Original Article

Heart Failure Mortality among Older Medicare Beneficiaries: Association with Left Ventricular Function Evaluation and Angiotensin-converting Enzyme Inhibitor Use

Authors: Ali Ahmed, MD, MPH, FACP, Richard Maisiak, PHD, Richard M. Allman, MD, James F. DeLong, MD, FACP, Robert Farmer

Abstract

Background: Left ventricular function evaluation and angiotensin-converting enzyme (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 ± 7.5 years. Both left ventricular function evaluation (hazard ratio, 0.83; 95% confidence interval, 0.705–0.976) and ACE inhibitor 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.


Key Points


* Left ventricular function evaluation and angiotensin-converting enzyme 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 prognosis that can be favorably altered by following recommended management guidelines.

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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 of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation 1995; 92: 2764–2784.
 
3. Consensus recommendations for the management of chronic heart failure: On behalf of the membership of the advisory council to improve outcomes nationwide in heart failure. Am J Cardiol 1999; 83 (2A): 1A–38A.
 
4. Berkin KE. Does everyone in heart failure need echocardiography? Age Ageing 1999; 28: 421–422(editorial).
 
5. Aronow WS. Echocardiography should be performed in all elderly patients with congestive heart failure. J Am Geriatr Soc 1994; 42: 1300–1302.
 
6. Gurwitz JH, Osganian V, Goldberg RJ, Chen ZY, Gore JM, Alpert JS. Diagnostic testing in acute myocardial infarction: Does patient age influence utilization patterns? The Worcester Heart Attack Study. Am J Epidemiol 1991; 134: 948–957.
 
7. The Large State Peer Review Organization Consortium. Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. Arch Intern Med 1997; 157: 1103–1108.
 
8. Krumholz HM, Wang Y, Parent EM, Mockalis J, Petrillo M, Radford MJ. Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med 1997; 157: 2242–2247.
 
9. DeLong JF, Allman RM, Sherrill RG, Schiesz N. A congestive heart failure project with measured improvements in care. Eval Health Prof 1998; 21: 472–486.
 
10. 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.
 
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 Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302.
 
14. Aronow WS, Kronzon I. Effect of enalapril on congestive heart failure treated with diuretics in elderly patients with prior myocardial infarction and normal left ventricular ejection fraction. Am J Cardiol 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, et 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: International Classification of Diseases, 9th revision, Clinical Modification. Washington, DC, U.S. Department of Health and Human Services, 1997, ed 5.
 
18. National Heart, Lung, and Blood Institute. 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. Mortality from congestive heart failure: United States, 1980–1990. MMWR 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 subjects. Circulation 1993; 88: 107–115.
 
21. Croft JB, Giles WH, Pollard 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. Jencks 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 2000; 284: 1670–1676.
 
23. Health Care Financing Administration. Heart Failure National Project Overview (originally published as part of HCFA 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.