There is significant variation in the prescription of guideline-recommended medications and evidence-based therapies for outpatients with heart failure and reduced ejection fraction (HFREF), and the solution to improving the quality of care for these patients may lie in addressing practice-level differences, according to a study published Oct. 15 in Circulation: Heart Failure .

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The study identified 12,556 HFREF patients from 45 cardiology practices participating in the ACC's PINNACLE Registry®  from July 2008 to December 2010. Two therapies were tested for practice rates of treatment including: (1) angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB); and (2) beta blockers (BB). Results showed the unadjusted practice-level prescription rates for ACEI/ARB ranged from 44 to 100 percent (median: 85 percent; interquartile range [IQR]: 75 to 89 percent). For BB, the practice-level prescription rates ranged from 49 to 100 percent (median: 92 percent; IQR: 83 to 95 percent). The optimal combined treatment measure saw a prescription rate range from 37 to 100 percent (median: 79 percent; IQR: 66 to 85 percent).

Even after adjusting for demographics, insurance status and comorbidities, practice-level variation in treatment rates remained with a median rate ratio (MRR) for ACEI/ARB of 1.11 (95 percent confidence interval [CI] 1.08-1.18), 1.08 for BB therapy (95 percent CI 1.05-1.15) and 1.17 for optimal combined treatment (1.13-1.26).

The study also captured characteristics of eligible patients who received or did not receive the two therapies or a combined treatment measure. The study authors noted that those treated with an ACEI/ARB compared to those who were not were "younger; more frequently men and of white race; more likely to have a history of stroke, angina and atrial fibrillation; more likely to have had PCI or CABG within 12 months; and more likely to be treated with antiplatelet agents." Patients who were treated with a BB compared to those who were not were "younger; more likely non-smokers; and more likely to have CAD, dyslipidemia, diabetes, prior MI, CABG within the past 12 months and be treated with antiplatelet agents." Optimal combined treatment measure patients were "younger; more frequently men and of white race; more likely to have CAD, dyslipidemia, angina, a history of MI or PCI within the last 12 months; and more likely to be treated with antiplatelet agents."

The results of the study are consistent with findings from the two-year IMPROVE HF study, and the authors suggest "further work is needed to understand the characteristics and processes of high-performing practices and to disseminate those processes to all practices to improve the use of guideline-based therapies for HFREF in the outpatient setting."

Keywords: Angiotensin Receptor Antagonists, Stroke, Platelet Aggregation Inhibitors, Insurance Coverage, Demography, Comorbidity, Registries, Dyslipidemias, Outpatients, Heart Failure, Confidence Intervals, Diabetes Mellitus

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