Search

The aging population routinely has comorbid conditions requiring complicated medication regimens, yet nonadherence can preclude optimal outcomes. This study explored the association of adherence in the elderly with demographic, socioeconomic, and disease burden measures. Data were from the fifth visit (2011-2013) for 6,538 participants in the Atherosclerosis Risk in Communities Study, conducted in four communities. The Morisky-Green-Levine Scale measured self-reported adherence. Forty percent of respondents indicated some nonadherence, primarily due to poor memory. Logit regression showed, surprisingly, that persons with low reading ability were more likely to report being adherent. Better self-reported physical or mental health both predicted better adherence, but the magnitude of the association was greater for mental than for physical health. Compared with persons with normal or severely impaired cognition, mild cognitive impairment was associated with lower adherence. Attention to mental health measures in clinical settings could provide opportunities for improving medication adherence. [ABSTRACT FROM AUTHOR]

Patients discharged from the hospital on an angiotensin-converting enzyme inhibitor had a significant decrease in 30-day death or readmission (by 30% in 1,195 unselected Medicare patients hospitalized with congestive heart failure). Other independent predictors of poor outcome determined by multivariate analysis included history of congestive heart failure, male gender, increased number of comorbidities, higher serum blood urea nitrogen, and lower serum sodium. [ABSTRACT FROM AUTHOR]

Background: Self-management programs for patients with heart failure can reduce hospitalizations and mortality. However, no programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care., Methods: We performed a 12-month randomized controlled trial. From November 2001 to April 2003, we enrolled participants aged 30-80, who had heart failure and took furosemide. Intervention patients received education on self-care emphasizing daily weight measurement, diuretic dose self-adjustment, and symptom recognition and response. Picture-based educational materials, a digital scale, and scheduled telephone follow-up were provided to reinforce adherence. Control patients received a generic heart failure brochure and usual care. Primary outcomes were combined hospitalization or death, and heart failure-related quality of life., Results: 123 patients (64 control, 59 intervention) participated; 41% had inadequate literacy. Patients in the intervention group had a lower rate of hospitalization or death (crude incidence rate ratio (IRR) = 0.69; CI 0.4, 1.2; adjusted IRR = 0.53; CI 0.32, 0.89). This difference was larger for patients with low literacy (IRR = 0.39; CI 0.16, 0.91) than for higher literacy (IRR = 0.56; CI 0.3, 1.04), but the interaction was not statistically significant. At 12 months, more patients in the intervention group reported monitoring weights daily (79% vs. 29%, p < 0.0001). After adjusting for baseline demographic and treatment differences, we found no difference in heart failure-related quality of life at 12 months (difference = -2; CI -5, +9)., Conclusion: A primary care-based heart failure self-management program designed for patients with low literacy reduces the risk of hospitalizations or death.

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.

Background: Heart failure (HF) is a common clinical syndrome resulting in high morbidity and mortality. We examined the spectrum of ventricular dysfunction, and investigated the predictors of angiotensin-converting enzyme (ACE) inhibitor, beta-blocker, and spironolactone prescription in 1613 managed care patients with HF., Methods and Results: The diagnosis of HF was made by a HF discharge diagnosis or at least 3 physician encounters with a HF diagnosis during 2000. Logistic regression was used to identify predictors of medication prescription. Preserved systolic function was documented in 37%, moderate-severe systolic dysfunction in 31%, mild systolic in 14%, and 18% had inadequate documentation. The mean age was 69 years, 58% were women, 24% African American, and 60% were Medicare patients. Patients without HF type documented were the least aggressively treated. Coronary artery disease, hypertension, and diabetes predicted increased utilization of ACE inhibitor and beta-blocker therapies. History of nephropathy was associated with less ACE inhibitor prescription. Advancing age predicted less utilization of beta-blockers and spironolactone. Neither ethnicity nor gender influenced medication prescription., Conclusion: Preserved left ventricular function was common. Documentation of significant systolic dysfunction was associated with improved quality of care. Interventions to encourage documentation of HF type and further study of HF with preserved systolic function are warranted.

Background: Diastolic heart failure (DHF) is common in older women. There have been no clinical trials that have identified therapies to improve symptoms in these patients. A total of 32 women with New York Heart Association class II and III DHF (left ventricular ejection fraction >45% and symptoms of dyspnea or fatigue) were randomized into a 12-week home-based, low-to-moderate intensity (40% and 60%, respectively) exercise and education program (intervention) or education only program (control). Methods and results The intervention group improved in the 6-minute walk test from 840 +/- 366 ft to 1043 +/- 317 ft versus 824 +/- 367 ft to 732 +/- 408 ft in the control group (P =.002). Quality of life also improved in the intervention group compared with the control group as measured by the Living with Heart Failure Questionnaire (41 +/- 26 to 24 +/- 18 vs 27 +/- 18 to 28 +/- 22 at 12 weeks, P =.002; 24 +/- 18 to 19 +/- 18 vs 28 +/- 22 to 32 +/- 27 at the 3-month follow-up, P =.014) and the Geriatric Depression Scale (6 +/- 4 to 4 +/- 4 vs 5 +/- 3 to 7 +/- 5 at 12 weeks, P =.012; 4 +/- 4 to 4 +/- 4 vs 7 +/- 5 to 7 +/- 5 at the 3-month follow-up, P =.009)., Conclusions: Women with DHF exhibit significant comorbidities and physical limitations. Home-based, low-to-moderate intensity exercise, in addition to education, is an effective strategy for improving the functional capacity and quality of life in women with DHF. Further study is needed to assess the long-term effect of exercise on clinical outcomes.

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.

Background: The clinical characteristics of heart failure differ significantly between African American patients and white patients, apparently as a result of differences in the pathobiology of the condition in the races. We investigated the hypothesis that race also influences the survival of patients with heart failure., Methods: Data from the University of North Carolina Heart Failure Database were analyzed for 853 patients (44% African American, 32% women) who had symptomatic heart failure (New York Heart Association class 2.8 +/- 0.02 [mean +/- SEM]) with a reduced left ventricular ejection fraction of 26% +/- 0.5% and a body mass index of 27 +/- 0.2. Data on vital status were available in 96.4% of these patients, with a mean length of follow-up of 3.8 +/- 0.1 years., Results: An unadjusted univariate proportional-hazards analysis suggested similar survival rates between African American patients and white patients in the study population (relative risk, 0.90; 95% CI, 0.73-1.10; P =.293). Adjusted analysis, taking into account the characteristics shown to be of prognostic importance, demonstrated no difference in survival rate between African American patients and white patients (relative risk,1.12; 95% CI, 0.89-1.42; P =.336). The adjusted relative risk of all-cause mortality in the respective races among patients with heart failure caused by ischemic heart disease was 1.21 (95% CI, 0.80-1.84; P =.367)., Conclusion: African American and white patients with symptomatic heart failure had similar survival rates in our database.