Age-related underutilization of left ventricular function evaluation in older heart failure patients.ABSTRACT
Background. Underutilization of left ventricular function ventricular function,
n the cyclic contraction and relaxation of the ventricular myocardium. (LVF LVF Loyalist Volunteer Force
LVF Left Ventricular Function
LVF Left Ventricular Failure
LVF Linear Variable Filter
LVF Libertarian Victory Fund (political fundraising group)
LVF Lavatory Vent Fan
LVF Line Voltage Fluctuation ) 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 African American Multiculture A person having origins in any of the black racial groups of Africa. See Race. . 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.
HEART FAILURE is the number one hospital discharge diagnosis for patients aged 65 years and older in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . 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 Cardiovascular disease
Disease that affects the heart and blood vessels.
Mentioned in: Lipoproteins Test
cardiovascular disease with increasing prevalence and mortality rate. (2,3)
The Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality,
n.pr formerly known as the Agency for Health Care Policy and Research, this agency researches the quality of medical care and health services. (AHRQ AHRQ,
n.pr See Agency for Healthcare Research and Quality. formerly the AHCPR AHCPR,
n.pr See Agency for Healthcare Research and Quality. ) heart failure clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. 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 The American College of Cardiology (ACC) is a nonprofit medical association established in 1949 to educate, research and influence health care public policy. The president for the 2006–2007 year is Steven E. Nissen.  The organization has 39 chapters in the U.S. and the American Heart Association American Heart Association (AHA),
n.pr a national voluntary health agency that has the goal of increasing public and medical awareness of cardiovascular diseases and stroke, and thereby reducing the number of associated deaths and disabilities. also made similar recommendations. (5)
The United States Census Bureau The United States Census Bureau (officially Bureau of the Census as defined in Title 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. ) is a part of the United States Department of Commerce.
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 AQAF Alabama Quality Assurance Foundation ) 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 ICD-9-CM International Classification of Disease, 9th edition, Clinical Modification
A standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6-digit number, which allows ) and diagnosis-related group diagnosis-related group Managed care A prospective payment system used by Medicare and other insurers to classify illnesses according to diagnosis and treatment; DRGs are used to group all charges for hospital inpatient services into a single 'bundle' for payment (DRG DRG,
n the abbreviation for diagnosis-related group.
see dorsal respiratory group.
DRG Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and ) 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 Hypertensive heart disease
High blood pressure resulting in a disease of the heart.
Mentioned in: Myocarditis
hypertensive heart disease with congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. ") 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 dyspnea /dysp·nea/ (disp-ne´ah) labored or difficult breathing.dyspne´ic
paroxysmal nocturnal dyspnea at rest, dyspnea of exertion, orthopnea, paroxysmal nocturnal dyspnea paroxysmal nocturnal dyspnea
n. Abbr. PND
Acute dyspnea caused by the lung congestion and edema that results from partial heart failure and occurring suddenly at night, usually an hour or two after the individual has fallen asleep. ); (3) signs (jugular jugular /jug·u·lar/ (jug´u-lar)
2. pertaining to a jugular vein.
3. a jugular vein.
adj. venous distension dis·ten·tion also dis·ten·sion
The act of distending or the state of being distended.
[Middle English distensioun, from Old French, from Latin , third heart sound, displaced point of maximum cardiac impulse, or pulmonary rales); (4) radiographic radiographic (rā´dēōgraf´ik),
adj relating to the process of radiography, the finished product, or its use. evidence (cardiomegaly cardiomegaly /car·dio·meg·a·ly/ (-meg´ah-le) abnormal enlargement of the heart.
Enlargement of the heart. Also called macrocardia, megalocardia. , pulmonary venous congestion The condition of a network when there is not enough bandwidth to support the current traffic load.
congestion - When the offered load of a data communication path exceeds the capacity. , or pulmonary edema Pulmonary Edema Definition
Pulmonary edema is a condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately. ); or (5) treatment with digoxin digoxin: see digitalis. and diuretics Diuretics Definition
Diuretics are medicines that help reduce the amount of water in the body.
Diuretics are used to treat the buildup of excess fluid in the body that occurs with some medical conditions such as congestive heart . The AQAF maintained patient confidentiality patient confidentiality Medical practice A Pt's right to privacy and freedom from public dissemination of information that the Pt regards as being of a personal nature. See HIPAA, Medical privacy. and hospital confidentiality, and the University of Alabama at Birmingham UAB began in 1936 as the Birmingham Extension Center of the University of Alabama. Because of the rapid growth of the Birmingham area, it was decided that an extension program for students who had difficulties which prevented them from studying in Tuscaloosa was needed. 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 ventriculography /ven·tric·u·log·ra·phy/ (ven-trik?u-log´rah-fe)
1. radiography of the cerebral ventricles after introduction of air or other contrast medium.
2. , multiple gated acquisition (MUGA Multiple-Gated Acquisition (MUGA) Scan Definition
The multiple-gated acquisition (MUGA) scan is a non-invasive nuclear test that uses a radioactive isotope called technetium to evaluate the functioning of the heart's ventricles. ) scan, or echocardiography Echocardiography Definition
Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart muscle. Ultrasound waves that rebound or echo off the heart can show the size, shape, and movement of the heart's valves and 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 angiotensin-converting enzyme /an·gio·ten·sin-con·vert·ing en·zyme/ (-ten´sin kon-vert´ing en´zim) see peptidyl-dipeptidase A.
n. (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 radiograph /ra·dio·graph/ (-graf?) the film produced by radiography.
n. results, and electrocardiography electrocardiography (ĭlĕk'trōkärdēŏg`rəfē), science of recording and interpreting the electrical activity that precedes and is a measure of the action of heart muscles. 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 A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. for Windows, Release 10.0.0 (17) was used to analyze the data. Patients were stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. 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 Pearson's chi-square test
see chi-square test. . Using logistic regression, we calculated the odds ratio (OR) with 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (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 confounding
when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies.
confounding factor 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 coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. , 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 dyspnea on exertion Cardiology Shortness of breath which occurs with effort, often a sign of heart failure or ischemia , orthopnea, paroxysmal nocturnal dyspnea, fatigue, angina, and lower-extremity edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. . 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.
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 ejection fraction
The blood present in the ventricle at the end of diastole and expelled during the contraction of the heart.
Ejection fraction was documented for 557 patients (88%), and 324 (58%) had left ventricular systolic Systolic
The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. dysfunction (ejection fraction <40%).
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 atrial fibrillation
Irregular rhythm (arrhythmia) of contraction of the atria (upper heart chambers). The most common major arrhythmia, it may result as a consequence of increased fibrous tissue in the aging heart, of heart disease, or in association with severe infection. . 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 bi·var·i·ate
Mathematics Having two variables: bivariate binomial distribution.
Adj. 1. 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 Expected value
The weighted average of a probability distribution. Also known as the mean 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.
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 retrospective study,
a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. , 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 peer review organization Professional review organization, qualilty improvement organization Managed care An independent or sponsored group of physicians or other appropriate peers–eg, allied health professionals who conduct pre-admission, continued stay, Consortium also found an inverse association between age and LVF evaluation among patients with heart failure (11); however, no multivariate analysis multivariate analysis,
n a statistical approach used to evaluate multiple variables.
n a set of techniques used when variation in several variables has to be studied simultaneously. 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 acute myocardial infarction (·kyōōtˑ mī·ō·karˑ·dē· (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 ech·o·car·di·o·gram
A visual record produced by echocardiography.
A non-invasive ultrasound test that shows an image of the inside of the heart. with Doppler flow as the single most useful diagnostic test in patients with heart failure. (21) The CMS (1) See content management system and color management system.
(2) (Conversational Monitor System) Software that provides interactive communications for IBM's VM operating system. , 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 spironolactone /spir·o·no·lac·tone/ (spi?rah-no-lak´ton) one of the spirolactones, an aldosterone inhibitor that blocks the aldosterone-dependent exchange of sodium and potassium in the distal tubule, thus increasing excretion of sodium , 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 valvular /val·vu·lar/ (val´vu-ler) pertaining to, affecting, or of the nature of a valve.
Relating to, having, or operating by means of valves or valvelike parts. disorder, dyskine tic left ventricular aneurysm Ventricular Aneurysm Definition
Ventricular aneurysm is a complication of a heart attack (myocardial infarction). It is a ballooning of a section of a blood vessel in the heart that first appears several days or weeks after an acute myocardial , cardiac thrombi thrombi /throm·bi/ (throm´bi) plural of thrombus. , and constrictive pericarditis con·stric·tive pericarditis
Tuberculous or other infection of the pericardium, with thickening of the membrane and constriction of the cardiac chambers. , 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 magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures. 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 Medicare and Medicaid
U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. Services (CMS, formerly the Health Care Financing Administration Health Care Financing Administration,
n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. ), Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS . 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).
(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 National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services.
NCHS is the United States' principal health statistics agency. , 1998. DHHS DHHS Department of Health & Human Services (US government)
DHHS Dana Hills High School (Dana Point, California)
DHHS Deaf and Hard of Hearing Services
DHHS Deaf and Hard of Hearing Services 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 National Heart, Lung, and Blood Institute,
n.pr established in 1948, this division of the National Institutes of Health is responsible for research and education on cardiovascular, pulmonary, systemic diseases, and sleep disorders. , 1996
(3.) Current Trends: Mortality from Congestive con·ges·tive
Of or characterized by congestion.
pertaining to or associated with congestion. See also congestive heart failure. Heart Failure--United States, 1980-1990. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, 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 DHSS (Brit) n abbr (formerly) (= Department of Health and Social Security) → Ministerium für Gesundheit und Sozialfürsorge 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 practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. . 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 Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. and angioplasty in SHEP SHEP Cardiology A clinical trial–Systolic Hypertension in the Elderly Program–that evaluated efficacy of antihypertensives–with diuretics or β-blockers on M&M and stroke in Pts with isolated systolic HTN. 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 un·sta·ble angina
Angina pectoris characterized by pain of coronary origin that occurs in response to less exercise or other stimuli than usually required to produce pain. : potential impact of practice guidelines. Arch Intern Med 1998; 158:1113-1120
(10.) Gurwitz JH, Osganian V, Goldberg RJ, et al: Diagnostic testing Diagnostic testing
Testing performed to determine if someone is affected with a particular disease.
Mentioned in: Von Willebrand Disease 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 Angiotensin-Converting Enzyme Inhibitors Definition
Angiotensin-converting enzyme inhibitors (also called ACE inhibitors) are medicines that block the conversion of the chemical angiotensin I to a substance that increases salt and water retention in the 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 New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , 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 HCFA
Health Care Financing Administration
n.pr See Health Care Financing Administration. 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 Dop·pler echocardiography
The use of Doppler ultrasonography to augment echocardiograms that are two-dimensional by allowing velocities to be registered within the echocardiogram. in the diagnosis, prognosis, and management of valvular aortic stenosis aortic stenosis
n. Abbr. AS
Pathological narrowing of the orifice of the aortic valve.
A stiffening of the artery which carries blood from the heart to the body. , aortic regurgitation aortic regurgitation
Incompetence of the aortic valve of the heart, resulting in backward flow of blood. Also called aortic insufficiency. , and mitral mitral /mi·tral/ (mi´tril) shaped like a miter; pertaining to the mitral valve.
1. Relating to a mitral valve.
2. Shaped like a bishop's miter. annular annular /an·nu·lar/ (an´u-ler) ring-shaped.
Shaped like or forming a ring.
ring-shaped. 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 JAMA
Journal of the American Medical Association 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 gerontology: see geriatrics. 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 geriatrics (jĕrēă`trĭks), the branch of medicine concerned with conditions and diseases of the aged. Many disabilities in old age are caused by or related to the deterioration of the circulatory system (see arteriosclerosis), e.g. 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.