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National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure
R S Stafford1, D Saglam, D Blumenthal
1Health Policy Research and Development Unit, Massachusetts General Hospital, Boston, USA. stafford@sol.mgh.harvard.edu
Insights
Physician use of angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure (CHF) increased slightly but remained low. Wide variations in ACE inhibitor prescribing suggest a need to improve physician practices for CHF patients.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Clinical trials and guidelines support angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure (CHF).
- National physician practices regarding ACE inhibitor use in CHF patients were previously unknown.
Purpose of the Study:
- To examine national physician practices for ACE inhibitor use in patients with CHF.
- To identify trends and predictors of ACE inhibitor prescribing from 1989 to 1994.
Main Methods:
- Analysis of 1529 physician office visits for CHF from the National Ambulatory Medical Care Surveys (1989-1994).
- Evaluation of changes in ACE inhibitor and other CHF medication use over time.
- Multiple logistic regression to identify predictors of ACE inhibitor use.
Main Results:
- Congestive heart failure prevalence increased from 0.9% to 1.1% of office visits.
- ACE inhibitor use rose from 24% to 31% (P = .02) between 1989 and 1994.
- ACE inhibitor use was higher among cardiologists, in the Midwest, for white patients, privately insured patients, and men.
Conclusions:
- Despite evidence supporting ACE inhibitors for CHF, national use rates remain low.
- Significant variations in prescribing patterns indicate a need to address physician practices.
- Focus should shift from clinical trials to improving real-world physician adherence to guidelines.
Background:
While the use of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure (CHF) is supported by the results of clinical trials and expert guidelines, national physician practices are unknown.
Methods:
We analyzed 1529 physician office visits by patients with CHF available from the 1989 through 1994 National Ambulatory Medical Care Surveys. We examined changes over time in the use of ACE inhibitors and use of other medications for CHF. Potential clinical and nonclinical predictors of use of ACE inhibitors were evaluated using multiple logistic regression.
Results:
The prevalence of CHF increased from 0.9% of all office visits in 1989 to 1.1% in 1994. Use of ACE inhibitors increased from 24% in visits by patients with CHF in 1989 to 31% in 1994 (P = .02). From 1989 through 1994, use of ACE inhibitors was more likely in visits to cardiologists (46% vs 22% for all other physicians), in the Midwest (31% vs 24% in all other regions), in whites (27% vs 21% in nonwhites), in privately insured patients (31% vs 24% in all others), and in men (29% vs 23% in women). Multiple logistic regression analysis showed independent effects of specialty, region, and sex. Other medications commonly used for patients with CHF included diuretics (62% of visits for 1989-1994), digoxin (38%), and calcium channel antagonists (15%). Use of diuretics showed no significant trend between 1989 and 1994, whereas use of digoxin decreased significantly.
Conclusion:
The low rates of use of ACE inhibitors in patients with CHF and the wide variations in their use suggest a need to move beyond clinical trials and focus attention on modifying physician practices.