Trends and inequities in beta-blocker prescribing for heart failure

Shah, Sunil; Carey, Iain M.; DeWilde, Stephen; Richards, Nicky; Cook, Derek G

doi:10.3399/bjgp08x376195

Cited by 41 publications

(49 citation statements)

References 29 publications

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“…A more recent study observed underuse of ␤-blockers among patients living in the most deprived areas of the United Kingdom. 6 The extent to which any healthcare system in the world is delivering equitable HF care is thus uncertain.…”

Section: Editorial See P 1006 Clinical Perspective On P 1057mentioning

confidence: 99%

“…2,6,7,9 The US National Heart Failure Project constructed a nationally representative cohort of elderly Medicare beneficiaries by randomly sampling hospitalizations from each state between 1998 and 1999. 2 Adjusted likelihood of ACEI prescription at discharge was similar in patients of lower and higher socioeconomic status (RR, 1.03; 95% CI, 0.93-1.11).…”

Section: Treatment: Socioeconomic Inequalitymentioning

confidence: 99%

“…5 Even greater uncertainty surrounds the impact of socioeconomic circumstances on the actual treatment of HF patients. 2,6 -9 Previous reports have been limited in number, size of population, 7-9 range of treatments examined, 2,6,8 contemporariness, 2,7-9 and trend analyses over time. The paucity of evidence reflects the limited ability of many international healthcare systems to link medication and socioeconomic information.…”

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confidence: 99%

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Community Care in England

Hawkins

Scholes²,

Bajekal³

et al. 2012

Circulation

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Background-Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, ␤-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival. Methods and Results-This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (nϭ13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, ␤-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality. Conclusions-Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.

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Section: Editorial See P 1006 Clinical Perspective On P 1057mentioning

confidence: 99%

Section: Treatment: Socioeconomic Inequalitymentioning

confidence: 99%

mentioning

confidence: 99%

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Community Care in England

Hawkins

Scholes²,

Bajekal³

et al. 2012

Circulation

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“…However, a number of studies from Europe have found consistently lower use of ACE-inhibitors and beta blockers in older outpatients, although many of these studies have methodologic limitations and had limited ability to account for potential confounders. 13,[34][35][36] Our results suggest that interpreting age differences in prescribing requires nuance. In our study, older patients had meaningfully lower rates of ACE inhibitor/ARB and beta blocker use in both absolute and relative terms, and the frequency of chart-documented reasons for not prescribing these drugs did not vary between age groups.…”

Section: Discussionmentioning

confidence: 99%

Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans

et al. 2011

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BACKGROUND: Older patients often receive less guideline-concordant care for heart failure than younger patients. OBJECTIVE: To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chartdocumented reasons for non-adherence to guidelines. DESIGN AND PATIENTS: Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program). MAIN MEASURES: Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers. RESULTS: Among 2,772 patients, mean age was 73 +/− 10 years, 87% received an ACE inhibitor or ARB, and 82% received a beta blocker. When patients with explicit chart-documented reasons for not receiving these drugs were excluded, 95% received an ACE inhibitor or ARB and 89% received a beta blocker. In multivariable analyses controlling for a variety of patient and health system characteristics, the adjusted odds ratio for ACE-inhibitor and ARB use was 0.43 (95% CI 0.24-0.78) for patients age 80 and over vs. those age 50-64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI 0.48-0.93) between the two age groups. The magnitude of these associations was similar but not statistically significant after excluding patients with chart-documented reasons for not prescribing ACE inhibitors or ARBs and beta blockers. CONCLUSIONS: A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.KEY WORDS: guideline adherence; heart failure; aging; health services research; quality of care.

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“…1 We recently investigated use of home blood pressure (BP) monitoring in stroke patients registered at a deprived inner city general practice in Lambeth. In March 2008 we sent confidential postal questionnaires, backed up by a telephone call if required, to 74 patients listed on the stroke register at an inner London general practice.…”

mentioning

confidence: 99%