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CLINICAL RESEARCH: HEART FAILURE

Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge

Javed Butler, MD, MPH, FACC^*||,*, Patrick G. Arbogast, PhD, James Daugherty, MS, Manoj K. Jain, MD, MPH^||, Wayne A. Ray, PhD and Marie R. Griffin, MD, MPH

^* Cardiology Division, Vanderbilt University, Nashville, Tennessee, USA
Department of Preventive Medicine, Vanderbilt University, Nashville, Tennessee, USA
Center for Education and Research in Therapeutics, Vanderbilt University, Nashville, Tennessee, USA
Geriatrics Research, Education, and Clinical Center, Nashville VAMC, Nashville, Tennessee, USA
^|| Centers for Healthcare Quality Inc., Memphis, Tennessee, USA

Manuscript received November 24, 2003; revised manuscript received January 5, 2004, accepted January 13, 2004.

^* Reprint requests and correspondence: Dr. Javed Butler, Cardiology Division, 383-PRB, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
javed.butler{at}vanderbilt.edu

OBJECTIVES: This study was designed to assess outpatient angiotensin-converting enzyme inhibitor (ACEI) use after heart failure (HF) hospitalization.

BACKGROUND: Assuring therapy with ACEIs at discharge after HF hospitalization is a key Medicare quality measure. The benefits of such quality improvement attempts will be limited if therapy is not continued long-term.

METHODS: To assess the factors associated with filling an ACEI prescription in the 30 days postdischarge and the proportion of patients who filled such prescriptions subsequently up to 365 days postdischarge, we studied 219 patients with depressed ejection fraction (EF) specifically and 960 HF patients in general.

RESULTS: Sixty-seven percent of patients with depressed EF and 55% of the total cohort were discharged with ACEIs. Overall 81.2%/77.1% (depressed EF/total cohort) of survivors discharged with ACEIs had filled a prescription by 30 days postdischarge; only 66.3%/63.3% were current users at 365 days. In contrast, for patients with no discharge order for ACEIs, only 12.7%/12.0% (depressed EF/total cohort) had filled such a prescription by 30 days and 12.5%/18.8% were current users at 365 days postdischarge. Patients with a discharge order for ACEIs were more likely to fill a prescription within 30 days postdischarge (hazard ratio 10.93, 95% confidence interval 5.28, 22.61, for patients with depressed EF).

CONCLUSIONS: For patients with HF who are discharged while taking ACEIs, there is a significant decline in use after discharge. Patients not discharged with ACEIs are unlikely to be started as outpatients. Quality improvement efforts therefore need to be focused on both discharge planning and outpatient care.

Abbreviations and Acronyms   ACEI = angiotensin-converting enzyme inhibitor   ARB = angiotensin receptor blocker   CMS = Centers for Medicare and Medicaid Services   EF = ejection fraction   HF = heart failure   HR = hazard ratio   JCAHO = Joint Commission for Accreditation of Healthcare Organizations

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