Heart failure mortality among older medicare beneficiaries: association with left ventricular function evaluation and angiotensin-converting enzyme inhibitor use. (Original Article).Background: Left ventricular function ventricular function, n the cyclic contraction and relaxation of the ventricular myocardium. evaluation and 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. angiotensin-converting enzyme n. (ACE) inhibitor use are the two basic indicators of heart failure quality of care. In this retrospective follow-up study, we analyzed the association between these two quality indicators and mortality in elderly hospitalized heart failure patients. Methods: The patients in our study were older Alabama Medicare beneficiaries discharged with a diagnosis of heart failure in 1994. Cox regression analyses, adjusted for various patient and care characteristics, were performed to estimate the overall mortality rate. Results: The mean age of the 1,090 patients in our study was 79 [+ or -] 7.5 years. Both left ventricular function evaluation (hazard ratio The hazard ratio in survival analysis is the effect of an explanatory variable on the hazard or risk of an event. For a less technical definition than is provided here, consider hazard ratio to be an estimate of relative risk and see the explanation on that page. , 0.83; 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%. , 0.705-0.976) and ACE inhibitor ACE inhibitor (ā'sē'ē`, ās) or angiotensin-converting enzyme inhibitor (ăn'jēōtĕn`sĭn) use (hazard ratio, 0.77; 95% confidence interval, 0.655-0.905) were associated with a lower 3-year mortality rate. Adjustment for various patient and care characteristics did not alter these associations. Conclusion: Left ventricular function evaluation and ACE inhibitor use were each associated with increased survival time in older Medicare beneficiaries with heart failure. ********** The determination of left ventricular function (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 ) status is the cornerstone of diagnostic evaluation diagnostic evaluation Workup Medtalk An evaluation used to diagnose disease Components Medical Hx, CXR or other images, collection of specimens from blood for lab analysis for heart failure patients. 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 , multiple gated acquisition scan, or 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. can be used to determine whether heart failure is associated with impaired or preserved left ventricular (LV) 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. function. Although LVF evaluation is recommended for all patients with heart failure (1-5) it is often underused. (6-11) How this underuse underuse Health care The failure to provide a medical intervention when it is likely to produce a favorable outcome for a Pt–eg, failure to give influenza vaccine to an elderly Pt with DM. Cf Misuse, Overuse. is associated with subsequent use of angiotensin-converting enzyme (ACE) inhibitors and mortality in older heart failure patients, however, is unknown. Patients who have LV systolic dysfunction gain significant survival benefits from the use of ACE inhibitors. (12,13) Survival benefits of ACE inhibitors in heart failure patients with preserved LVF have also been documented. (14,15) however, most of these studies have excluded older adults with heart failure. Gambassi et al (16) demonstrated the survival benefit of ACE inhibitors in heart failu re patients who were residents of long-term care facilities long-term care facility n. See skilled nursing facility. . The purpose of this study was to examine the association of the LVF evaluation and the discharge prescription of ACE inhibitors with 3-year survival in older adults hospitalized with heart failure. Patients and Methods Patients The patients included in our study were Medicare beneficiaries age 65 years or older who were discharged from 11 Alabama hospitals between January and December 1994 with a primary diagnosis of heart failure. We described the study design and data source previously. (11) Briefly, in 1994, the Alabama Quality Assurance Foundation (AQAF AQAF Alabama Quality Assurance Foundation ), the state's 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, , conducted a quality improvement project that identified Medicare beneficiaries discharged with a diagnosis of heart failure on the basis of the ICD ICD International Classification of Diseases (of the World Health Organization); intrauterine contraceptive device. ICD abbr. -9-CM: International Classification of Diseases. 9th revision, clinical Modification (17) classification system 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 codes. The diagnosis of heart failure was confirmed by complete chart review and was later verified using diagnostic criteria described elsewhere. (11) Quality Indicators The first quality indicator (QI) was LVF. evaluation during the index hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. , and the second QI was the use of an ACE inhibitor at discharge. The denominator for both QIs was the total number of patients hospitalized with heart failure. Mortality The mortality data were obtained from AQAF through the membership lists (denominator file) of 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 (formerly known as 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. ). Created annually, this file lists pertinent residential, demographic, and mortality data for each Medicare beneficiary in the state of Alabama. Data Abstraction See abstraction. (data) data abstraction - Any representation of data in which the implementation details are hidden (abstracted). Abstract data types and objects are the two primary forms of data abstraction. We described our data abstraction method previously. (11) Briefly, data were abstracted at the respective hospitals by trained study nurses, and the reliability and validity of abstraction were later verified by random reabstraction of 5% of the charts by another group of study nurses and physicians on the panel. The concordance rates concordance rate n. A quantitative statistical expression for the concordance of a given genetic trait, especially in pairs of twins in genetic studies. for both reliability and validity for key variables were 95% or more. Data regarding patient demographics, medical history, and hospital stay were abstracted. Analysis For descriptive analyses, we compared baseline patient characteristics using the two QIs, and statistical significance was tested using Pearson's [chi square chi square (kī), n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] test and Student's t test as appropriate. By performing logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. analysis, we estimated the crude and adjusted odds ratios (ORs) with the 95% confidence interval (95% CI) for ACE inhibitor use of patients who received LVF evaluations. By performing Cox regression analysis In statistics, a mathematical method of modeling the relationships among three or more variables. It is used to predict the value of one variable given the values of the others. For example, a model might estimate sales based on age and gender. , we first estimated the unadjusted hazard ratio (HR) with 95% CI of the 3-year mortality rate. Cox regression models were fitted to data to adjust 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 patient characteristics (ie, age, race, sex, admission from nursing home, history of heart failure, contraindications to ACE inhibitors, LV systolic dysfunction, three or more co-morbidities) and processes of care (ie, care from a cardiologist Cardiologist Doctor who specializes in diagnosing and treating heart diseases. Mentioned in: Electrophysiology Study of the Heart, Lithotripsy cardiologist a physician who specializes in the diagnosis and treatment of heart disease. , admitting hospital) on the association between the QIs and the 3-year mortality rate. Both of the QIs and the other covariates were entered into the single mo del. In addition, we separately plotted the comparative, cumulative 3-year survival rate for each QI on Kaplan-Meier curves, using 3-year survival as the dependent variable and the QIs as the independent variables. All statistical significance ratios were calculated with the two-tailed [alpha] [less than or equal to]0.05. 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 8, was used to analyze the data (SPSS, Inc., Chicago, IL). Results Patient Characteristics Of the 1,090 patients, 343 (31%) were between 65 and 74 years of age, 466 (43%) were between 75 and 84 years of age, and 281 (26%) were age 85 years or older; 652 (60%) were women, and 192 (18%) were black. LVF evaluations were performed in 515 patients (47%) during the index hospitalization, and 528 patients (48%) were taking ACE inhibitors at discharge. Table 1 summarizes the comparison of patients by LVF evaluation status. Patients who underwent LVF evaluation were significantly younger, less likely to have been admitted to the hospital from a nursing home, and less likely to have a history of heart failure. More patients receiving LVF evaluation (59%) were cared for by cardiologists compared with those not receiving LVF evaluation (32%) (P < 0.001). Patients who were taking ACE inhibitors at discharge, however, were not more likely to have been cared for by a cardiologist than were those who were not taking these drugs (47 versus 42%; P = 0.098) (Table 2). Table 2 also summarizes patient characteristics by discharge use of ACE inhibitors. Patients who were taking ACE inhibitors at discharge were more likely to be women, to have a history of heart failure and hypertension, and to have taken ACE inhibitors before admission. They also were less likely to have been a resident of a nursing home or to have contraindications to the use of ACE inhibitors. Association between LVF Evaluation and ACE Inhibitor Use More patients who underwent LVF evaluation were taking ACE inhibitors at discharge than those who did not undergo LVF evaluation (55 versus 43%; P < 0.001). Patients who underwent LVF evaluation were 59% more likely to receive ACE inhibitors at discharge than were those who did not undergo LVF evaluation (unadjusted OR, 1.59; 95% CI, 1.26-2.03). Adjustment for age, sex, race, admission from nursing home, history of heart failure, ACE inhibitor use, LV systolic dysfunction, contraindication contraindication /con·tra·in·di·ca·tion/ (-in?di-ka´shun) any condition which renders a particular line of treatment improper or undesirable. con·tra·in·di·ca·tion n. to ACE inhibitor use, three or more co-morbidities, care by a cardiologist, and hospital did not alter this association (adjusted OR, 1.85; 95% CI, 1.32-2.61). Mortality Rate There were 669 deaths (61%) during the 3-year follow-up period. Eighty-four patients (8%) died in the hospital. More than one-third of the patients (n = 427; 39%) were dead within 1 year after discharge from the hospital, and more than half(n = 553; 51%) were dead by the end of the second year. By the end of the 3-year follow-up period, 295 (57%) of the 515 patients who underwent LVF evaluation and 374 (65%) of the 575 who did not undergo LVF evaluation were dead (P = 0.009). Two hundred eighty-nine (55%) of the 528 patients who received ACE inhibitors and 380 (68%) of the 562 who did not receive ACE inhibitors were dead by the end of the 3-year follow-up period (P < 0.001). Association between Quality Indicators and 3-year Mortality Rate Patients who underwent LVF evaluation were 17% more likely to die within 3 years of being discharged with a diagnosis of heart failure than were those who did not undergo LVF evaluation (unadjusted HR, 0.83; 95% CI, 0.71-0.98). Adjustment for various patient and care characteristics did not significantly alter the magnitude or the precision of this association (adjusted HR, 0.76; 95% CI, 0.61-0.94) (Table 3). Similarly, older patients with heart failure who were taking ACE inhibitors at discharge were 23% less likely to die within 3 years after discharge than were those who were not taking the drug at discharge (unadjusted HR, 0.77; 95% CI, 0.66-0.91). The relationship remained unaffected after adjustment for various patients and care characteristics (adjusted HR, 0.81; 95% CI, 0.69-0.97) (Table 3). When we repeated the analyses after excluding patients who died in the hospital, we found similar results. We also repeated the analyses for patients with incident heart failure and found similar results (adjusted HR, 0.64; 95% CI, 0.41-0.99). Association between Quality Indicators and 4-year Survival The mean survival time during the 4-year follow-up period was 58 days longer for patients who underwent LVF evaluation than for those who did not (702 versus 644 d). The probability of surviving for 4 years after hospital discharge was 6% higher for patients who underwent LVF evaluation than for those who did not (45 versus 39%; log-rank test, P = 0.0243) (Fig. 1). The survival benefit of LVF evaluation was apparent within several months after discharge and persisted throughout the 3-year follow-up period. When we restricted our analysis to patients with incident heart failure, the mean survival time of those who had undergone LVF evaluation was found to be 103 days longer than that of patients who did not undergo LVF evaluation (795 versus 692 d), which bordered on statistical significance (log-rank test, P = 0.0375). Similarly, during the 3-year follow-up period, patients who were taking an ACE inhibitor at discharge had a mean survival time 107 days longer than those who were not (723 versus 616 d). The probability of 3-year postdischarge survival was also higher for patients who were taking ACE inhibitors than for those who were not (45 versus 38%; log-rank test, P = 0.0015) (Fig. 2). The survival benefit for patients who were taking ACE inhibitors at discharge was evident during the early postdischarge period and lasted through the end of the 3-year follow-up period. Among the patients who underwent LVF evaluation (n = 515), 238 patients (46%) had LV systolic dysfunction and 277 (54%) had preserved systolic function. Among these patients who were evaluated for LVF, the rate of ACE inhibitor prescription was significantly higher when LV systolic dysfunction was present than when LVF was preserved (60 versus 50%; P = 0.01). The rate of ACE inhibitor prescription among the patients who did not undergo LVF evaluation was 43%, which was significantly lower than the rate of ACE inhibitor use in patients with LV systolic dysfunction (P < 0.05), but not significantly lower than the rate for patients who did not have LV systolic dysfunction (P = 0.07). Discussion Our study provides strong evidence that LVF evaluation was associated with both increased ACE inhibitor use and decreased mortality rate in older patients with heart failure. No other study has demonstrated such a direct association between LVF evaluation and survival in patients with heart failure. Our results also confirm the survival benefits of treatment with ACE inhibitors in older patients with heart failure. These findings are important, because heart failure remains a public health concern. The prevalence of heart failure 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. is estimated to be 5 million, and another 400,000 people are newly diagnosed with heart failure every year. (18) More than 40,000 deaths annually in the United States are directly attributed to heart failure, and more than 200,000 additional deaths are secondarily associated with heart failure. (18) Most of these deaths occur in patients age 65 years or older. (19) This study confirms the poor prognosis of patients discharged with a diagnosis of heart failure. Si xty-one percent of the patients in our study were dead within 3 years of the index hospitalization discharge, and 61% of the patients who were taking an ACE inhibitor at discharge were dead by the end of the 3-year follow-up period. These rates are similar to the rates found in the Framingham study, in which almost half of the patients with heart failure were dead within 5 years of the date of diagnosis. (20) Almost three-fourths of a nationwide sample of Medicare beneficiaries hospitalized in 1986 with incident heart failure died within 4 years of discharge. (21) Although LVF evaluation and ACE inhibitor use for LV systolic dysfunction are widely recommended, these basic Qls of heart failure care continue to be underused. (22) To respond to this concern, the Center for Medicare and Medicaid Services' National Heart Failure Project has incorporated both LVF evaluation and ACE inhibitor use in Medicare beneficiaries with heart failure as two major QIs that need further improvement. (23) Although heart failure patients who did not undergo LVF evaluation were older, more likely to be residents of long-term care facilities, and more likely to have preexisting pre·ex·ist or pre-ex·ist v. pre·ex·ist·ed, pre·ex·ist·ing, pre·ex·ists v.tr. To exist before (something); precede: Dinosaurs preexisted humans. v.intr. heart failure (all of which are known to be associated with increased risk of death), adjustment for these and other potential confounding variables, including ACE inhibitor use, did not alter the association between LVF evaluation and mortality rate. The survival benefit observed in patients who received LVF evaluation most likely was due to subsequent use of ACE inhibitors in patients with LV systolic dysfunction. It is also likely that LVF evaluation was associated with other unmeasured variables, which resulted in the long-term survival of those patients who underwent LVF evaluation. The association between ACE inhibitor use and survival time noted in our study is consistent with that in the literature. Garg and Yusuf, (24) in a meta-analysis of 32 randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. , controlled trials controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. of ACE inhibitors, demonstrated that of the 7,105 patients enrolled in these trials, 1,320 patients (19%) died. Patients in these studies who were taking ACE inhibitors had a 17% reduction in mortality rate (pooled relative risk, 0.83; 95% CI, 0.76-0.90). Most of these studies excluded patients who were 65 years of age or older and patients with relative contraindications to the prescription of ACE inhibitors, such as hypotension hypotension or low blood pressure Condition in which blood pressure is abnormally low. It may result from reduced blood volume (e.g., from heavy bleeding or plasma loss after severe burns) or increased blood-vessel capacity (e.g., in syncope). , renal insufficiency renal insufficiency A defect in renal ability to 'clear' waste products, a sign of inadequate glomerular filtration , and hyperkalemia Hyperkalemia Definition The normal concentration of potassium in the serum is in the range of 3.5 to 5.0 mM. Hyperkalemia refers to serum or plasma levels of potassium ions above 5.0 mM. (conditions that are associated with higher mortality rate). In the Cooperative North Scandinavian Enalapril Survival Study (12) (ie, the CONSENSUS trial), which enrolled relatively older patients (mean age, approximately 70 yr), there was a 31% reduction in the risk of death within 1 year among patients who were taking ACE inhibitors compared with th ose who were taking a placebo (36 versus 52%). Among nursing home residents, Gambassi et al (16) demonstrated an 11% reduction in the 1-year mortality rate of patients who were treated with ACE inhibitors compared with those who were treated with digoxin digoxin: see digitalis. (31 versus 43%). We observed a 28% reduction in the risk-adjusted 1-year mortality in patients who were taking ACE inhibitors at discharge (adjusted HR, 0.72; 95% CI, 0.572-0.90), which is higher than the rate observed by Gambassi et al (16) and that reported in most randomized, controlled trials, (24) but it is comparable to that of the Cooperative North Scandinavian Enalapril Survival Study. (12) Our study has several limitations. Because of the retrospective nature of the study, we had no data on the duration of heart failure. The duration of heart failure after the initial diagnosis has important prognostic prog·nos·tic adj. 1. Of, relating to, or useful in prognosis. 2. Of or relating to prediction; predictive. n. 1. A sign or symptom indicating the future course of a disease. 2. implications. (20) Most of the patients in our study had prevalent heart failure, and we were able to adjust only for history of heart failure as a categorical That which is unqualified or unconditional. A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding. Categorical is also used to describe programs limited to or designed for certain classes of people. variable. In our study, preexisting heart failure was independently associated with a 43% increase in the risk of 3-year mortality (adjusted HR, 1.43; 95% CI, 1.17-1.74). We also had no data regarding whether patients who were prescribed ACE inhibitors at discharge were indeed taking those medications or whether any other medications, especially [beta]-blockers, were prescribed for them. Other limitations include a lack of data regarding functional status and severity of heart failure or other comorbid conditions. Our study results may not be generalizable gen·er·al·ize v. gen·er·al·ized, gen·er·al·iz·ing, gen·er·al·iz·es v.tr. 1. a. To reduce to a general form, class, or law. b. To render indefinite or unspecific. 2. to other states or health care settings or to patients younger than 65 years of age. Despite these limitations, our study confirms the poor prognosis of patients with heart failure, especially those who are hospitalized with acute exacerbation. The Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and has identified LVF evaluation and ACE inhibitor use as the two basic quality indictors for the care of heart failure patients. This study demonstrates that the practice of these two basic quality indicators of heart failure care was associated with significant survival benefit in older adults hospitalized with heart failure. [FIGURE 1 OMITTED] [FIGURE 2 OMITTED]
Table 1
Patient characteristics by left venticular function evaluation (a)
Demographic All patients LVFE not performed
characteristic (n = 1,090) (n = 575)
Mean age (yr) 79.1 [+ or -] 7.5 79.7 [+ or -] 7.4
No. of women (%) 662 (60%) 350 (61%)
Black (%) 192 (18%) 110 (19%)
Admission from NH (%) 97 (9%) 67 (12%)
History of heart failure (%) 801 (74%) 461 (80%)
CAD (%) 273 (25%) 154 (27%)
Hypertension (%) 182 (17%) 93 (16%)
Diabetes (%) 272 (25%) 142 (25%)
Care by cardiologist (%) 486 (45%) 184 (32%)
Demographic LVFE performed
characteristic (n = 515) P value
Mean age (yr) 78.4 [+ or -] 7.5 0.005
No. of women (%) 302 (59%) 0.454
Black (%) 82 (16%) 0.165
Admission from NH (%) 30 (6%) 0.001
History of heart failure (%) 340 (66%) <0.001
CAD (%) 119 (23%) 0.162
Hypertension (%) 89 (17%) 0.624
Diabetes (%) 130 (25%) 0.835
Care by cardiologist (%) 302 (59%) <0.001
(a)LVFE, left ventricular function evaluation
NH, nursing home
CAD, coronary artery disease
Table 2
Patient characterists by use of angiotensin-converting enzyme inhibitor
(a)
All patients Not taking ACEI at
Demographic characteristic (n = 1,090) discharge (n = 562)
Mean age (yr) 79.1 [+ or -] 79.1 [+ or -] 7.5
No. of women (%) 662 (60%) 314 (56%)
Black (%) 192 (18%) 93 (17%)
Admission from NH (%) 97 (9%) 62 (11%)
History of heart failure (%) 801 (74%) 396 (7 1%)
CAD (%) 273 (25%) 131 (23%)
Hypertension (%) 182 (17%) 68 (12%)
Diabetes (%) 272 (25%) 129 (23%)
Previous use of ACE inhibitor (%) 413 (38%) 70 (16%)
Contraindication to ACE 198 (18%) 143 (25%)
inhibitor (%)
Care by cardiologist (%) 486 (45%) 237 (42%)
Taking ACIE at
Demographic characteristic discharge (n = 528) P value
Mean age (yr) 79.1 [+ or -] 7.5 0.902
No. of women (%) 338 (64%) 0.006
Black (%) 99 (19%) 0.340
Admission from NH (%) 35 (7%) 0.011
History of heart failure (%) 405 (77%) 0.02
CAD (%) 142 (27%) 0.172
Hypertension (%) 114 (22%) <0.001
Diabetes (%) 143 (27%) 0.115
Previous use of ACE inhibitor (%) 323 (61%) <0.001
Contraindication to ACE 55 (10%) <0.001
inhibitor (%)
Care by cardiologist (%) 249 (47%) 0.098
(a)ACE, angiotensin-converting enzyme
NH, nursing home
CAD, coronary artery disease
Table 3
Crude and adjusted risk for 3-year mortality among older medicare
beneficiaries discharged with a diagnosis of heart failure (a)
Crude hazard Adjusted hazard
Variable ratio (95% CI) ratio (b) (95% CI)
As a continuous variable 1.016 (1.005-1.027) 1.016 (1.004-1.028)
age (yr)
Women 0.687 (0.583-0.809) 0.694 (0.585-0.822)
Black 0.886 (0.716-1.097) 0.810 (0.649-1.01)
Left ventricular function 0.830 (0.705-0.976) 0.755 (0.609-0.936)
evaluation
Discharge on ACE inhibitors 0.770 (0.655-0.905) 0.812 (0.686-0.962)
(a)CI, confidence interval
ACE, angiotensin-converting enzyme
(b)Also adjusted for admission from nursing home, history of heart
failure, left ventricular systolic dysfunction, three or more
comorbidities, contraindications to the use of ACE inhibitors, and
hospital (as dummy variable).
Accepted March 18, 2002. References (1.) Konstam MA, Dracup K, Baker DW, Bottorff MB, Brooks NH, Dacey RA, et al. Heart failure: Evaluation and care of patients with left ventricular systolic dysfunction. J Card Fail 1995; 1:183-187. (2.) Williams JF Jr, Bristow MR, Fowler MB, Francis GS, Garson A Jr, Gersh BJ, et al. Guidelines for the evaluation and management of heart failure: Report of the American College American College is the name of:
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Quality of care for Medicare patients hospitalized with heart failure in rural Georgia. South Med J 1999;92:782-789. (11.) Ahmed A, Allman RM, DeLong JF, Bodner EV, Howard G. Age-related underutilization of left ventricular function evaluation in older heart failure patients. South Med J 2002;95:695-702. (12.) The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987;316:1429-1435. (13.) The SOLVD SOLVD Cardiology A series of clinical trials–Studies of Left Ventricular Dysfunction that evaluated the effect of antihypertensives–eg, with enalapril, an ACE inhibitor, on M&M in Pts with CHF. Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions ejection fraction n. The blood present in the ventricle at the end of diastole and expelled during the contraction of the heart. Ejection fraction and congestive heart failure. N Engl J Med 1991;325:293-302. (14.) Aronow WS, Kronzon I. Effeet of enalapril on congestive heart failure treated with diuretics Diuretics Definition Diuretics are medicines that help reduce the amount of water in the body. Purpose Diuretics are used to treat the buildup of excess fluid in the body that occurs with some medical conditions such as congestive heart in elderly patients with prior myocardial infarction myocardial infarction: see under infarction. and normal left ventricular ejection fraction. Am J Cordial cordial: see liqueur. 1993;71:602-604. (15.) Philbin EF, Rocco TA Jr. Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function. Am Heart J 1997;134:188-195. (16.) Gambassi G, Lapane KL, Sgadari A, Carbonin P, Gatsonis C, Lipsitz LA, Ct al. Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure: SAGE Study Group-Systematic Assessment of Geriatric drug use via Epidemiology. Arch Intern Med 2000;160:53-60. (17.) World Health Organization. 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 : International Classification of Diseases. 9th revision, Clinical Modification, Washington, DC, U.S. 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 , 1997, ed 5. (18.) 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. . Congestive Heart Failure in the United States: A New Epidemic. Bethesda, MD, National Heart, Lung, and Blood Institute, National Institutes of Health, 1996. Available at: http://www.nhlbi.nih.gov/health/public/heart/other/CHF.htm. Accessed November 25, 2002. (19.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Mortality from congestive 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(5):77-81. (20.) Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study The Framingham Heart Study is a cardiovascular study based in Framingham, Massachusetts. The study began in 1948 with 5,209 adult subjects from Framingham, and is now on its third generation of participants. subjects. Circulation 1993;88:107-l15. (21.) Croft CROFT, obsolete. A little close adjoining to a dwelling-house, and enclosed for pasture or arable, or any particular use. Jacob's Law Dict. JB, Giles WH, Pollard pollard fine protein-rich feed supplement for farm animals; a byproduct from the milling of wheat for flour. Called also shorts. RA, Keenan NL, Casper ML, Anda RF. Heart failure survival among older adults in the United States: A poor prognosis for an emerging epidemic in the Medicare population. Arch Intern Med 1999;159:505-510. (22.) Jeneks SF, Cuerdon T, Burwen DR, Fleming B, Houck PM, Kussmaul AE, et al. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA JAMA abbr. Journal of the American Medical Association 2000;284:1670-1676. (23.) Health Care Financing Administration. Heart Failure National Project Overview (originally published as part of HCFA HCFA abbr. Health Care Financing Administration HCFA, n.pr See Health Care Financing Administration. Pub. No. 10156). Washington, DC, Health Care Financing Administration, 1999. Available at: http://www.cmri-ca.org/healthcare_docs/CHF/chf_cms_description.pdf. Accessed November 25, 2002. (24.) Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure: Collaborative Group on ACE Inhibitor Trials. JAMA 1995;273:1450-1456. RELATED ARTICLE: Key Points * Left ventricular function evaluation and angiotensin-converting enzyme inhibitor angiotensin-converting enzyme inhibitor: see ACE inhibitor. use, the 2 key quality indicators of heart failure care, are often underutilized. * Randomized, controlled trials of angiotensin-converting enzyme inhibitors often excluded older patients, and were restricted to those with systolic dysfunction and without contraindications to the angiotensin-converting enzyme inhibitor. * Of 1,090 older Alabama Medicare beneficiaries discharged with a diagnosis of heart failure, 732 (67%) died within 3 years of discharge. * Patients receiving left ventricular function evaluation had a risk reduction of 24% in 3-year risk-adjusted mortality rate, and those taking angiotensin-converting enzyme inhibitors at discharge had a 19% risk reduction. * Heart failure remains a disease with a poor prognosts that can be favorably altered by following recommended management guidelines. From the Division of Gerontology gerontology: see geriatrics. and Geriatric Medicine, Department of Medicine, the Center for Aging, and the Center for Outcomes and Effectiveness Education and Research, School of Medicine, and the Department of Epidemiology and International Health, School of Public Health, 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. , Birmingham, AL; the Veterans Affairs Veterans Affairs is a term of the business that deals with the relation between a government and its veteran communities, usually administered by the designated government agency. Medical Center, Birmingham, AL; the Southeast Center of Excellence in Geriatric Medicine, Birmingham, AL; and the Alabama Quality Assurance Foundation, Birmingham, AL. The analyses on which this publication is based were performed under Contract 500-96-P60, titled "Utilization and Quality Control Peer Review Organization for the State of Alabama," sponsored by the Center for Medicare and Medicaid Services (formerly the Health Care Financing Administration), US. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does the mention of trade names, commercial products, or organizations imply endorsement by the U.S. 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 Center for Medicare and Medicaid Services, 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 c ontributions to the author concerning experience in engaging with issues presented are welcome. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Ali Ahmed, MD, Division of Geriatric Medicine, University of Alabama at Birmingham, 1530 Third Avenue S., CH-19, Suite 219, Birmingham, AL 35294-2041. Email: aahmed@uab.edu Dr. Ahmed is supported by a faculty training support grant from the Southeast Center of Excellence in Geriatric Medicine. During part of the initial data analysis, he was also supported by an Academic Geriatric Fellowship grant from the American Federation of Aging Research. Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602-0124 |
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