriers to MRA use in 3 categories: patient-based barriers (concerns about polypharmacy and comorbidities, adverse effects, perceived patient nonadherence), provider-based barriers (unclear roles and responsibilities, coordination and transitions of care, lack of experience or familiarity with MRAs), and system-based barriers (system overload and provider time constraints, lack of systematic follow-up procedures).

CONCLUSIONS

Eight primary barriers to MRA adoption at the provider, patient, and health system levels were identified from the prescriber perspective. These barriers can inform the creation of multilevel interventions that will be required to close the gap in MRA adoption.

Factors associated with ordering laboratory monitoring of high-risk medications

BACKGROUND

Knowledge about factors associated with provider ordering of appropriate testing is limited.

OBJECTIVE

To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications.

METHODS

Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables are patient characteristics such as age, gender, comorbidity burden, whether the medication requiring monitoring is new or chronic, and drug-test characteristics such as inclusion in black box warnings. We used multivariable logistic regression, accounting for clustering of drugs within patients and patients within providers.

RESULTS

Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone-Phenobarbital level) to 97% (Azathioprine-CBC), with half of the drug-test pairs in the 85-91% ordered range. Test ordering was associated with higher provider prescribing volume for study drugs and specialist status (primary care providers were less likely to order tests than specialists). Patients with higher comorbidity burden and older patients were more likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered.

CONCLUSIONS

Interventions to improve laboratory monitoring should focus on areas with the greatest potential for improvement: providers with lower frequencies of prescribing medications with monitoring recommendations and those prescribing these medications for healthier and younger patients; patients with less interaction with the health care system are at particular risk of not having tests ordered. Black box warnings were associated with higher ordering rates and may be a tool to increase appropriate test ordering.

The journey of the frail older adult with heart failure: implications for management and health care systems

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Potential overtreatment and undertreatment of diabetes in different patient age groups in primary care after the introduction of performance measures

OBJECTIVE

To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups.

RESEARCH DESIGN AND METHODS

We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups.

RESULTS

For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%).

CONCLUSIONS

The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.

Reasons for not prescribing guideline-recommended medications to adults with heart failure

BACKGROUND

Little is known about how often contextual factors such as patient preferences and competing priorities impact prescribing of guideline-recommended medications, or about the extent to which these factors are documented in medical records and available to performance measurement systems.

METHODS

Mixed-methods study of 295 veterans aged 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a β-blocker and/or an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker. Reasons for nontreatment were identified from clinic notes and from interviews with 62 primary care clinicians caring for these patients. These reasons were classified using a published taxonomy.

RESULTS

Among 295 patients not receiving guideline-recommended drugs for heart failure, chart review identified biomedical reasons for nonprescribing in 42%-58% of patients and contextual reasons in 11%-17%. Clinician interviews identified twice as many reasons for nonprescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P<0.001). In these interviews, biomedical reasons for nonprescribing were cited in 50%-70% of patients, and contextual reasons in 64%-70%. The most common contextual reasons were comanagement with other clinicians (32%-35% of patients), patient preferences and nonadherence (15%-24%), and clinician belief that the medication is not indicated in the patient (12%-20%).

CONCLUSIONS

Contextual reasons for not prescribing angiotensin converting enzyme inhibitor / angiotensin-receptor blockers and β-blockers are present in two thirds of patients with heart failure who did not receive these medications, yet are poorly documented in medical records. The structure of medical records should be improved to facilitate documentation of contextual reasons for not providing guideline-recommended care.

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study

Background

Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients’ side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician’s as well as the patient’s view.

Methods

With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.

Results

Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient’s non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.

Conclusions

Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

Is albuminuria screening and treatment optimal in patients with type 2 diabetes in primary care? Observational data of the GIANTT cohort

BACKGROUND

Failure of diagnosing and treatment of albuminuria play a role in morbidity and mortality in type 2 diabetes (T2DM). We evaluated guideline adherence and factors associated with albuminuria screening and treatment in T2DM patients in primary care.

METHODS

Guidelines recommend annual measurement of albuminuria and, if increased, treatment with renin-angiotensin-aldosterone system (RAAS) blockers. We performed a cohort study of T2DM patients managed by 182 Dutch general practitioners (GPs; Groningen Initiative to Analyse Type 2 diabetes Treatment database), and evaluated guideline adherence in the years 2007-2009. We assessed whether demographic, clinical, organizational or provider factors determined guideline adherence with multilevel analyses.

RESULTS

Data were available for 14 120 T2DM patients [47.6% male, mean age 67.3 ± 11.7 years, median diabetes duration 6 (IQR: 3-10) years]. The albumin-creatinine ratio (ACR) was measured in 45.2% in 2007, 57.4% in 2008 and 56.8% in 2009. Only 23.7% of all patients were measured every year and 21.4% were never measured. The ACR was more often measured in patients <75 years, with a previous ACR measurement, using anti-diabetic medication, and receiving additional care by a diabetes support facility. RAAS treatment was prescribed to 78.4% of patients with prevalent micro/macroalbuminuria, 66.5% with incident micro/macroalbuminuria, 59.3% with normoalbuminuria and 52.1% of those without ACR measurements. In those not treated with RAAS blockers, it was initiated in 14.3, 12.3, 3.0 and 2.3%, respectively. The presence of micro/macroalbuminuria, higher blood pressure, incidence of cardiovascular events and treatment with antihypertensive medication were the determinants of RAAS-treatment initiation.

CONCLUSIONS

Guideline implementation regarding the management of albuminuria in T2DM patients in primary care should be further improved.

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients

Background

The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear.

Methods

The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers.

Results

The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers.

Conclusions

The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.

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

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.