Data feedback efforts in quality improvement: lessons learned from US hospitals.

BACKGROUND: Data feedback is a fundamental component of quality improvement efforts, but previous studies provide mixed results on its effectiveness. This study illustrates the diversity of hospital based efforts at data feedback and highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement. METHODS: Open ended interviews with 45 clinical and administrative staff in eight US hospitals in 2000 concerning their perceptions about the effectiveness of data feedback in supporting performance improvement efforts were analysed. The hospitals were chosen to represent a range of sizes, geographical regions, and beta blocker improvement rates over a 3 year period. Data were organized and analyzed in NUD-IST 4 using the constant comparative method of qualitative data analysis. RESULTS: Although the data feedback efforts at the hospitals were diverse, the interviews suggested that seven key themes may be important: (1) data must be perceived by physicians as valid to motivate change; (2) it takes time to develop the credibility of data within a hospital; (3) the source and timeliness of data are critical to perceived validity; (4) benchmarking improves the meaningfulness of data feedback; (5) physician leaders can enhance the effectiveness of data feedback; (6) data feedback that profiles an individual physician's practices can be effective but may be perceived as punitive; (7) data feedback must persist to sustain improved performance. Embedded in several themes was the view that the effectiveness of data feedback depends not only on the quality and timeliness of the data, but also on the organizational context in which such efforts are implemented. CONCLUSIONS: Data feedback is a complex and textured concept. Data feedback strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.

Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting.

BACKGROUND: Evidence-based clinical practice guidelines recommend the use of warfarin sodium for stroke prevention in most patients with atrial fibrillation (AF) who do not have risk factors for hemorrhagic complications, irrespective of age. METHODS: The medical records of all residents of a convenience sample of long-term care facilities in Connecticut (n = 21) were reviewed. The percentages of all patients with AF (AF patients) and ideal candidates for warfarin therapy (ie, AF patients with no risk factors for hemorrhage) who received warfarin were determined; for patients receiving warfarin, the percentage of days spent in the therapeutic range of international normalized ratio (INR) values (2.0-3.0) was also assessed. The relationship between receipt of warfarin and the presence of stroke and bleeding risk factors was assessed in multivariate models. RESULTS: Atrial fibrillation was present in 429 (17%) of the 2587 long-term care residents. Overall, 42% of AF patients were receiving warfarin. However, only 44 (53%) of 83 ideal candidates were receiving this therapy. In residents who received warfarin therapy, the therapeutic range of INR values was maintained only 51% of the time. The odds of receiving warfarin in the study sample decreased with increasing number of risk factors for bleeding and increased (nonsignificant trend) with increasing number of stroke risk factors present. CONCLUSIONS: Atrial fibrillation is very common among residents of long-term care facilities. Even among apparently ideal candidates, warfarin therapy is underused for stroke prevention in patients with AF. Prescribing decisions and monitoring related to warfarin therapy in the long-term care setting warrant improvement.

Sex differences in cardiac catheterization: the role of physician gender.

CONTEXT: Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. OBJECTIVE: To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. DESIGN, SETTING, AND PATIENTS: Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104 >231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. MAIN OUTCOME MEASURE: Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. RESULTS: Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P =.001) or female physicians (34.8% vs 45.8%; P =.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction =.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval (CI), 0.88-0.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95%CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. CONCLUSIONS: Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

The Connecticut Cardiovascular Consortium: a unique, state-wide research collaboration to advance clinical outcomes in patients with heart disease.

The establishment of "best clinical practices" founded upon evidence-based medicine has become an increasingly important priority. Frequently, management guidelines are derived from published research data and disseminated among practitioners to help optimize patient care. The ultimate clinical impact of these guidelines in the "real world," however, is often clouded by an incomplete assessment of patient outcomes throughout the continuum of health-care delivery models. In order to address this gap in clinical outcome assessment, we propose to establish the Connecticut Cardiovascular Consortium. The Consortium will consist of a collaborative partnership among all 31 Connecticut hospitals working in concert with Connecticut Office of Health Care Access (OHCA). The primary objective of the Consortium will be to assess, compare, and optimize clinical outcomes among Connecticut residents with cardiovascular disease. As an initial goal for the Consortium, we further propose to undertake a prospective, observational study of Connecticut residents who present with ST Segment Elevation Acute Myocardial Infarction (STEMI). Recent advances in pharmacologic and mechanical reperfusion for STEMI have resulted in a need to define the optimal use of these therapies in the community at large. The primary purpose of this study will be to determine the relative merits of different treatment patterns for STEMI with regard to the use of fibrinolytic therapy and percutaneous coronary intervention (PCI). Particular emphasis will be placed on assessing the relative benefits of urgent mechanical revascularization performed at the state's seven tertiary facilities with PCI capability compared to all other treatment modalities. Successful completion of this unique collaborative endeavor is expected to have significant impact on improved patient care and on current health-care policy for medical resource allocation. Moreover, continued collaboration of health-care providers within the Connecticut Cardiovascular Consortium infrastructure should serve as a useful mechanism for ongoing improvements in evidence-based cardiovascular medicine and clinical research in the state of Connecticut.

The association between white blood cell count and acute myocardial infarction mortality in patients > or =65 years of age: findings from the cooperative cardiovascular project.

OBJECTIVES: The purpose of the study was to examine the association between white blood cell (WBC) count on admission and 30-day mortality in patients with acute myocardial infarction (AMI). BACKGROUND: Elevations in WBC count have been associated with the development of AMI and with long-term mortality in patients with coronary artery disease. However, the relationship between WBC count and prognosis following AMI is less clear. METHODS: Using the Cooperative Cardiovascular Project database, we evaluated 153,213 patients > or = 65 years of age admitted with AMI. RESULTS: An increasing WBC count is associated with a significantly higher risk of in-hospital events, in-hospital mortality and 30-day mortality. Relative to those patients in the lowest quintile, patients in the highest quintile were three times more likely to die at 30 days (10.3% vs. 32.3%; p < 0.001). After adjustment for confounding factors, WBC count was found to be a strong independent predictor of 30-day mortality (odds ratio = 2.37; 95% confidence interval 2.25 to 2.49, p = 0.0001 for the highest quintile of WBC count). CONCLUSIONS: White blood cell count within 24 h of admission for an AMI is a strong and independent predictor of in-hospital and 30-day mortality as well as in-hospital clinical events. Although the mechanism of the association remains speculative, the results of this study have important clinical implications for risk-stratifying patients with AMI.

Blood transfusion in elderly patients with acute myocardial infarction.

BACKGROUND: Anemia may have adverse effects in patients with coronary artery disease. However, the benefit of blood transfusion in elderly patients with acute myocardial infarction and various degrees of anemia is uncertain. METHODS: We conducted a retrospective study of data on 78,974 Medicare beneficiaries 65 years old or older who were hospitalized with acute myocardial infarction. Patients were categorized according to the hematocrit on admission (5.0 to 24.0 percent, 24.1 to 27.0 percent, 27.1 to 30.0 percent, 30.1 to 33.0 percent, 33.1 to 36.0 percent, 36.1 to 39.0 percent, or 39.1 to 48.0 percent), and data were evaluated to determine whether there was an association between the use of transfusion and 30-day mortality. RESULTS: Patients with lower hematocrit values on admission had higher 30-day mortality rates. Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission fell into the categories ranging from 5.0 to 24.0 percent (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.11 to 0.45) to 30.1 to 33.0 percent (adjusted odds ratio, 0.69; 95 percent confidence interval, 0.53 to 0.89). It was not associated with a reduction in 30-day mortality among those whose hematocrit values fell in the higher ranges. In one of seven subgroup analyses (among patients who survived at least two days), transfusion was not associated with a reduction in mortality for patients with hematocrit values of 30.1 percent or higher. CONCLUSIONS: Blood transfusion is associated with a lower short-term mortality rate among elderly patients with acute myocardial infarction if the hematocrit on admission is 30.0 percent or lower and may be effective in patients with a hematocrit as high as 33.0 percent on admission.

Acute myocardial infarction in the elderly: differences by age.

OBJECTIVES: We evaluated the clinical characteristics and outcomes of elderly patients hospitalized with acute myocardial infarction (AMI) to describe differences by age. BACKGROUND: Elderly patients with AMI are perceived as a homogeneous population, though the extent by which clinical characteristics vary among elderly patients has not been well described. METHODS: Data from 163,140 hospital admissions of Medicare beneficiaries age > or =65 years between 1994 and 1996 with AMI at U.S. hospitals were evaluated for differences in clinical characteristics and mortality across five age-based strata (in years): 65 to 69, 70 to 74, 75 to 79, 80 to 84 and > or =85. RESULTS: Older age was associated with a greater proportion of patients with functional limitations, heart failure, prior coronary disease and renal insufficiency and a lower proportion of male and diabetic patients. Of note, the proportion of patients presenting with chest pain within 6 h of symptom onset, and with ST-segment elevation, was lower in each successive age group. Thirty-day mortality rates were higher in older age groups (65 to 69: 10.9%, 70 to 74: 14.1%, 75 to 79: 18.5%, 80 to 84: 23.2%, > or =85: 31.2%, p = 0.001 for trend). The effect of age persisted but was attenuated after adjustment for differences in patient characteristics; similar trends were observed for one-year mortality. CONCLUSIONS: Our data indicate significant age-associated differences in clinical characteristics in elderly patients with AMI, which account for some of the age-associated differences in mortality. The practice of grouping older patients together as a single age group may obscure important age-associated differences.

Quality of care among elderly patients hospitalized with unstable angina.

BACKGROUND: Guidelines for the management of unstable angina have been published by the United States Agency for Health Care Policy and Research (currently known as the Agency for Healthcare Research and Quality); however, little information is available about the quality of unstable angina care, particularly among elderly patients. METHODS: We examined 1196 elderly Medicare-insured patients hospitalized with unstable angina (ruled out for acute myocardial infarction) at Connecticut hospitals between August and November 1995 to evaluate quality of care provided during hospitalization. Patients without therapeutic contraindications were evaluated for the use of 5 Agency for Health Care Policy and Research guideline-recommended measures: electrocardiographic examination within 20 minutes of admission, use of aspirin on admission, intravenous heparin on admission, achievement of therapeutic anticoagulation among patients provided heparin, and prescription of aspirin on discharge. RESULTS: Less than half (49.6%) of patients underwent electrocardiographic examination within 20 minutes of admission. After excluding patients with contraindications, aspirin was provided to 80.1% of patients and intravenous heparin to 59.2% of indicated patients, of whom only 43.3% achieved therapeutic anticoagulation. Aspirin was prescribed to 82.3% of eligible patients at discharge. Performance on the 5 quality measures varied widely among hospitals. CONCLUSIONS: Agency for Health Care Policy and Research guideline-recommended risk stratification and therapeutic interventions are underused in elderly patients hospitalized with unstable angina, with quality of care varying widely among hospitals.

Predictors of costs of caring for elderly patients discharged with heart failure.

BACKGROUND: Investments in programs to improve outcomes and reduce readmissions for patients who survive hospitalization with heart failure will be economically most favorable for those who have the highest risk. Little information is available, however, to stratify the risk of these patients incurring costs after discharge. In this study, we sought to determine correlates of costs in a representative sample of patients with heart failure in the 6 months after discharge. METHODS: We reviewed medical records of 2181 patients aged > or = 65 years who were discharged alive from 18 Connecticut hospitals in 1994 and 1995 with a principal discharge diagnosis of heart failure. Outcomes 6 months after discharge, including all-cause readmission and cost, heart failure-related readmission and cost, and death, were obtained from the Medicare administrative database. A 2-stage sample selection model was used to identify the independent correlates of cost. Risk scores were calculated to identify subsets of patients at risk for generating high costs. RESULTS: On average, patients discharged with heart failure incurred costs of $2388 resulting from heart failure-related admissions and $7101 resulting from admissions from any cause during the 6 months after discharge. An average admission for heart failure cost $7174, whereas an admission resulting from any cause cost $8589. The multivariate models explained 7% of the variation in cost, although clinical characteristics such as recent heart failure admissions, kidney failure, and hypertension were significant independent correlates of increased cost. Older age and a history of stroke were independently associated with decreased cost. Patients without any of the risk factors associated with increased costs still incurred $1500 to $5000, on average, in the 6 months after discharge. CONCLUSIONS: Patients with heart failure generate substantial hospital costs in the 6 months after discharge. Given the emerging evidence for effective programs to reduce readmission, investments in interventions that produce even modest reductions in risk would be economically favorable.

Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction: results from the Cooperative Cardiovascular Project.

OBJECTIVES: We sought to develop a model based on information available from the medical record that would accurately stratify elderly patients who survive hospitalization with an acute myocardial infarction (AMI) according to their risk of one-year mortality. BACKGROUND: Prediction of the risk of mortality among older survivors of an AMI has many uses, yet few studies have determined the prognostic importance of demographic, clinical and functional data that are available on discharge in a population-based sample. METHODS: In a cohort of patients aged > or = 65 years who survived hospitalization for a confirmed AMI from 1994 to 1995 at acute care, nongovernmental hospitals in the U.S., we developed a parsimonious model to stratify patients by their risk of one-year mortality. RESULTS: The study sample of 103,164 patients, with a mean age of 76.8 years, had a one-year mortality of 22%. The factors with the strongest association with mortality were older age, urinary incontinence, assisted mobility, presence of heart failure or cardiomegaly any time before discharge, presence of peripheral vascular disease, body mass index <20 kg/m2, renal dysfunction (defined as creatinine >2.5 mg/dl or blood urea nitrogen >40 mg/dl) and left ventricular dysfunction (left ventricular ejection fraction <40%). On the basis of the coefficients in the model, patients were stratified into risk groups ranging from 7% to 49%. CONCLUSIONS: We demonstrate that a simple risk model can stratify older patients well by their risk of death one year after discharge for AMI.

Quality of medical care and excess mortality in older patients with mental disorders.

BACKGROUND: This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. METHODS: This study examined a national cohort of 88 241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. RESULTS: After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. CONCLUSIONS: Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction. The study suggests the potential importance of improving these patients' medical care as a step toward reducing their excess mortality.

Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma.

OBJECTIVES: We evaluated the use and effectiveness of beta-blocker therapy after acute myocardial infarction (AMI) for elderly patients with chronic obstructive pulmonary disease (COPD) or asthma. BACKGROUND: Because patients with COPD and asthma have largely been excluded from clinical trials of beta-blocker therapy for AMI, the extent to which these patients would benefit from beta-blocker therapy after AMI is not well defined. METHODS: Using data from the Cooperative Cardiovascular Project, we examined the relationship between discharge use of beta-blockers and one-year mortality in patients with COPD or asthma who were not using beta-agonists, patients with COPD or asthma who were concurrently using beta-agonists and patients with evidence of severe disease (use of prednisone or previous hospitalization for COPD or asthma) compared with patients without COPD or asthma. RESULTS: Of 54,962 patients without contraindications to beta-blockers, patients with COPD or asthma (20%) were significantly less likely to be prescribed beta-blockers at discharge after AMI. After adjusting for demographic and clinical factors, we found that beta-blockers were associated with lower one-year mortality in patients with COPD or asthma who were not on beta-agonist therapy (relative risk [RR] = 0.85, 95% confidence interval [CI] 0.73 to 1.00), similar to patients without COPD or asthma (RR = 0.86, 95% CI 0.81 to 0.92). A survival benefit for beta-blockers was not found among patients concurrently using beta-agonists or with severe COPD or asthma. CONCLUSIONS: Beta-blocker therapy after AMI may be beneficial for COPD or asthma patients with mild disease. A survival benefit was not found for elderly AMI patients with more severe pulmonary disease.

Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.

CONTEXT: Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions. OBJECTIVE: To assess the predictive value of classification schemes that estimate stroke risk in patients with AF. DESIGN, SETTING, AND PATIENTS: Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge. MAIN OUTCOME MEASURE: Hospitalization for ischemic stroke, determined by Medicare claims data. RESULTS: During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval [CI], 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6. CONCLUSION: The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

Racial differences in the use of cardiac catheterization after acute myocardial infarction.

BACKGROUND: Several studies have reported that black patients are less likely than white patients to undergo cardiac catheterization after acute myocardial infarction. The role of the race of the physician in this pattern is unknown. METHODS: We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for acute myocardial infarction in 1994 and 1995, to evaluate whether differences between black patients and white patients in the use of cardiac catheterization within 60 days after acute myocardial infarction varied according to the race of their attending physician. RESULTS: Our study cohort consisted of 35,676 white and 4039 black patients with acute myocardial infarction who were treated by 17,550 white and 588 black physicians. Black patients had lower rates of cardiac catheterization than white patients, regardless of whether their attending physician was white (rate of catheterization, 38.4 percent vs. 45.7 percent; P< 0.001) or black (38.2 percent vs. 49.6 percent, P<0.001). We did not find a significant interaction between the race of the patients and the race of the physicians in the use of cardiac catheterization. The adjusted mortality rate among black patients was lower than or similar to that among white patients for up to three years after the infarction. CONCLUSIONS: Racial differences in the use of cardiac catheterization are similar among patients treated by white physicians and those treated by black physicians, suggesting that this pattern of care is independent of the race of the physician.

A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed?

CONTEXT: Based on evidence that beta-blockers can reduce mortality in patients with acute myocardial infarction (AMI), many hospitals have initiated performance improvement efforts to increase prescription of beta-blockers at discharge. Determination of the factors associated with such improvements may provide guidance to hospitals that have been less successful in increasing beta-blocker use. OBJECTIVES: To identify factors that may influence the success of improvement efforts to increase beta-blocker use after AMI and to develop a taxonomy for classifying such efforts. DESIGN, SETTING, AND PARTICIPANTS: Qualitative study in which data were gathered from in-depth interviews conducted in March-June 2000 with 45 key physician, nursing, quality management, and administrative participants at 8 US hospitals chosen to represent a range of hospital sizes, geographic regions, and changes in beta-blocker use rates between October 1996 and September 1999. MAIN OUTCOME MEASURES: Initiatives, strategies, and approaches to improve care for patients with AMI. RESULTS: The interviews revealed 6 broad factors that characterized hospital-based improvement efforts: goals of the efforts, administrative support, support among clinicians, design and implementation of improvement initiatives, use of data, and modifying variables. Hospitals with greater improvements in beta-blocker use over time demonstrated 4 characteristics not found in hospitals with less or no improvement: shared goals for improvement, substantial administrative support, strong physician leadership advocating beta-blocker use, and use of credible data feedback. CONCLUSIONS: This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts. In addition, the study suggests possible elements of successful efforts to increase beta-blocker use for patients with AMI.

Aspirin and angiotensin-converting enzyme inhibitors among elderly survivors of hospitalization for an acute myocardial infarction.

BACKGROUND: Aspirin and angiotensin-converting enzyme (ACE) inhibitors are recommended for secondary prevention after acute myocardial infarction (AMI), but several studies have suggested that the combination of these medications may produce a negative interaction. OBJECTIVE: To evaluate the effect and interaction of aspirin and ACE inhibitors on mortality among elderly patients who survived a hospitalization for AMI. METHODS: We evaluated the effect and interaction of aspirin and ACE inhibitors on mortality in patients aged 65 years and older who survived hospitalization with a confirmed AMI who were ideal candidates for the therapies. RESULTS: Among the 14 129 patients, 26% received aspirin only, 20% received ACE inhibitors only, 38% received both, and 16% received neither at discharge. In the multivariate analysis, patients who received both aspirin and ACE inhibitors alone had a significantly lower 1-year mortality (adjusted risk ratio [ARR], 0.86 [95% confidence interval (CI), 0.78-0.95] vs 0.85 [95% CI, 0.77-0.93], respectively) compared with patients who received neither aspirin nor ACE inhibitors at discharge. Prescribing both aspirin and ACE inhibitors was associated with a slightly lower risk of mortality (ARR, 0.81; 95% CI, 0.74-0.88) than that seen in aspirin-only or ACE inhibitor-only groups, but the difference was not significantly different from the use of either medication alone. CONCLUSIONS: The benefit of ACE inhibitors and aspirin is consistent with what would be expected from overall results of randomized trials; prescribed together, the effect is slightly greater than with either one alone, but not significantly or substantially so.

Aspirin and the treatment of heart failure in the elderly.

OBJECTIVES: We sought (1) to determine how often aspirin is prescribed as a discharge medication among patients 65 years or older and hospitalized with both heart failure and coronary artery disease; (2) to identify patient characteristics associated with the decision to prescribe aspirin; and (3) to evaluate the association between aspirin prescription at discharge and 1-year survival. METHODS: We performed a retrospective cohort study of consecutive Medicare beneficiary survivors of a hospitalization for heart failure at 18 Connecticut hospitals (up to 200 hospitalizations per hospital) from 1994 to 1995. RESULTS: Among the 1110 patients in the study sample who did not have a contraindication to aspirin, aspirin therapy was prescribed for 456 (41%) at discharge. Patients who were prescribed aspirin at discharge had a lower 1-year mortality after discharge than patients who were not prescribed aspirin (odds ratio, 0.71; 95% confidence interval, 0.54-0.94), even after adjustment for baseline differences in demographic, clinical, and treatment characteristics between the 2 groups. CONCLUSIONS: This study has identified a strong association between the use of aspirin and lower mortality in older patients with both heart failure and coronary artery disease. The benefit of aspirin is consistent with that expected from randomized trials of other groups of patients with vascular disease.

Angiotensin-converting enzyme inhibitor dosages in elderly patients with heart failure.

BACKGROUND: We sought to describe the dosages of angiotensin-converting enzyme (ACE) inhibitor prescribed to elderly patients with heart failure at hospital discharge, the factors associated with dosing level, and the association of these dosages with 1-year outcomes. METHODS: Demographic, procedural, and medication data were collected retrospectively from medical records at 18 Connecticut hospitals. Information on mortality and readmission was obtained from the Health Care Financing Administration administrative databases. Dosages of ACE inhibitor were grouped into 3 categories: dosages recommended in practice guidelines or higher (target dose), dosages used in clinical trials but lower than guideline recommendations (subtarget dose), and dosages lower than those used in clinical trials (low dose). RESULTS: A total of 554 patients, 65 years old or less with confirmed heart failure and systolic dysfunction, were prescribed an ACE inhibitor at discharge. Target, subtarget, and low doses were given in 19%, 63%, and 18% of the patients, respectively. Few demographic or clinical factors were related to lower dosages. Both subtarget and target doses of ACE inhibitors were associated with a significantly lower adjusted 1-year mortality (relative risk 0.67, P =.04; relative risk 0.51, P =.02, respectively) compared with low doses of ACE inhibitors. CONCLUSIONS: In a representative elderly cohort of patients with heart failure with systolic dysfunction, the majority (82%) were discharged on doses of ACE inhibitors consistent with those used in clinical trials. We observed a dose-response relationship between higher doses and lower mortality. Future studies will need to determine whether this association is causal.