Utilization of evidence-based treatment in elderly patients with chronic heart failure: using Korean Health Insurance claims database

Treatment Strategies of Improving Quality of Care in Patients With Heart Failure

Heart failure (HF) is a global health problem closely related to morbidity and mortality. As the burden of HF increases, it is necessary to manage and treat this condition well. However, there are differences between real-world practice and guidelines for the optimal treatment for HF. Patient-related, healthcare provider-related, and health system-related factors contribute to poor adherence to optimal care. This review article aims to examine HF treatment patterns and treatment adherence in real-world practice, identify clinical gaps to suggest ways to improve the quality of care for HF and clinical outcomes for patients with HF. Although it is important to optimize treatment based on evidence-based guidelines to the greatest extent, it is known that there is still poor treatment adherence, and many patients do not receive guideline-directed medical therapy, especially at the early stages. To improve medication adherence, qualitative evaluation through performance measurement, as well as education of patients, caregivers and medical staff through a multidisciplinary approach are important.

Physician adherence and patient-reported outcomes in heart failure with reduced ejection fraction in the era of angiotensin receptor-neprilysin inhibitor therapy

This Korean nationwide, multicenter, noninterventional, prospective cohort study aimed to analyze physician adherence to guideline-recommended therapy for heart failure (HF) with reduced ejection fraction (HFrEF) and its effect on patient-reported outcomes (PROs). Patients diagnosed with or hospitalized for HFrEF within the previous year were enrolled. Treatment adherence was considered optimal when all 3 categories of guideline-recommended medications (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors; beta-blockers; and mineralocorticoid receptor antagonists) were prescribed and suboptimal when ≤ 2 categories were prescribed. The 36-Item Short Form Survey (SF-36) scores were compared at baseline and 6 months between the 2 groups. Overall, 854 patients from 30 hospitals were included. At baseline, the optimal adherence group comprised 527 patients (61.7%), whereas during follow-up, the optimal and suboptimal adherence groups comprised 462 (54.1%) and 281 (32.9%) patients, respectively. Patients in the suboptimal adherence group were older, with a lower body mass index, and increased comorbidities, including renal dysfunction. SF-36 scores were significantly higher in the optimal adherence group for most domains (P < 0.05). This study showed satisfactory physician adherence to contemporary treatment for HFrEF. Optimal adherence to HF medication significantly correlated with better PROs.

Trends in Meniscal Allograft Transplant in the Republic of Korea, 2010-2018: An Analysis Based on the Korean National Health Insurance Claims Database

Background:

Analyzing the current trends in meniscal allograft transplant (MAT) is important. However, no recent descriptive epidemiological study based on a national registry database has been reported.

Purpose:

To assess serial trends in the incidence of MAT in the Republic of Korea between 2010 and 2018, stratified by age and sex.

Study Design:

Descriptive epidemiology study.

Methods:

The number of MAT procedures between 2010 and 2018 was assessed using the Korean National Health Insurance claims database. We used code N0825 for isolated MAT and code N0820 for MAT combined with other procedures, such as ligament reconstruction, realignment surgery, and cartilage procedures. The incidence of MAT was calculated using the general population data of the Republic of Korea, and Poisson log-linear regression analysis was used to assess statistical serial trends.

Results:

A total of 369 patients underwent MAT in 2010 and 774 in 2018, with an increase of 47.6%. The incidence of MAT per 100,000 person-years in the Republic of Korea increased significantly during the period studied, from 0.75 in 2010 to 1.50 in 2018 (annual relative risk = 1.09; 95% CI, 1.08-1.10; P < .001), whereas the rate of MAT combined with other procedures increased from 5.1% in 2014 to 16.0% in 2018. MAT was mostly performed in men in their early 20s. Most MAT procedures were performed in the summer and winter, with distinct seasonal variances.

Conclusion:

In the Republic of Korea, the incidence of MAT in 2018 was 1.50 per 100,000 person-years, with an average annual increase of 10% since 2010. MAT was mostly performed in men in their early 20s, and the rate of MAT combined with other procedures has increased since 2014.

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

BACKGROUND

Studies have demonstrated that heart failure (HF) patients who receive direct pharmacist input as part of multidisciplinary care have better clinical outcomes. This study evaluated/compared the difference in prescribing practices of guideline-directed medical therapy (GDMT) for chronic HF patients between two multidisciplinary clinics-with and without the direct involvement of a pharmacist.

METHODS

A retrospective audit of chronic HF patients, presenting to two multidisciplinary outpatient clinics between March 2005 and January 2017, was performed; a Multidisciplinary Ambulatory Consulting Service (MACS) with an integrated pharmacist model of care and a General Cardiology Heart Failure Service (GCHFS) clinic, without the active involvement of a pharmacist.

RESULTS

MACS clinic patients were significantly older (80 vs. 73 years, p < .001), more likely to be female (p < .001), and had significantly higher systolic (123 vs. 112 mmHg, p < .001) and diastolic (67 vs. 60 mmHg, p < .05) blood pressures compared to the GCHF clinic patients. Moreover, the MACS clinic patients showed more polypharmacy and higher prevalence of multiple comorbidities. Both clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in HFrEF. However, HFpEF patients in the MACS clinic were significantly more likely to be prescribed ACEIs/ARBs (70.5% vs. 56.2%, p = 0.0314) than the GCHFS patients. Patients with both HFrEF and HFpEF (MACS clinic) were significantly less likely to be prescribed β-blockers and mineralocorticoid receptor antagonists. Use of digoxin in chronic atrial fibrillation (AF) in MACS clinic was significantly higher in HFrEF patients (82.5% vs. 58.5%, p = 0.004), but the number of people anticoagulated in presence of AF (27.1% vs. 48.0%, p = 0.002) and prescribed diuretics (84.0% vs. 94.5%, p = 0.022) were significantly lower in HFpEF patients attending the MACS clinic. Age, heart rate, systolic blood pressure (SBP), anemia, chronic renal failure, and other comorbidities were the main significant predictors of utilization of GDMT in a multivariate binary logistic regression.

CONCLUSIONS

Lower prescription rates of some medications in the pharmacist-involved multidisciplinary team were found. Careful consideration of demographic and clinical characteristics, contraindications for use of medications, polypharmacy, and underlying comorbidities is necessary to achieve best practice.

Acute decompensated heart failure in a non cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF)

Background

Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking.

Methods

This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded.

Results

Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively.

Conclusion

Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Economic Impact of Adherence to Pain Treatment Guidelines in Chronic Pain Patients

Objectives

This research compared health care resource use (HCRU) and costs for pharmacotherapy prescribing that was adherent vs nonadherent to published pain management guidelines. Conditions included osteoarthritis (OA) and gout (GT) for nociceptive/inflammatory pain, painful diabetic peripheral neuropathy (pDPN) and post-herpetic neuralgia (PHN) for neuropathic pain, and fibromyalgia (FM) for sensory hypersensitivity pain.

Methods

This retrospective cohort study used claims from MarketScan Commercial and Medicare Databases identifying adults newly diagnosed with OA, GT, pDPN, PHN, or FM during July 1, 2006, to June 30, 2013, with 12-month continuous coverage before and after initial (index) diagnosis. Patients were grouped according to their pharmacotherapy pattern as adherent, nonadherent, or “unsure” according to published pain management guidelines using a claims-based algorithm. Adherent and nonadherent populations were compared descriptively and using multivariate statistical analyses for controlling bias.

Results

Final cohort sizes were 441,465 OA, 76,361 GT, 10,645 pDPN, 4,010 PHN, and 150,321 FM, with adherence to guidelines found in 51.1% of OA, 25% of GT, 59.5% of pDPN, 54.9% of PHN, and 33.5% of FM. Adherent cohorts had significantly (P < 0.05) fewer emergency department (ED) visits and lower proportions with hospitalizations or ED visits. Mean health care costs increased following diagnosis across all conditions; however, adherent cohorts had significantly lower increases in adjusted costs pre-index to postindex (OA $5,286 vs $9,532; GT $3,631 vs $7,873; pDPN $9,578 vs $16,337; PHN $2,975 vs $5,146; FM $2,911 vs $3,708; all P < 0.001; adherent vs nonadherent, respectively).

Conclusions

Adherence to pain management guidelines was associated with significantly lower HCRU and costs compared with nonadherence to guidelines.

Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps

Heart failure (HF) is a major and increasing global public health problem. In Asia, aging populations and recent increases in cardiovascular risk factors have contributed to a particularly high burden of HF, with outcomes that are poorer than those in the rest of the world. Representation of Asians in landmark HF trials has been variable. In addition, HF patients from Asia demonstrate clinical differences from patients in other geographic regions. Thus, the generalizability of some clinical trial results to the Asian population remains uncertain. In this article, we review differences in HF phenotype, HF management, and outcomes in patients from East and Southeast Asia. We describe lessons learned in Asia from recent HF registries and clinical trial databases and outline strategies to improve the potential for success in future trials. This review is based on discussions among scientists, clinical trialists, industry representatives, and regulatory representatives at the CardioVascular Clinical Trialist Asia Forum in Singapore on July 4, 2014.

Development of a novel algorithm to determine adherence to chronic pain treatment guidelines using administrative claims

Objective

To develop a claims-based algorithm for identifying patients who are adherent versus nonadherent to published guidelines for chronic pain management.

Methods

Using medical and pharmacy health care claims from the MarketScan® Commercial and Medicare Supplemental Databases, patients were selected during July 1, 2010, to June 30, 2012, with the following chronic pain conditions: osteoarthritis (OA), gout (GT), painful diabetic peripheral neuropathy (pDPN), post-herpetic neuralgia (PHN), and fibromyalgia (FM). Patients newly diagnosed with 12 months of continuous medical and pharmacy benefits both before and after initial diagnosis (index date) were categorized as adherent, nonadherent, or unsure according to the guidelines-based algorithm using disease-specific pain medication classes grouped as first-line, later-line, or not recommended. Descriptive and multivariate analyses compared patient outcomes with algorithm-derived categorization endpoints.

Results

A total of 441,465 OA patients, 76,361 GT patients, 10,645 pDPN, 4,010 PHN patients, and 150,321 FM patients were included in the development of the algorithm. Patients found adherent to guidelines included 51.1% for OA, 25% for GT, 59.5% for pDPN, 54.9% for PHN, and 33.5% for FM. The majority (~90%) of patients adherent to the guidelines initiated therapy with prescriptions for first-line pain medications written for a minimum of 30 days. Patients found nonadherent to guidelines included 30.7% for OA, 6.8% for GT, 34.9% for pDPN, 23.1% for PHN, and 34.7% for FM.

Conclusion

This novel algorithm used real-world pharmacotherapy treatment patterns to evaluate adherence to pain management guidelines in five chronic pain conditions. Findings suggest that one-third to one-half of patients are managed according to guidelines. This method may have valuable applications for health care payers and providers analyzing treatment guideline adherence.

Prescription of potentially inappropriate medication in Korean older adults based on 2012 Beers Criteria: a cross-sectional population based study

Background

A high number of elderly people with multiple comorbidities are exposed to the risk of polypharmacy and prescription of potentially inappropriate medication (PIM). The purpose of this study was to determine the prevalence and patterns of PIM prescription in Korean older adults according to the 2012 Beers Criteria.

Methods

A retrospective study was conducted using data from the Korean Health Insurance Review and Assessment (KHIRA) database of outpatient prescription claims collected from January 1, 2009 to December 31, 2011. A total of 523,811 elderly subjects aged 65 years and older were included in the study, and several covariates related to the prescription of PIMs were obtained from the KHIRA database. These covariates were analyzed using Student’s t test and the chi-square test; furthermore, multivariate logistic regression analysis was used to evaluate the risk factors associated with the prescription of PIMs.

Results

A total of 80.96 % subjects were prescribed at least one PIM independent of their diagnosis or condition according to the 2012 Beers Criteria. The most commonly prescribed medication class was first-generation antihistamines with anticholinergic properties (52.33 %). Pain medications (43.04 %) and benzodiazepines (42.53 %) were next in line. When considering subjects’ diagnoses or conditions, subjects diagnosed with central nervous system conditions were most often prescribed PIMs. Female sex, severity of comorbidities, and polypharmacy were significant risk factors for PIM prescriptions.

Conclusions

This study confirmed that PIM prescription is common among elderly Koreans. A clinical decision support system should be developed to decrease the prevalence of PIM prescriptions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0285-3) contains supplementary material, which is available to authorized users.

Heart Failure in Older Adults

Heart failure (HF) is a leading cause of morbidity, hospitalization, and mortality in older adults and a growing public health problem placing a huge financial burden on the health care system. Many challenges exist in the assessment and management of HF in geriatric patients, who often have coexisting multimorbidity, polypharmacy, cognitive impairment, and frailty. These complex "geriatric domains" greatly affect physical and functional status as well as long-term clinical outcomes. Geriatric patients have been under-represented in major HF clinical trials. Nonetheless, available data suggest that guideline-based medical and device therapies improve morbidity and mortality. Nonpharmacologic strategies, such as exercise training and dietary interventions, are an active area of research. Targeted geriatric evaluation, including functional and cognitive assessment, can improve risk stratification and guide management in older patients with HF. Clinical trials that enroll older patients with multiple morbidities and HF and evaluate functional status and quality of life in addition to mortality and cardiovascular morbidity should be encouraged to guide management of this age group.

How to best assess quality of drug treatment in patients with heart failure

BACKGROUND

The proportion of patients with heart failure (HF) treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) is frequently used as quality indicator. This study aimed to compare agreement between different methods of calculating this quality indicator. In addition, characteristics for patients and care providers associated with a high proportion treated with ACEI or ARB were analyzed.

METHODS

This Swedish cross-sectional register-based study was conducted in the Stockholm region (2.1 million inhabitants). The proportion of patients with HF treated with ACEI or ARB was calculated by different methods applied on an administrative database on healthcare consumption, diagnoses, and dispensed drugs and by self-reported data from all primary care centers in the region.

RESULTS

A total of 32,677 patients recorded with a HF diagnosis 2008-2012 and alive July-December 2012 were identified. The proportion treated with ACEI or ARB varied depending on observation period and care provider included (range register 52-74 %). There was a large variation between different primary care centers (range register 36-88 %, range self-reported 8-100 %) and a poor agreement between methods (Bland-Altman; rhoc range 0.07-0.23). Predictors for high proportion treated were low age, high socioeconomic status, cardiovascular comorbidity, and diagnosis recorded both in primary care and in hospitals.

CONCLUSIONS

There is poor agreement between different methods to evaluate adherence to guidelines for drug treatment in HF. Differences between practices concerning patient age, socioeconomic status, comorbidity, and care given by different providers should be taken into account in quality assessment.

Prevalence, incidence, and associated factors of avascular necrosis in Korean patients with systemic lupus erythematosus: a nationwide epidemiologic study

Avascular necrosis (AVN) is one of the most frequent types of organ damage in systemic lupus erythematosus (SLE). However, little is currently known about the epidemiology of AVN in SLE patients. The aim of this study was to estimate the prevalence and incidence of AVN in Korean patients with SLE based on National Health Insurance (NHI) claims data and to determine the risk factors for AVN among SLE patients. This study was conducted using the 2006-2010 data of 25,358 SLE patients from the NHI program. AVN cases were defined as those with at least one diagnosis of AVN. The prevalence was calculated by dividing the number of AVN cases by the number of SLE cases in the same year. The annual incidence was calculated by dividing the number of incident AVN cases by the number of SLE-prevalent cases not previously diagnosed with AVN. Patients who developed AVN in 2008-2010 were compared with SLE patients who did not develop AVN to identify any risk factors. The prevalence of AVN among SLE patients (2006-2010) was 31.5-34.2 per 1,000 persons and was similar in all the years studied. The incidence per 1,000 persons of AVN among SLE patients was 8.6 [95 % confidence interval (95 % CI) 6.9-10.3] in 2008, 9.8 (95 % CI 8.0-11.6) in 2009, and 8.4 (95 % CI 6.8-10.0) in 2010. Regression analysis indicated that taking an oral corticosteroid [odds ratio (OR) 2.12, 95 % CI 1.39-3.23] or an intravenous corticosteroid (OR 1.5, 95 % CI 1.2-1.89) was significantly associated with AVN. In addition, AVN was associated with use of immunosuppressive agents (OR 2.12, 95 % CI 1.66-2.72), hydroxychloroquine (OR 1.4, 95 % CI 1.09-1.81), and lipid-lowering agents (OR 1.78, 95 % CI 1.24-2.57) among the prescribed medications, and with hypertension (OR 1.39, 95 % CI 1.08-1.79) among the comorbidities. The prevalence and incidence of AVN among SLE patients, which were 31.5-34.2 and 8.4-9.8 per 1,000 persons, respectively, may be representative of the entire population of symptomatic AVN patients with SLE in Korea. AVN is associated with the use of corticosteroids, immunosuppressants, hydroxychloroquine, lipid-lowering agents, and with hypertension. Studies of large, prospective cohorts are needed to confirm these results.

Has beta-blocker use increased in patients with heart failure in internal medicine settings? Prognostic implications: RICA registry

INTRODUCTION AND OBJECTIVES

Underuse of beta-blockers has been reported in elderly patients with heart failure. The aim of this study was to evaluate the current prescription of beta-blockers in the internal medicine setting, and its association with morbidity and mortality in heart failure patients.

METHODS

The information analyzed was obtained from a prospective cohort of patients hospitalized for heart failure (RICA registry] database, patients included from March 2008 to September 2011) with at least one year of follow-up. We investigated the percentage of patients prescribed beta-blockers at hospital discharge, and at 3 and 12 months, and the relationship of beta-blocker use with mortality and readmissions for heart failure. Patients with significant valve disease were excluded.

RESULTS

A total of 515 patients were analyzed (53.5% women), with a mean age of 77.1 (8.7) years. Beta-blockers were prescribed in 62.1% of patients at discharge. A similar percentage was found at 3 months (65.6%) and 12 months (67.9%) after discharge. All-cause mortality and the composite of all-cause mortality and readmission for heart failure were significantly lower in patients treated with beta-blockers (hazard ratio=0.59, 95% confidence interval, 0.41-0.84 vs hazard ratio=0.64, 95% confidence interval, 0.49-0.83). This decrease in mortality was maintained after adjusting by age, sex, ejection fraction, functional class, comorbidities, and concomitant treatment.

CONCLUSIONS

The findings of this study indicate that beta-blocker use is increasing in heart failure patients (mainly elderly) treated in the internal medicine setting, and suggest that the use of these drugs is associated with a reduction in clinical events.

SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR): a multi-center, retrospective, observational study

BACKGROUND

Clinical practice guidelines have been slowly and inconsistently applied in clinical practice, and certain evidence-based, guideline-driven therapies for heart failure (HF) have been significantly underused. The purpose of this study was to survey guideline compliance and its effect on clinical outcomes in the treatment of systolic HF in Korea.

METHOD AND RESULTS

The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR) trial was a multi-center, retrospective, observational study on subjects with systolic HF (ejection fraction <45%) admitted to 23 university hospitals. The guideline adherence indicator (GAI) was defined as a performance measure on the basis of 3 pharmacological classes: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor II blocker (ARB), beta-blocker (BB), and aldosterone antagonist (AA). Based on the overall adherence percentage, subjects were divided into 2 groups: those with good guideline adherence (GAI ≥50%) and poor guideline adherence (GAI <50%). We included 1319 regional participants as representatives of the standard population from the Korean national census in 2008. Adherence to drugs at discharge was as follows: ACEI or ARB, 89.7%; BB, 69.2%; and AA, 65.9%. Overall, 82.7% of the patients had good guideline adherence. Overall mortality and re-hospitalization rates at 1 year were 6.2% and 37.4%, respectively. Survival analysis by log-rank test showed a significant difference in event-free survival rate of mortality (94.7% vs. 89.8%, p = 0.003) and re-hospitalization (62.3% vs. 56.4%, p = 0.041) between the good and poor guideline-adherence groups.

CONCLUSIONS

Among patients with systolic HF in Korea, adherence to pharmacologic treatment guidelines as determined by performance measures, including prescription of ACEI/ARB and BB at discharge, was associated with improved clinical outcomes.