Treatment of Chronic Heart Failure in a Managed Care Setting

BACKGROUND Effective therapy for chronic heart failure (CHF) is underutilized despite a broad consensus regarding treatment recommendations. METHODS As a quality improvement project designed to reduce preventable hospitalizations associated with CHF, we examined use of angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and beta-adrenergic receptor blockers (BB) in a population of patients enrolled in a managed care plan. Medicare and commercial enrollees were included. Patients with CHF were identified using claims data (International Classification of Disease 9th Clinical Modification code 428) covering January 1, 1998 through December 31, 1998. Drug utilization data were obtained from the plan's pharmacy benefits database. Data were available for 1220 patients. RESULTS The mean age (+/- SD) was 71 +/- 12 years, 53% were female, and 84% were Medicare enrollees. Prescriptions for ACEI, ARB and BB were filled by 52%, 9% and 25% of patients, respectively. Prescriptions for diuretics, digitalis preparations, and calcium channel blockers (CCB) were filled by 69%, 34%, and 32%, respectively. Therefore, almost half of patients with CHF were not receiving ACEI therapy, even though it had been proven to reduce morbidity and mortality related to CHF. Furthermore, three-quarters of patients were not receiving BB therapy, a similarly effective therapy. In contrast, CCB and digitalis have not been convincingly shown to reduce mortality in patients with CHF broadly defined. Utilization of CCB and digitalis exceeded that of BB. CONCLUSIONS Managed care organizations should develop, test, and implement network-level strategies designed to optimize the appropriate utilization of effective drug therapies for patients with CHF.