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Age-related underutilization of left ventricular function evaluation in older heart failure patients.

ABSTRACT

Background. Underutilization of left ventricular function (LVF) evaluation in older patients with heart failure has been well documented, but age-related variation in the use of LVF evaluation has not been.

Methods. We studied age-related variation of LVF evaluation in older Medicare-beneficiaries discharged with a diagnosis of heart failure in 1994 in Alabama.

Results. A total of 1,090 patients had a mean [+ or -] SD age of 79 [+ or -] 7.5 years; 60% were female and 18% were African American. Of these, 636 (58%) had LVF evaluation. Compared with patients aged 65 to 74 years, those 75 to 84 years of age and those aged 85 and older were less likely to receive LVF evaluation. Age of 85 years and older was also independently associated with lower odds of LVF evaluation.

Conclusion. The overall rate of LVF evaluation was low, and performance of evaluation decreased with patient age. Left ventricular function evaluation should be performed in all patients with heart failure. Considerable opportunities exist for improving care among hospitalized Medicare beneficiaries diagnosed with heart failure.

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HEART FAILURE is the number one hospital discharge diagnosis for patients aged 65 years and older in the United States. In 1995, heart failure was documented as the principal diagnosis in 872,000 hospitalizations. (1) In 1996, an estimated 4.8 million Americans had heart failure, and another 400,000 were newly diagnosed with that condition. (2) Most patients with heart failure are older adults; both prevalence and incidence of heart failure increase with age. Heart failure is the only cardiovascular disease with increasing prevalence and mortality rate. (2,3)

The Agency for Healthcare Research and Quality (AHRQ formerly the AHCPR) heart failure clinical practice guidelines recommend that left ventricular function (LVF) be evaluated in all patients with heart failure. (4) The heart failure guidelines of the American College of Cardiology and the American Heart Association also made similar recommendations. (5)

The United States Census Bureau has projected that by 2025, the proportion of the population aged 65 years and older would be 20% of the total US population. (6) The oldest old, that group of people aged 85 years and older, are the fastest-growing segment of the population, and their number will reach 19 million (5% of the US population) by 2050. (6) Studies have documented underutilization of invasive cardiovascular diagnostic and treatment modalities in older individuals, (7-9) and studies have also shown underutilization of LVF evaluation among all age categories. (10-14) Few studies have investigated age-related changes in the utilization of noninvasive procedures in the medical management of cardiovascular diseases in general, and heart failure in particular, among older adults. (15, 16) This study examined whether a similar age-related underutilization of LVF evaluation existed in the management of heart failure among hospitalized older adults.

METHODS

This study is a secondary analysis of the baseline data-set of a heart failure quality-improvement project by the Alabama Quality Assurance Foundation (AQAF) that involved retrospective medical record review. The subjects were fee-for-service Medicare beneficiaries aged 65 years and older, discharged between January 1994 and December 1994 with a principal diagnosis of heart failure. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and diagnosis-related group (DRG) codes were used to identify patients with heart failure. Charts of all patients who had a documentation of ICD-9-CM code 428 (principal discharge diagnosis of "heart failure") or ICD-9-CM code 402.91 (principal discharge diagnosis of "hypertensive heart disease with congestive heart failure") or a DRG code 127 ("heart failure") were reviewed. For the purpose of this study, the diagnosis of heart failure was confirmed by the presence of 1 of the following: (1) history of heart failure; (2) symptoms (dyspnea at rest, dyspnea of exertion, orthopnea, paroxysmal nocturnal dyspnea); (3) signs (jugular venous distension, third heart sound, displaced point of maximum cardiac impulse, or pulmonary rales); (4) radiographic evidence (cardiomegaly, pulmonary venous congestion, or pulmonary edema); or (5) treatment with digoxin and diuretics. The AQAF maintained patient confidentiality and hospital confidentiality, and the University of Alabama at Birmingham Institutional Review Board approved the current study.

An expert panel at AQAF that included 2 cardiologists, 2 internists and 1 family physician, identified LVF evaluation as a quality-indicator based on the AHRQ heart failure guideline recommendations. (4) Left ventricular function evaluation was defined as contrast left ventriculography, multiple gated acquisition (MUGA) scan, or echocardiography during the index admission or at any time before that admission. All 1,090 patients were considered eligible for LVF evaluation. We then assessed LVF evaluation in patients with no history of heart failure (new-onset heart failure) and those with new-onset heart failure who were not receiving angiotensin-converting enzyme (ACE) inhibitors at the time of hospitalization.

Eleven Alabama acute-care hospitals participated in the original AQAF project. The facilities were a mix of rural and urban hospitals, with size varying from 64 to 908 beds. Using MEDPRO (administrative claims history for Medicare Part A) files and based on the ICD-9-CM and DRG codes, AQAF identified all patients discharged from each hospital with a principal diagnosis of heart failure. The hospitals then made the charts of those patients available to nurse-reviewers for on-site abstraction. Charts of 120 randomly selected eligible cases of patients discharged in 1994 with the diagnosis of heart failure were abstracted. If fewer than 120 cases had been discharged by a particular hospital during the study period, all eligible cases were abstracted. Trained study-nurses abstracted data between January 1995 and March 1995. After a thorough review of the medical record, they abstracted data on patient demographics, medical history, and hospital course. Medical history included history of heart failure, past LVF evaluation, home use of ACE inhibitors, and intolerance to ACE inhibitors. Data were abstracted regarding presenting symptoms and signs, laboratory values, chest radiograph results, and electrocardiography findings. Information from echocardiography, MUGA scan, and contrast left ventriculography performed for LVF evaluation comprised data on the course of the index hospitalization. Comorbid conditions were ascertained using the ICD-9-CM codes. The reliability of the abstraction was verified by random re-abstraction of 5% of the charts by another group of nurse-abstractors. The validity of the data was evaluated by comparing the results of the nurse-abstractors with those of the expert physicians on the panel. The concordance rates for both reliability and validity on key variables were [greater than or equal to]95%.

SPSS for Windows, Release 10.0.0 (17) was used to analyze the data. Patients were stratified into 3 age categories as follows: the young-old (aged 65 to 74 years), the old (aged 75 to 84 years) and the old-old (aged 85 years and older). Data were analyzed for the demographic features, historical features, and admission characteristics of the patients, based on age categories. Performance of LVF evaluation was then compared among the age categories, and the statistical significance was tested using Pearson's chi-square tests. Using logistic regression, we calculated the odds ratio (OR) with 95% confidence interval (95% CI) of LVF evaluation for age categories 75 to 84 years and 85 years and older (the group aged 65 to 74 years served as the reference age group). To control for the confounding effects of demographics and other factors, we created a multiple logistic regression model. In the first step of the model, age 75 to 84 years and 85 years and older (using the group aged 65 to 74 years as the reference a ge group), female sex, and African American race/ethnicity were forced into the model. In the next step, we entered new-onset heart failure, nursing home admission, hypertension, coronary artery disease, preadmission use of ACE inhibitors, care by cardilologists, and hospital (as a dummy variable, using the hospital with lowest LVF evaluation rate as the reference). In the final step, we entered admission symptoms of dyspnea at rest, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, angina, and lower-extremity edema. Admission symptoms were entered in a separate step in the model, since there could be wide variations in the documentation of admission symptoms. We also performed similar analyses restricted to patients with incident heart failure, and to those with incident heart failure who were not already on an ACE inhibitor. We used the Hosmer-Lemeshow goodness-of-fit test to evaluate the overall fit of the model. (18) A 2-tailed test with [alpha] of < .05 was used to determine statisti cal significance.

RESULTS

After excluding subjects without documentation of age (n = 29), those younger than 65 years of age (n = 123), and those who did not meet the criteria for diagnosis of heart failure (n = 9), the study included 1,090 subjects. Of these, 343 (31%) were aged 65 to 74 years, 466 (43%) were aged 75 to 84 years, and 281 (26%) were 85 years and older. A total of 1,078 patients (99%) met 2 or more of the criteria for diagnosis of heart failure, and 937 (86%) met 3 or more of the criteria. Left ventricular function evaluation was performed before or during the index hospitalization on 636 patients (58%). Of these, 515 patients (81%) had LVF evaluation during the index hospitalization; echocardiography was the most common procedure (96%), followed by MUGA scan (15%); 12% of patients had both MUGA scan and echocardiography. Three patients, all from the group aged 65 to 74 years, had left ventriculogram. One hundred ninety-six patients (18%) had a previous LVF evaluation; of these, 75 (38%) had repeated LVF evaluation dur ing the index hospitalization. Of the 636 patients with LVF evaluation, left ventricular ejection fraction was documented for 557 patients (88%), and 324 (58%) had left ventricular systolic dysfunction (ejection fraction <40%).

Patient Characteristics

Subjects had a mean age [+ or -] SD of 79[+ or -]7.5 years with a range of 65 to 104 years; 60% were women and 18% were African American. Table 1 summarizes the demographic characteristics of the study population. Women were more likely to be older. As expected, older patients were more likely to be admitted from nursing homes, but even in that age group, 82% were admitted from home. Hypertension, diabetes, and cardio-myopathy were more common among younger patients, who were also more likely to use diuretics. Older patients were less likely to have been cared for by a cardiologist, with 53%, 45% and 33%, for the youngest to oldest age groups, respectively, under the care of a cardiologist (P < .001). The mean [+ or -]SD length of stay for the index admission was 6.7 [+ or -] 5.5 days for all patients, and no age-related variation was noted. When we used square-root-transformed length-of-stay, we found similar results.

Table 2 presents the data for characteristics on admission by the 3 age-categories. While younger patients were more likely to be symptomatic, older patients were more likely to have atrial fibrillation. There were no other statistically significant differences in the admission physical findings, laboratory values, or chest radiograph by age category.

Left Ventricular Function Evaluation

Compared with 66% of patients aged 65 to 74 years, 57% of those aged 75 to 84 years and 51% of those aged 85 years and older received LVF evaluation (Figure). When patients who had past LVF evaluation were excluded, 49% had LVF evaluation, and an age-related underutilization was noted (55% for ages 65 to 74 years, 48% for 75 to 84 years, and 45% for 85 years and older (P = .043). Among patients with new-onset heart failure, 63% received LVF evaluation, and fewer patients aged 85 years and older received LVF evaluation (64%, 69%, and 52% for the youngest to oldest age groups, respectively) (P = .052). Among patients with incident heart failure and without preadmission ACE inhibitor use, 65% had LVF evaluation; however, no significant age-related variation was noted in the youngest to oldest age categories, 67%, 69%, and 56%, respectively (P = .208).

Results of Bivariate Analyses

Table 3 shows the variables associated with LVF evaluation in the bivariate analyses. Compared with patients 65 to 74 years of age, those aged 75 to 84 years and those aged 85 years and older had 32% and 47%, respectively, lower odds of receiving LVF evaluation. When age was used as a continuous variable, for every year increase in age after 65 years, patients had 2% lower odds of receiving LVF evaluation (OR = 0.982; 95% CI = 0.964-1.001; P = .062). For patients with incident heart failure, age had a similar association (OR = 0.97) with LVF evaluation, which bordered on significance (95% CI = 0.94-1.00). Among patients without preadmission ACE inhibitor use, both the group aged 75 to 84 years (OR = 0.65; 95% CI= 0.45-0.94) and the group 85 years and older (OR = 0.52; 95% CI= 0.34-0.79) were associated with lower odds of LVF evaluation. When we restricted our analysis to patients with incident heart failure who were not receiving ACE inhibitors at the time of admission, age was not associated with LVF evalua tion (Table 4); however, care by cardiologist and symptoms of dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea were associated with higher odds of LVF evaluation.

Results of Multivariate Analyses

After adjustment for various patient and care characteristics, those patients aged 85 years and older had 33% lower odds of receiving LVF evaluation than patients aged 65 to 74 years (Table 3). Care by a cardiologist was also independently associated with higher rate of LVF evaluation. In addition, admission symptoms of dyspnea on exertion, orthopnea, and angina were also independently associated with LVF evaluation (Table 3). The multivariate logistic regression model was fit to data (chi-square = 10.44; Hosmer-Lemeshow goodness-of-fit test P = .24). The expected number of events in all the groups exceeded 5, and none of the groups had an expected value of less than 1. Among patients with new-onset heart failure and without any preadmission ACE inhibitors use, age of 85 years and older was associated with 46% lower odds of LVF evaluation. That was not statistically significant (Table 4); however, care by cardiologists and admission symptoms of orthopnea were independently associated with higher odds of rece iving LVF evaluation.

DISCUSSION

The primary purpose of this study was to determine whether hospitalized older patients with heart failure were less likely than younger patients to receive LVF evaluation. The results of our study showed an overall underutilization of LVF evaluation for older hospitalized patients with heart failure. More importantly, we have also shown that older patients with heart failure were less likely to receive LVF evaluation. After adjustment for patient characteristics and other processes of care, age of 85 years and older was independently associated with lower odds of LVF evaluation. Even in a subset of patients who were considered ideal candidates for LVF evaluation--those with incident heart failure and not already on an ACE inhibitor--age of 85 years and older was associated with about a 40% reduction in the odds of receiving LVF evaluation. Although the association was not statistically significant, the direction and magnitude of this association underlines its clinical and public health importance.

Why were older heart failure patients less likely to receive noninvasive (all except 3 patients had noninvasive procedures in our study) procedures for LVF evaluation? Although exploration of the underlying mechanism of age-related underutilization is beyond the scope of this retrospective study, our data provide several plausible explanations. Patients cared for by cardiologists in our study were more likely to be younger and, therefore, more likely to receive LVF evaluation. Other investigators have also shown a similar relationship between cardiology care and LVF evaluation. (19,20) Also, younger patients in our study were more likely to experience symptoms of dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, and were also more likely to be on diuretics. We observed that the presence of these symptoms was associated with higher odds of receiving LVF evaluation. It is likely that lack of care from a cardiologist and absence of typical symptoms of heart failure increased the risk of not bein g evaluated for LVF status in our study. In fact, when we created a multivariate model to adjust for care by a cardiologist and admission symptoms of dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, the association between the groups aged 75 to 84 years and aged 85 years and older and LVF evaluation were no longer statistically significant

It is also possible that physicians did not perform LVF evaluation either because a patient had had past LVF evaluation or was already on an ACE inhibitor. Patients who had undocumented past LVF evaluation were likely to be misclassified as eligible for LVF evaluation during the index hospitalization. In our study, fewer older patients had past LVF evaluation (24%, 17% and 11% for the groups aged 65 to 74 years, 75 to 84 years, and 85 years and older, respectively) (P < .001). If the low rate of past LVF evaluation in patients aged 85 years and older was due to underdocumentation because the procedures were done in the more remote past (there was no age-related variation in the preadmission use of ACE inhibitors), then current LVF evaluation of that group could potentially be underestimated. To evaluate the impact of undocumented past LVF evaluation on current LVF evaluation, we performed subgroup analyses in patients with no history of heart failure, since these patients would have been less likely to have had past LVF evaluation. The results of these subgroup analyses showed that patients aged 85 years and older were still less likely to receive LVF evaluation, suggesting that our finding of association between age and LVF evaluation cannot be explained by age-related variation in the documentation of past LVF evaluation. To assess the impact of ACE-inhibitor therapy on LVF evaluation, we performed a subgroup analysis excluding patients who were already on an ACE inhibitor and found similar age-related variation in LVF evaluation.

Our finding of the association between increasing age and decreased use of LVF evaluation is consistent with others in the literature. Investigators of the 10 Large State Peer Review Organization Consortium also found an inverse association between age and LVF evaluation among patients with heart failure (11); however, no multivariate analysis was done to determine independence of association between age and LVF evaluation. On the other hand, others have not observed any age-related variation in LVF evaluation among patients with acute myocardial infarction (8,16)

It is important that LVF be known in all patients with heart failure. Major national heart failure guidelines have recommended LVF evaluation for patients with heart failure. (4,5,21) In the Consensus Recommendations for the Management of Chronic Heart Failure, a national panel of heart failure experts identified LVF evaluation as the single most important measurement and echocardiogram with Doppler flow as the single most useful diagnostic test in patients with heart failure. (21) The CMS, in its National Heart Failure Project launched in January 1999, has identified LVF evaluation as one of its target quality-indicators for which opportunities for improvement exist. (22) The primary purpose of LVF evaluation is to identify patients with left ventricular systolic dysfunction so that treatment with ACE inhibitors, [beta]-blockers, spironolactone, and digoxin (if the patient is symptomatic) can be initiated. In addition to evaluating LVF, echocardiography allows physicians to assess conditions such as endocar dial vegetation, severe valvular disorder, dyskine tic left ventricular aneurysm, cardiac thrombi, and constrictive pericarditis, abnormalities that might be causally associated with heart failure or affect its management. (21,23) It also allows evaluation of other degenerative cardiac disorders common in old age. (24) Hendry et al (25) showed that in older patients with heart failure (mean age, 82 years), echocardiographic findings changed the primary diagnosis in 28% of patients and influenced management plans in 41% of patients. It has been recommended that LVF evaluation should be done in all patients with suspected heart failure, irrespective of age. (23,26) If echocardiographic findings are inadequate to define LVF, MUGA scan or cardiac magnetic resonance imaging should be considered. (29,23,26)

Our study has several limitations. The data for the study were collected in the same year as the AHRQ heart failure guidelines were published. Although to some degree this might explain the low overall rate of LVF evaluation that we observed, it is unlikely to have affected the age-related variation in those performances. A more recent study has shown that from 1998 to 1999, the performance of LVF evaluation in Alabama was 65%, which is comparable to our finding. (27) Studies have also shown that physician practice patterns regarding heart failure management had already started to change by the time data for this study was collected. (28)

We were also unable to assess physician preferences in our analysis. Older patients in our study were less likely to be referred by their primary care physicians for cardiology consultation (36%, 32%, and 24% for ages 65 to 74 years, 75 to 84 years, and 85 years or more, respectively) (P =.008). Similarly, other physician biases for less aggressive management for older patients might have decreased the performance of LVF evaluation in that age group. Although we had no data on functional status, we were able to adjust for symptoms, comorbid conditions and care by cardiologists as surrogate markers for functional status and frailty.

In conclusion, we observed an overall underutilization of LVF evaluation. In addition, we observed an age-related underutilization of LVF evaluation among older heart failure patients and independent inverse association with patients aged 85 years and older. Left ventricular function evaluation should be done in all incident heart failure patients and in all prevalent cases, if not previously performed. Every effort should be made to evaluate LVF of older heart failure patients, and age should not be a barrier to LVF evaluation.

Disclaimer: The analyses upon which this publication is based were performed under Contract Number 500-96-P60, entitled "Utilization and Quality Control Peer Review Organization for the State of Alabama," sponsored by the Center for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration), Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the CMS, which has encouraged identification of quality-improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to us concerning experience in engaging with issues presented are welcomed.
Proportion of patients receiving left ventricular function evaluation
by age category (65-74 years, 75-84 years, and [greater than or
equal to] 85 years).


 65-74Y 75-84Y 85+Y

All patients
 (n = 1,090) 66% 57% 51%
 (P < .001)

Patients with incident heart failure
 (n = 289) 64% 69% 52%
 (P <.05)

Patient with incident heart failure
with preadmission ACE inhibitors
 (n = 240) 67% 69% 56%
 (P <.208)


Note: Table made from bar graph.
TABLE 1

Baseline Patient Characteristics by Age Category


 All 65-74 Yrs 75-84 Yrs
 (N = 1,090) (n = 343) (n = 466)

Female 652 (60%) 181 (53%) 270 (58%)
African American 192 (18%) 67 (19%) 79 (17%)
Nursing home admission 97 (9%) 13 (4%) 35 (7%)
History of heart failure 801 (73%) 256 (75%) 341 (73%)
Admission medications
 ACE inhibitors 413 (38%) 138 (40%) 166 (36%)
 Digoxin 588 (54%) 181 (53%) 245 (53%)
 Diuretics 298 (27%) 120 (35%) 96 (21%)
Comorbidities
 Coronary artery disease 273 (25%) 92 (27%) 114 (24%)
 Cardiomyopathy 167 (15%) 70 (20%) 66 (14%)
 Arrhythmias 378 (35%) 90 (26%) 190 (41%)
 Hypertension 182 (17%) 73 (21%) 67 (14%)
 Diabetes 272 (25%) 119 (35%) 107 (23%)
 Chronic obstructive
 pulmonary disease 345 (32%) 120 (35%) 158 (34%)
 Pneumonia 144 (13%) 42 (12%) 69 (15%)
 Fluid and electrolyte
 imbalance 311 (28%) 104 (30%) 128 (27%)
Care by cadiologists

 By admission 145 (13%) 60 (17%) 59 (13%)
 By consultation 341 (31%) 123 (36%) 150 (32%)

 [greater than or
 equal to] 85 Yrs
 (n = 281) P Value

Female 201 (72%) < .001
African American 46 (17%) .52
Nursing home admission 49 (18%) < .001
History of heart failure 204 (73%) .83
Admission medications
 ACE inhibitors 109 (38%) .38
 Digoxin 162 (58%) .35
 Diuretics 82 (29%) < .001
Comorbidities
 Coronary artery disease 67 (24%) .65
 Cardiomyopathy 31 (11%) .003
 Arrhythmias 98 (35%) < .001
 Hypertension 42 (15%) .022
 Diabetes 46 (16%) < .001
 Chronic obstructive
 pulmonary disease 67 (24%) .005
 Pneumonia 33 (12%) .80
 Fluid and electrolyte
 imbalance 79 (28%) .64
Care by cadiologists

 By admission 26 (9%) < .001
 By consultation 68 (24%)
Table 2

Admission Characteristics by Age Category


 All 65-74 Yrs
 (N = 1,090) (n = 343)

Symptoms
 Dyspnea at rest 975 (89%) 309 (90%)
 Dyspnea on exertion 279 (26%) 103 (30%)
 Orthopnea 356 (33%) 143 (42%)
 PND * 230 (21%) 93 (27%)
 Fatigue 56 (5%) 20 (6%)
 Angina 30 (3%) 9 (3%)
 Leg swelling 621 (57%) 213 (62%)

Physical signs
 Pulse (beats per minute) + 92 ([+ or -]22) 92 ([+ or -]21)
 Systolic BP ** (mm Hg) + 147 ([+ or -]32) 146 ([+ or -]33)
 Third heart sound 201 (18%) 67 (19%)
 Jugular venous distension 452 (41%) 137 (40%)
 Pulmonary rales 744 (68%) 228 (66%)
 PMI ++ displaced 97 (9%) 38 (11%)

Laboratory values
 BUN (ss)(mg/dL) + 29.3 ([+ or -]21.1) 27.8 ([+ or -]20.8)
 Serum creatinine (mg/dL) + 1.61 ([+ or -]1.28) 1.66 ([+ or -]1.38)
 Serum sodium (mEq/L) + 138 ([+ or -]5.9) 139 ([+ or -]5.3)
 Serum potassium (mEq/L) + 4.3 ([+ or -]0.68) 4.3 ([+ or -]0.67)

Chest radiograph
 Cardiomegaly 707 (65%) 215 (63%)
 Pulmonary edema 334 (31%) 103 (30%)

Electrocardiogram
 Atrial fibrillation 254 (23%) 61 (18%)

 [greater than or
 75-84 Yrs equal to]85 Yrs
 (n = 466) (n = 281)

Symptoms
 Dyspnea at rest 420 (90%) 246 (87%)
 Dyspnea on exertion 116 (25%) 60 (21%)
 Orthopnea 140 (30%) 73 (26%)
 PND * 92 (20%) 45 (16%)
 Fatigue 22 (5%) 14 (5%)
 Angina 14 (3%) 7 (2.5%)
 Leg swelling 245 (53%) 163 (58%)

Physical signs
 Pulse (beats per minute) + 92 ([+ or -]22) 91 ([+ or -]22)
 Systolic BP ** (mm Hg) + 147 ([+ or -]33) 146 ([+ or -]30)
 Third heart sound 86 (18%) 48 (17%)
 Jugular venous distension 197 (42%) 118 (42%)
 Pulmonary rales 333 (71%) 183 (65%)
 PMI ++ displaced 39 (8%) 20 (7%)

Laboratory values
 BUN (ss)(mg/dL) + 29.3 ([+ or -]19.9) 31.1 ([+ or -]23.1)
 Serum creatinine (mg/dL) + 1.59 ([+ or -]1.27) 1.59 ([+ or -]1.17)
 Serum sodium (mEq/L) + 139 ([+ or -]5.6) 139 ([+ or -]7.1)
 Serum potassium (mEq/L) + 4.3 ([+ or -]0.67) 4.4 ([+ or -]0.72)

Chest radiograph
 Cardiomegaly 301 (65%) 191 (68%)
 Pulmonary edema 152 (33%) 79 (28%)

Electrocardiogram
 Atrial fibrillation 117 (25%) 76 (27%)



 P Value

Symptoms
 Dyspnea at rest .483
 Dyspnea on exertion .042
 Orthopnea <.001
 PND * .002
 Fatigue .772
 Angina .903
 Leg swelling .024

Physical signs
 Pulse (beats per minute) + .71
 Systolic BP ** (mm Hg) + .96
 Third heart sound .734
 Jugular venous distension .784
 Pulmonary rales .137
 PMI ++ displaced .195

Laboratory values
 BUN (ss)(mg/dL) + .168
 Serum creatinine (mg/dL) + .680
 Serum sodium (mEq/L) + .948
 Serum potassium (mEq/L) + .013

Chest radiograph
 Cardiomegaly .382
 Pulmonary edema .414

Electrocardiogram
 Atrial fibrillation .012

* Paroxysmal nocturnal dyspnea.

+ [+ or -] SD.

** Blood pressure.

++ Point of maximum impulse.

(ss) Blood urea nitrogen.
TABLE 3

Variables Associated with Use of Left Ventricular Function Evaluation:
Crude and Adjusted Odds Ratio (95% Confidence Interval)

 Crude Adjusted *

Age 75 to 84 years 0.68 (0.51-0.91) 0.82 (0.59-1.14)
Age [greater than 0.53 (0.38-0.73) 0.67 (0.46-0.98)
or equal to] 85 years
Female 0.89 (0.69-1.14) 1.07 (0.80-1.42)
African American 1.00 (0.73-1.37) 1.05 (0.72-1.52)
Incident heart failure 0.77 (0.58-1.01) 1.43 (1.04-1.96)
Care by cardiologists 4.44 (3.40-5.79) 4.79 (3.54-6.47)
Admission characteristics
 Dyspnea of exertion 3.11 (2.28-4.25) 1.95 (1.37-2.76)
 Orthopnea 2.74 (2.07-3.61) 1.99 (1.45-2.76)
 Angina 3.67 (1.40-9.67) 3.14 (1.10-8.93)

* Also adjusted for admission from nursing home, history of heart
failure, coronary artery disease, hypertension, preadmission use of ACE
inhibitors, admission symptoms of paroxysmal nocturnal dyspnea, fatigue,
lower extremity edema, and hospital (used as dummy variable).
TABLE 4

Variables Associated With Use of Left Ventricular Function Evaluation:
Crude and Adjusted Odds Ratios (95% Confidence Intervals) in Patients
With New-Onset Heart Failure and Not Receiving ACE Inhibitors Before
Admission

 Crude Adjusted *

Age 75 to 84 years 1.08 (0.57-2.05) 0.91 (0.44-1.89)
Age [greater than or 0.62 (0.30-1.25) 0.54 (0.24-1.22)
 equal to]85 years
Female 0.89 (0.51-1.55) 1.29 (0.68-2.46)
African American 0.66 (0.32-1.35) 0.81 (0.36-1.83)
Care by cardiologist 4.17 (2.27-7.66) 6.06 (3.01-12.17)
Dyspnea on exertion 1.91 (1.02-3.59) -
Orthopnea 3.28 (1.75-6.17) 2.26 (1.14-4.51)
Paroxysmal nocturnal 3.19 (1.52-2.93) -
 dyspnea

* Also adjusted for admission from nursing home, coronary artery
disease, hypertension, care by cardiologists, admission symptoms of
dyspnea, fatigue, and lower extremity edema, and hospital (used as
dummy variable).


References

(1.) Graves EJ, Owings MF: 1996 Summary: National Hospital Discharge Survey. Advance Data From Health and Vital Statistics. Hyattsville, Md, US Department of Health and Human Services, Centers for Disease Control, National Center for Health Statistics, 1998. DHHS Publication No. 301

(2.) Congestive Heart Failure in the United States: A New Epidemic. Data Facts Sheets. Bethesda, Md, National Institutes of Health, National Heart, Lung, and Blood Institute, 1996

(3.) Current Trends: Mortality from Congestive Heart Failure--United States, 1980-1990. MMWR Morb Mortal Wkly Rep 1994; 43:77-81

(4.) Konstam MA, Dracup K, Bottoroff M, et al: Heart Failure: Evaluation and Care of Patients With Left Ventricular Systolic Dysfunction: Clinical Practice Guideline. Rockville, Md, US Department of Health and Human Services, Agency for Health Care Policy and Research, 1994. DHSS Publication No. 94-0612

(5.) Williams J, Bristow M, Fowler M, et al: Guidelines for the evaluation and management of heart failure: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 1995; 92:2764-2784

(6.) Hobbs B, Damon B, McKenny N, et al: The Sixty-Five Plus in the United States. United States Census Bureau. Current Population Report, Special Studies. Washington, DC, US Government Printing Office, 1996

(7.) Bearden D, Allman R, McDonald R, et al: Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J AM Geriatr Soc 1994; 42:1143-1149

(8.) Bearden D, Allman R, Sundarum 5, et al: Age-related variability in the use of cardiovascular imaging procedures. J Am Geriatr Soc 1993; 41:1075-1082

(9.) Giugliano RP, Camargo CA Jr, Lloyd-Jones DM, et al: Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines. Arch Intern Med 1998; 158:1113-1120

(10.) Gurwitz JH, Osganian V, Goldberg RJ, et al: Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? the Worcester Heart Attack Study. Am J Epidemiol 1991; 134:948-957

(11.) Newman J, Ahmed O, Hyngstrom T, et al: Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. Arch Intern Med 1997; 157:1103-1108

(12.) Krumholz HM, Wang Y, Parent EM, et al: Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med 1997; 157:2242-2247

(13.) DeLong, J, Allman R, Sherrill R, et al: A congestive heart failure project with measured improvement in care. Eval Health Prof 1998; 21:472-486

(14.) Baker DW, Fitzgerald D, Moore CL: Quality of care for Medicare patients hospitalized with heart failure in rural Georgia. South Med J 1999; 92:782-789

(15.) Ganz DA, Lamas GA, Orav EJ, et al: Age-related differences in management of heart disease: a study of cardiac medication use in an older cohort. Pacemaker Selection in the Elderly (PASE) investigators. J Am Geriatr Soc 1999; 47:145-150

(16.) Rosenthal G, Fortisky R: Differences in the treatment of patients with acute myocardial infarction according to patient age. J Am Geriatr Soc 1994; 42:826-832

(17.) SPSS for Windows [computer program]. Release 10.0.0. Chicago, Ill, SPSS Inc, 2000

(18.) Hosmer D, Lemeshow S: Applied Logistic Regression. New York, Wiley-lnterscience, 1989

(19.) Philbin EF, Weil HF, Erb TA, et al: Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes. Chest 1999; 116:346-354

(20.) Edep ME, Shah NB, Tateo IM, et al: Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997; 30:518-526

(21.) Packer M, Cohn J, Abraham W, et al: The consensus recommendation for the management of chronic heart failure. Am J Cardiol 1999; 83:lA-38A

(22.) Heart Failure National Project Overview (Originally published as part of HCFA Publication No, 10156). Health Care Financing Administration, 1999. Available at: http://www.hcfa.gov/quality/download/3s.pdf

(23.) Aronow WS: Echocardiography should be performed in all elderly patients with congestive heart failure. J Am Geriatr Soc 1994; 42:1300-1302

(24.) Aronow WS: Usefulness of M-mode, 2-dimensional, and Doppler echocardiography in the diagnosis, prognosis, and management of valvular aortic stenosis, aortic regurgitation, and mitral annular calcium in older patients. J Am Geriatr Soc 1995; 43:295-300

(25.) Hendry A, Hacking L, Langhorne P, et al: Evaluation of echocardiography in the management of elderly patients with heart failure. Age Ageing 1999; 28:447-450

(26.) Berkin KE: Does everyone in heart failure need echocardiography? Age Ageing 1999; 28:421-422

(27.) Jencks SF, Cuerdon T, Burwen DR, et al: Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA 2000; 284:1670-1676

(28.) Smith NL, Psaty BM, Pitt B, et al: Temporal patterns in the medical treatment of congestive heart failure with angiotensin-converting enzyme inhibitors in older adults, 1989 through 1995. Arch Intern Med 1998; 158:1074-1080

RELATED ARTICLE: KEY POINTS

* Most heart failure patients are 65 years and older, and heart failure is the number one hospital discharge diagnosis among patients 65 years and older.

* Left ventricular function (LVF) evaluation, essential to determine impaired versus preserved LVF, is often underutilized.

* Of 1,090 patients 65 years and older discharged with a diagnosis of heart failure, 636 (58%) received LVF evaluation.

* For every 1-year increase in age after 65 years, the odds of receiving LVF evaluation decreased by 2%.

* Left ventricular function evaluation should be done in all patients with heart failure, irrespective of age.

From the Division of Gerontology and Geriatric Medicine Department of Medicine, School of Medicine, Department of Epidemiology and International Health anti Department of Biostatistics, School of Public Health, center for Aging, and Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham; Section of Geriatrics Heart Failure Clinic, and Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center; and the Alabama Quality Assurance Foundation.

Supported by a grant from the Southeast Center of Excellence in Geriatric Medicine and the John A. Hartford Foundation of New York (Ali Ahmed, MD, MPH).

Reprint requests to Ali Ahmed, MD, MPH, 1530 3rd Ave S, CH-19, Suite 219, Birmingham AL 35294-2041.
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Author:Howard, George
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Jul 1, 2002
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