Heart failure between 1986 and 1994: Temporal trends in drug-prescribing practices, hospital readmissions, and survival at an academic medical center

doi:10.1016/S0002-8703(97)80013-0

American Heart Journal

Volume 134, Issue 5, Part 1, November 1997, Pages 901-909

https://doi.org/10.1016/S0002-8703(97)80013-0 Get rights and content

Since 1987, publications in widely circulated medical journals have reported improved survival and lower hospital readmision rates when patients with heart failure and systolic dysfunction are treated with angiotensin-converting enzyme (ACE) inhibitors. We describe changes in ACE inhibitor use among patients hospitalized with heart failure between 1986 and 1993. Simultaneous trends in readmissions and survival rates are reported. Subjects were 612 consecutive patients hospitalized with a principal diagnosis of heart failure at an academic medical center during the period of Sept. 1, 1986, to Dec. 31, 1987 (interval I) or during the period Aug. 1, 1992, to Nov. 30, 1993 (interval II). Medical records were reviewed for 434 patients, consisting of all patients hospitalized with heart failure during interval II and a randomly selected 50% subset of patients hospitalized during interval I. Among 145 patients with systolic dysfunction whose medical records were reviewed, ACE inhibitor prescriptions significantly increased between interval I and interval II (43% vs 71%, p<0.01, odds ratio 3.22, 95% confidence interval 1.62 to 6.42). Prescriptions of ACE inhibitors combined with digoxin and a diuretic also increased (37% vs 56%, p=0.02, odds ratio 2.22, 95% confidence interval 1.14 to 4.32). Among all 612 patients, 6-month heart failure readmission rates increased from 13% to 21% (p=0.02, odds ratio 1.79, 95% confidence interval 1.10 to 2.82). There was no significant change in survival rate between interval I and interval II, however, survival rate was marginally significantly improved among patients with systolic dysfunction. Our results suggest that drug-prescribing practices have significantly changed between 1986 and 1993. The absence of observed improvement in outcomes may result from changes in hospital admission criteria for heart failure.

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Cited by (44)

Heart Failure-Related Hospitalization in the U.S., 1979 to 2004
2008, Journal of the American College of Cardiology
The purpose of this study was to determine hospitalizations for heart failure in the U.S. during the past 26 years.
Heart failure increased in the U.S.; however, little is known about the long-term trends in diseases leading to hospitalizations among patients with heart failure.
Using National Hospital Discharge Survey data from 1979 to 2004, we assessed trends in hospitalizations for heart failure as either a first-listed or additional (2nd to 7th) diagnosis. Among hospitalizations with any mention of heart failure, we assessed the distribution of first-listed diagnoses.
The number of hospitalizations with any mention of heart failure tripled from 1,274,000 in 1979 to 3,860,000 in 2004; 65% to 70% of admissions were patients with additional diagnoses of heart failure. Heart failure hospitalization rates increased sharply with age. More than 80% of hospitalizations were among patients of at least 65 years and were paid by Medicare/Medicaid. Age-adjusted hospitalization rates between 1979 and 2004 increased for heart failure as either the first-listed or additional diagnosis. Whereas heart failure was the first-listed diagnosis for 30% to 35% of these hospitalizations, the proportion with respiratory diseases and noncardiovascular, nonrespiratory diseases as the first-listed diagnoses increased. Heart failure hospitalizations that resulted in transfers to long-term care facilities increased, and in-hospital mortality and length of hospital stay declined.
With the increased aging of the U.S. population and advanced therapeutic interventions that improve survival, it is expected that heart failure hospitalizations at older ages and the associated economic burden to Medicare will continue to increase in the future.
Therapies for Acute Heart Failure in Patients With Reduced Kidney Function: A Community-Based Perspective
2008, American Journal of Kidney Diseases
Citation Excerpt :
To the best of our knowledge, this is the first population-based study that examined the use of different treatment modalities in patients hospitalized with clinical findings of acute HF according to degree of renal dysfunction. Changing trends in the use of different therapies for patients hospitalized with HF have been examined previously; however, without a particular focus on these prescribing practices according to the presence of kidney disease.13-15 Inhibition of the angiotensin-renin-aldosterone system is crucial to the management of patients with congestive HF, and this therapeutic approach has been shown to improve survival in most subsets of patients with HF examined.
Limited data exist describing the management of patients with decreased kidney function at the time of hospital presentation for acute heart failure (HF).
Nonconcurrent prospective study.
Patients hospitalized with clinical findings of decompensated HF (n = 4,350) at all 11 greater Worcester, MA, medical centers in 1995 and 2000. Patients were categorized into varying levels of kidney function based on their estimated glomerular filtration rate (eGFR).
GFR estimates from serum creatinine levels measured at the time of hospital admission.
Hospital receipt of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, digoxin, and diuretics.
Hospital charts were reviewed for prescribing of disease-modifying cardiac therapies, as well as therapies designed to provide symptomatic relief from HF.
Average eGFR in our study sample was 64.4 ± 33.1 mL/min/1.73 m², and patients were categorized further into 3 eGFR levels of less than 30 (n = 569), 30 to 59 (n = 1,488), and 60 mL/min/1.73 m² or greater (n = 2,293) for comparative purposes. Patients with greater eGFRs (≥60 mL/min/1.73 m²) were more likely to be treated with ACE inhibitors/ARBs (56% versus 39%) and digoxin (51% versus 46%) during hospitalization for HF than patients with lower eGFRs (<30 mL/min/1.73 m²; P < 0.05). Patients with lower eGFRs (<30 mL/min/1.73 m²) were more likely to be prescribed β-blockers than patients with greater eGFRs (≥60 mL/min/1.73 m²; 46% versus 39%; P < 0.01). Use of ACE inhibitors/ARBs increased between 1995 and 2000 in 2 of the 3 eGFR groups examined: eGFRs less than 30 mL/min/1.73 m² (33% in 1995; 42% in 2000) and eGFRs of 60 mL/min/1.73 m² or greater (51% in 1995; 59% in 2000). Use of β-blockers increased appreciably in all 3 eGFR groups (<30 mL/min/1.73 m², 27% in 1995; 58% in 2000; ≥60 mL/min/1.73 m²: 25% in 1995; 49% in 2000). However, less than one third of all patients were treated with both disease-modifying therapies in 2000.
We were unable to classify patients into those with systolic versus diastolic HF.
Our results suggest that use of disease-modifying therapies for patients hospitalized with clinical findings of acute HF and decreased kidney function remains less than desirable. Educational programs are needed to enhance the management of patients with decreased kidney function who develop HF.
Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE)
2007, American Heart Journal
Citation Excerpt :
Our findings both support and extend those findings. In 2 academic centers, the use of ACEI, β-blockers, and combination therapy increased from 1986 to 1993 and from 1990 to 1995 in outpatients with systolic HF.15,16 Results from the Cardiovascular Health Study in elderly HF outpatients showed an increase in the use of ACEI from 1989 to 199017 and an increase in the use of β-blockers from 1989 to 2000.18
The purpose of this study was to assess temporal trends in clinical characteristics, treatments, quality indicators, and outcomes for heart failure (HF) hospitalizations.
Characteristics, treatments, quality measures, and inhospital outcomes were measured over 12 consecutive quarters (January 2002 to December 2004) using data from 159 168 enrollments from 285 ADHERE hospitals.
Baseline characteristics were similar or showed only modest changes, and severity of illness by logistic regression was unchanged over all 12 quarters. Inhospital treatment changed significantly over time with inotrope use decreasing from 14.7% to 7.9% (P < .0001). Discharge instructions increased 133%; smoking counseling, 132%; left ventricular function measurement, 8%; and β-blocker use, 29% (all P < .0001). Clinical outcomes improved over time, including need for mechanical ventilation, which decreased 5.3% to 3.4% (relative risk 0.64, P < .0001); length of stay (mean), 6.3 to 5.5 days; and mortality, 4.5% to 3.2% (relative risk 0.71, P < .0001).
Over a 3-year period, demographics and clinical characteristics were relatively similar, but significant changes in intravenous therapy, enhancements in conformity to quality-of-care measures, increased administration of evidence-based HF medications, and substantial improvements in inhospital morbidity and mortality were observed during hospitalization for HF.
Use of Disease-Modifying Therapies in Patients Hospitalized with Heart Failure: A Population-Based Perspective
2007, American Journal of Medicine
Little data are available about the hospital management of patients with decompensated heart failure (HF) with individual and combination medical therapies, particularly from the more generalizable perspective of a population-based investigation. The purpose of our study was to describe the use of different cardiac medications in 2463 patients with new-onset HF who were discharged from all greater Worcester, Massachusetts, hospitals during 2000.
On the basis of a review of medical records, we examined the prescribing of 2 classes of cardiac medications that have been shown to improve the long-term prognosis of patients with HF (angiotensin pathway inhibitors and beta-blockers). We also examined the use of 2 therapies commonly used to improve the symptomatic status of patients with acute HF (diuretics and digoxin).
The mean age of the study sample was 76 years, and 57% were women. Approximately 1 in 5 patients were not prescribed beta-blockers or angiotensin inhibitors during their index hospitalization, whereas 1 in 3 patients were discharged with both of these effective cardiac medications. Diuretics were prescribed for virtually all patients (98%), followed by the use of digoxin in approximately half of patients (48%). The receipt of both beta-blockers and angiotensin pathway inhibitors was associated with several demographic, medical history, and clinical factors. Patients treated with both effective cardiac medications were also more likely to be counseled to monitor or modify several lifestyle factors that have been shown to be effective adjuncts to the medical management of patients with HF.
Considerable opportunity remains for the more optimal hospital management of patients with decompensated HF.
Digoxin Use and Digoxin Toxicity in the Post-DIG Trial Era
2006, Journal of Cardiac Failure
Citation Excerpt :
The average number of units per year sold is 39,600 ± 2408. There have been important changes in the use of pharmacologic therapies for the treatment of congestive heart failure in patients participating in clinical trials16 and in the community or academic setting12,13,17 over approximately 20 years. Although it is likely that many of the temporal changes leading to the adoption of new therapies have occurred in response to the publication and dissemination of clinical trials data, little is known about the impact on practice when an established drug is not shown to have a survival advantage.
The advent of medical therapies for congestive heart failure that have proven survival benefits, specifically angiotensin-converting enzyme (ACE) inhibitors, β-adrenergic antagonists, and the aldosterone antagonists, have called into question the use of digoxin for patients with normal sinus rhythm, left ventricular dysfunction, and symptomatic heart failure. This issue appears to have been heightened after the publication of the results of the Digitalis Investigation Group (DIG) Trial in 1997 that did not demonstrate a statistically significant impact of digoxin on mortality.
We used data from a large heart failure registry to examine digoxin use at the time of hospital admission for heart failure, a surveillance system for recording toxic drug exposures to describe patterns in digoxin toxicity and industry estimates for the use of digoxin antibody. Digoxin use has decreased significantly from 31.4% in late 2001 to 23.5% in late 2004 (P < .00001) independent of patient age, gender, or baseline creatinine. Conversely, the number of toxic or potentially toxic exposures to digoxin requiring hospitalization has not decreased.
Digoxin use is decreasing but there has not been a similar decline in cases of toxicity. Further analyses are required to delineate the reasons underlying these trends and the appropriateness of prescribing practices for both digoxin and its antidote.
The utility of microvascular perfusion assessment in heart failure: A pilot study
2005, Journal of Cardiac Failure
The evaluation of heart failure is routinely based on subjective patient symptoms and physician examination. We propose the noninvasive evaluation of microvascular and global perfusion can objectify heart failure severity and provide additional prognostic information.
A prospective, observational pilot study of patients previously stratified into New York Heart Association (NYHA) heart failure classes and who after a routine cardiology clinic evaluation were felt to be at their stable baseline state. Measurements included: thoracic impedance (Z_o), hypothenar tissue hemoglobin oxygen saturation (S_tO₂), and Z_o-derived cardiac index (CI). To determine if adverse outcomes (hospitalization or death) occurred, patients or their families were contacted 6 months after enrollment and their charts reviewed. Monitor values between the NYHA classes were compared using analysis of variance. Values of those who later developed adverse outcomes were compared to patients who remained stable using a Student t-test (P < .05 considered significant). A Kaplan-Meier survival curve was used to describe the adverse outcome rate over time, and a Cox's proportional hazards model was used to relate perfusion values to adverse outcomes.
There were no differences in CI (P = .08), Z_o (P = .38), or S_tO₂ (P = .14) found between NYHA classes (n = 46). After 6 months, 6 patients required hospitalization for heart failure and 1 died. This group had lower S_tO₂ values compared with the stable group (P = .015). The time course of the adverse events was found not to be due to chance alone when evaluated using a Kaplan-Meier curve and the S_tO₂ was significantly associated with time to adverse outcome (P < .05).
Outpatient heart failure patients who later develop adverse outcomes have significantly lower S_tO₂ values than those who remain stable. This suggests cardiac performance in stable heart failure patients may be better reflected at the microvascular level using measures such as S_tO₂ as opposed to a global level using the physical exam or impedance cardiography. S_tO₂ may serve as a predictor for future adverse events and as an adjunct to current evaluation techniques.

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^*: Supported in part by a Grant-in-Aid from the American Heart Association of Metropolitan Chicago.

^**: Presented in part at the National Society of General Internal Medicine Meeting, Washington D.C., May 2, 1996.

^a: From the Division of General Internal Medicine

^e: the Department of Preventive Medicine, Northwestern University Medical School

^d: Institute for Health Services Research and Policy Studies

^c: the Chicago Lakeside Veterans Affairs Hospital

^b: Division of Cardiology

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Heart failure between 1986 and 1994: Temporal trends in drug-prescribing practices, hospital readmissions, and survival at an academic medical center*,**

Am J Med

Am J Med

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J.

J Am Coll Cardiol

Report of the American College of Cardiology/American Heart Association task force on practice guidelines, committee on evaluation and management of heart failure. Guidelines for the evaluation and management of heart failure

J Am Coll Cardiol

National Center for Health Statistics 1989 summary: national hospital discharge survey

Heart failure: evaluation and care of patients with left ventricular systolic dysfunction

Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS)

N Engl J Med

Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration cooperative study

N Engl J Med

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

N Engl J Med

A comparison of enalapril with hydralazine isosorbide dinitrate in the treatment of chronic congestive heart failure

N Engl J Med

Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions

N Engl J Med