Lack of Improvement in Outpatient Management of Congestive Heart Failure in the United States FREE

Congestive heart failure (CHF) accounts for 3% of admissions to US hospitals, and the diagnosis carries a mortality rate of 20% at 1 year and 80% at 8 years.^1- 2 Numerous advances in the chronic medical management of CHF, including angiotensin antagonists, β-blockers, and aldosterone antagonists, have significantly reduced mortality in clinical trial populations with varying degrees of CHF severity.^2- 4 Practices proven in clinical trials, however, do not always readily translate to community practice.^5- 6 Previous studies in outpatient populations in the late 1990s through the early 2000s observed suboptimal adoption of evidence-based therapy for CHF. Using nationally representative data, we evaluated whether patterns of medication use have improved.

We used data from the National Disease and Therapeutic Index (NDTI) physician survey produced by IMS Health (Plymouth Meeting, Pennsylvania) to characterize contemporary trends in the outpatient use of recommended medications for CHF from January 1994 through March 2009. Estimates for 2009 are made using data from January through March 2009. The NDTI is an ongoing physician survey that provides nationally representative diagnostic and medication use information on patients treated by office-based, private practice physicians in the continental United States.

We used descriptive analyses to determine the proportion of visits where the use of selected medication classes was reported. For the NDTI estimates, 95% confidence intervals (CIs) were calculated using tables of relative standard errors that accounted for the complex, multistage NDTI sampling design.

The number of patient visits for CHF declined gradually over the 15-year study period, from 10.9 million nonhospital visits in 1994 to 8.5 in 2000 and to 5.7 million visits in 2008. Physician-reported degree of CHF severity for patient visits did not change appreciably over time. Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) use gradually increased from 34% (95% CI, 32%-36%) in 1994 to 45% (95% CI, 43%-46%) in 2002 (Figure). However, after 2002, there was a steady decline in ACEI or ARB use, decreasing to 32% (95% CI, 27%-35%) in 2009. Because ARB use remained steady after 1998, fluctuating between 4% and 9%, the trend in ACEI and ARB use was entirely due to the rise and fall in ACEI use for CHF. We observed a gradual increase in β-blocker use for outpatient CHF visits from 11% (95% CI, 9%-12%) in 1998 to a peak of 44% (95% CI, 42%-46%) in 2006. After 2006, there was a decline in β-blocker use to 37% (95% CI, 31%-40%) in 2009.

There was a slow increase in aldosterone antagonist use in CHF from 1% in 1998 to 11% in 2003, maintaining a fluctuating plateau through 2009 (range, 8%-12%). A stable proportion of patients with CHF was reported to be receiving treatment with digoxin from 1994 to 1997 (range, 39%-43%), with a substantial decline after 1997 to 32% in 1999, to 20% in 2004, and to 10% in 2009. The use of diuretics declined slowly over 15 years from 69% in 1994 to 56% in 2009.

Initial adoption of evidence-based therapies for CHF through the 1990s and mid-2000s was modest. What we observe after the mid-2000s is more troubling. Some therapies that previously were increasing slowly have reached a plateau. Other recommended therapies have declined. The persistence of this trend could lead to a regression in the beneficial outcomes achieved through the increasing use of these therapies. The current framework used to promulgate evidence-based therapy for CHF does not appear to be sufficient to facilitate appropriate levels of therapy. Our results suggest that further improvements in the adoption process are needed, perhaps through targeting at-risk patient subgroups and health care providers with lower rates of recommended medication use. These measures alone may not be sufficient, and investment in other, innovative approaches to promoting evidence-based prescribing practices is warranted. The correlation between use of these therapies and beneficial outcomes in these and other subpopulations also needs further assessment.

Correspondence: Dr Banerjee, Division of Cardiovascular Medicine, Stanford University School of Medicine, Falk Cardiovascular Research Building, 300 Pasteur Dr, Stanford, CA 94305 (dbanerjee@cvmed.stanford.edu).

Author Contributions:Study concept and design: Banerjee and Stafford. Acquisition of data: Banerjee and Stafford. Analysis and interpretation of data: Banerjee and Stafford. Drafting of the manuscript: Banerjee and Stafford. Critical revision of the manuscript for important intellectual content: Banerjee. Statistical analysis: Banerjee and Stafford. Administrative, technical, and material support: Banerjee and Stafford.

Financial Disclosure: None reported.

Funding/Support: Dr Banerjee is supported by an Institutional Training Award from the National Heart, Lung, and Blood Institute (T32-HL07034). Dr Stafford's contribution to this work was supported by a mid-career development award from the National Heart, Lung, and Blood Institute (K24-HL086703).

Role of the Sponsors: The funding source and IMS Health had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation or approval of the manuscript for publication.

Disclaimer: The statements, findings, conclusions, views, and opinions contained and expressed in this article are based in part on data obtained under license from the following IMS Health Incorporated information service: National Disease and Therapeutic Index (1994-2009), IMS Health Incorporated. The statements, findings, conclusions, views, and opinions contained and expressed herein are not necessarily those of IMS Health Incorporated or any of its affiliated or subsidiary entities.