Elsevier

American Heart Journal

Volume 165, Issue 6, June 2013, Pages 979-986.e1
American Heart Journal

Clinical Investigation
Heart Failure
Transitional adherence and persistence in the use of aldosterone antagonist therapy in patients with heart failure

https://doi.org/10.1016/j.ahj.2013.03.007Get rights and content

Background

Aldosterone antagonist therapy is recommended for selected patients with heart failure and reduced ejection fraction. Adherence to therapy in the transition from hospital to home is not well understood.

Methods

We identified patients with heart failure and reduced ejection fraction who were ≥65 years old, eligible for aldosterone antagonist therapy, and discharged home from hospitals in the Get With the Guidelines–Heart Failure registry between January 1, 2005, and December 31, 2008. We used Medicare prescription drug event data to measure adherence. Main outcome measures were prescription at discharge, outpatient prescription claim within 90 days, discontinuation, and adherence as measured with the medication possession ratio. We used the cumulative incidence function to estimate rates of initiation and discontinuation.

Results

Among 2,086 eligible patients, 561 (26.9%) were prescribed an aldosterone antagonist at discharge. Within 90 days, 78.6% of eligible patients with a discharge prescription filled a prescription for the therapy, compared with 13.0% of eligible patients without a discharge prescription (P < .001). The median medication possession ratio was 0.63 over 1 year of follow-up. Among 634 patients who filled a prescription within 90 days of discharge, 7.9% discontinued therapy within 1 year.

Conclusion

Most eligible patients were not prescribed aldosterone antagonist therapy at discharge from a heart failure hospitalization. Eligible patients without a discharge prescription seldom initiated therapy as outpatients. Most patients who were prescribed an aldosterone antagonist at discharge filled the prescription within 90 days and remained on therapy.

Section snippets

Data sources

We obtained clinical data for the study from the GWTG-HF registry and Medicare claims data from the Centers for Medicare & Medicaid Services. The GWTG-HF program is implemented voluntarily by hospitals8 and succeeded the OPTIMIZE-HF registry.9 Briefly, patients are eligible for inclusion in the registry if they are hospitalized for heart failure as a primary reason for admission or if they develop significant symptoms of heart failure during hospitalization. Patients are identified based on

Results

The Figure shows the composition of the study cohort. The initial linked data set consisted of 11,381 patients. After all exclusions, the study cohort included 2,086 patients eligible for aldosterone antagonist therapy at discharge. Patients who met the inclusion criteria differed from those who did not. Eligible patients were younger, more likely to be women, more likely to have heart failure of ischemic etiology, and less likely to have a history of anemia or depression (Table I). One-third

Discussion

To our knowledge, ours is the first study to combine data from a national inpatient clinical registry with Medicare prescription drug event data to examine adherence to evidence-based therapy for heart failure during the transition from hospital to home. Among eligible patients, only 1 in 5 was prescribed aldosterone antagonist therapy at discharge; of those, >78% filled the prescription within 90 days of discharge. In contrast, only 13% of eligible patients who were not prescribed an

Acknowledgements

Damon M. Seils, MA, Duke University, provided editorial assistance and prepared the manuscript.

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    James L. Januzzi, MD, served as guest editor for this article.

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