Prescriptions of recommended heart failure medications can be correlated with patient and physician characteristics

Prescribing trend in cardiovascular patients at Ethiopian university hospital: The number of medications and implication on the clinical improvement

Investigating the prescribing trend is important to improve rational prescribing. This study aimed at assessing the cardiovascular drug use, pattern, and its impact on clinical outcome. A cross-sectional study was employed in the outpatient department of chronic illness clinic of Gondar University specialized hospital, Ethiopia from 15 January 2017 to 15 March 2017. The independent variables were sociodemographic, medication, and other clinical information while cardiovascular disease improvement is the outcome variable. Binary logistic regression was used to test the association between the independent variables and the outcome variable. Kaplan Meier curve was used to analyze the clinical improvement while the Log-rank test was employed to compare the clinical outcome with the number of medications. Eight hundred thirty-three cardiovascular patient medical records were included in the final analysis. The majority (62.5%) of patients were females and more than 61% were above 50 years of age. Diuretics monotherapy accounted for a third (33.6%) of cardiovascular drug use, followed by combination therapy of angiotensin convertase enzyme inhibitors with Diuretics (21.8%) and calcium channel blockers with diuretics (8.3%). Cardiovascular patients followed for 72 months found to have a good level of clinical improvement on combination medication (Log Rank of 28.9, P = 0.000). In this study, diuretics monotherapy or in combination with angiotensin convertase enzyme inhibitors were found to be the frequently prescribed drugs in cardiovascular patients. Combination therapy has an implication for good cardiovascular improvement on long term follow-up. It seems clinicians were restricted to certain cardiovascular medications while plenty of choices are available from the diverse classes of cardiovascular drugs.

Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study

OBJECTIVE

To investigate whether general practitioners (GPs) follow treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients, and assess whether doctors' characteristics are related to their decisions.

DESIGN

Cross-sectional vignette study.

SETTING

Continuing Medical Education meeting.

PARTICIPANTS

451 Dutch GPs.

MAIN OUTCOME MEASURES

Answers to four multiple-choice treatment decisions in clinical vignettes of a patient with heart failure and a reduced ejection fraction. With univariable and multivariable regression analyses, respondent characteristics were related to optimal treatment decisions.

RESULTS

Of the 451 GPs, none took four optimal decisions: 7% considered stopping statin treatment, 36% initiated β-blocker treatment at a low-dose and 4% doubled the β-blocker in the up-titration phase. Finally, for our vignette patient now also suffering from chronic obstructive pulmonary disease, 45% of the GPs continued β-blocker therapy even when they considered prescribing a long-acting β2-agonist. While the relation between respondent characteristics and each decision was very different, none was independently associated with all four decisions. Giving priority to evidence-based medicine was independently related to stopping statin treatment and doubling the β-blocker in the up-titration phase.

CONCLUSIONS

GPs seem not to follow treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. The recommendations from guidelines may appear counterintuitive when statin treatment needs to be stopped when a patient feels comfortable, or when a β-blocker should be up-titrated in patients who experience more symptoms. Giving priority to evidence-based medicine is possibly positively related to difficult treatment decisions.

Adherence to treatment guidelines in the pharmacological management of chronic heart failure in an Australian population

Background

To document the pharmacotherapy of chronic heart failure (CHF) and to evaluate the adherence to treatment guidelines in Australian population.

Methods

The pharmacological management of 677 patients (female 46.7%, 75.5 ± 11.6 years) with CHF was retrospectively analyzed.

Results

The use of angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and β-blockers were 58.2 % and 34.7 %, respectively. Major reasons for non-use of ACE inhibitors/ARBs were hyperkalemia and elevated serum creatinine level. For patients who did not receive β-blockers, asthma and chronic obstructive pulmonary disease were the main contraindications. Treatment at or above target dosages for ACE inhibitors/ARBs and β-blockers was low for each medication (40.3% and 28.9%, respectively).

Conclusions

Evidenced-based medical therapies for heart failure were under used in a rural patient population. Further studies are required to develop processes to improve the optimal use of heart failure medications.

Physician and patient predictors of evidence-based prescribing in heart failure: a multilevel study

BACKGROUND

The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence.

METHODS

To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models.

RESULTS

Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92-0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02-1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38-1.05, p = 0.08).

CONCLUSIONS

A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.

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.