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Objectives: To evaluate an intervention to improve the quality of care of patients with heart failure in managed Medicare and Medicaid plans in North Carolina., Background: Utilization of angiotensin-converting enzyme inhibitors (ACE-I) and beta-adrenergic receptor blockers (BB) in heart failure (HF) patients remains suboptimal despite evidence-based guidelines supporting their use., Methods: Managed care plans identified adult patients with HF during 2000 (preintervention) and from July 1, 2001, through June 30, 2002 (postintervention). Outpatient medical records were reviewed to obtain data regarding type of heart failure, demographics, comorbidities, and therapies. The intervention consisted of guideline summary dissemination, performance audit with feedback, patient-specific chart reminders, and patient activation mailings., Results: We sampled 1613 patients from 5 plans during the preintervention period and 1528 patients during the postintervention period. Assessment of left ventricular function (LVF) increased from 88.2% to 92.5% of patients (P < .0001). Among patients with moderate to severe left ventricular systolic dysfunction, there was no substantive change in treatment with ACE-I or vasodilators, whereas, appropriate treatment with BB increased from 48.3% (with another 11.9% with documented contraindications) to 67.9% (with another 7.5% with documented contraindications). The quality gap decreased from 39.8% to 24.6% (P < .0001)., Conclusion: LVF assessment improved despite high preintervention rates. Treatment rates with ACE-I and vasodilators remained high, but did not improve. Treatment rates with BB improved substantially translating into a significant public health benefit. Health-care payers should consider development of financial incentives to encourage collaborative quality improvement programs.

Use of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, beta-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than beta-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for beta-blocker use.

Abstract: Rationale, aims, and objectives: Despite proven benefits for reducing incidence of major cardiac events, antihypertensive drug therapy remains underutilized in the United States. This analysis assesses antihypertensive drug adherence, utilization predictors, and associations between adherence and outcomes (a composite of cardiovascular events, Medicare inpatient payments, and inpatient days). Methods: The sample consisted of Atherosclerosis Risk in Communities Study cohort participants reporting hypertension without prevalent cardiovascular disease during 2006 to 2007 annual follow‐up calls. Atherosclerosis Risk in Communities records were linked to Medicare claims through 2012. Antihypertensive medication adherence was measured as more than 80% proportion days covered by using Medicare Part D claims. Standard and hierarchical regression models were used to evaluate adjusted associations between person characteristics and adherence and between adherence and outcomes. Results: Among 1826 hypertensive participants with Part D coverage, 31.5% had no antihypertensive class with more than 80% proportion days covered in the 3 months preceding the report of hypertension in 2006 to 2007. After adjustment for confounders, positive predictors of use included female gender and diabetes; negative predictors were African‐American race and current smoking. Adjusted association between receiving no therapy and a composite endpoint of cardiovascular outcomes through 2012 was not statistically significant (hazard ratio: 0.93; 95% confidence interval: 0.72, 1.22) nor was the adjusted association with Medicare inpatient days or payments (incremental difference at 48 months in payments: $1217; 95% CI: −$2030, $4463). Conclusions: Despite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy. Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials. The approach provides a model framework for rigorous assessment of detailed data that are increasingly available through emerging sources. [ABSTRACT FROM AUTHOR]

Objective: Increasingly, epidemiologic studies use administrative data to identify atrial fibrillation (AF). Capture of incident AF is not well documented. We examined incidence rates and concordance of AF diagnosis based on active cohort follow-up versus surveillance of Centers for Medicare and Medicaid Services data in the Atherosclerosis Risk in Communities study. Methods: Atherosclerosis Risk in Communities cohort participants without prevalent AF enrolled in fee-for-service Medicare, with inpatient and outpatient coverage, for at least 12 continuous months between 1991 and 2009 were included. In active Atherosclerosis Risk in Communities study follow-up, annual telephone calls captured hospitalizations and deaths with incident AF diagnosis codes. For Centers for Medicare and Medicaid Services data, incident AF was defined by billed inpatient and outpatient diagnoses. Results: Of 10,134 eligible cohort participants, 738 developed AF according to both Atherosclerosis Risk in Communities and Centers for Medicare and Medicaid Services data; an additional 93 and 288 incident cases were identified using only Atherosclerosis Risk in Communities and Centers for Medicare and Medicaid Services data, respectively. Incidence rates per 1,000 person-years were 10.8 (95% confidence interval: 10.1–11.6) and 13.6 (95% confidence interval: 12.8–14.4) in Atherosclerosis Risk in Communities and Centers for Medicare and Medicaid Services, respectively; agreement was 96%; kappa was 0.77 (95% confidence interval: 0.75–0.80). Earlier AF ascertainment by one system versus the other was not associated with any cardiovascular disease risk factors, after accounting for sociodemographic factors. Additional Centers for Medicare and Medicaid Services events did not alter observed associations between risk factors and AF. Conclusion: Among fee-for-service enrollees, AF incidence rates were slightly lower for active cohort follow-up than for Centers for Medicare and Medicaid Services surveillance, because the latter included outpatient atrial fibrillation. Concordance was high and combining the two approaches could provide a more complete picture of newly-diagnosed AF. [ABSTRACT FROM AUTHOR]