Temporal Trends and Hospital Variation in Mineralocorticoid Receptor Antagonist Use in Veterans Discharged With Heart Failure

Abstract

BackgroundDespite concerns about mineralocorticoid receptor antagonist therapies (MRAs) underuse and misuse in patients with heart failure, temporal and institutional variations of MRA prescription have not been reported.Methods and ResultsWe studied a national sample of veterans hospitalized for heart failure between 2003 and 2009 and left ventricular ejection fraction <40%. We identified ideal and non‐ideal candidates for MRA therapy based on American College of Cardiology/American Heart Association guidelines. We measured temporal trends and hospital variation of MRA prescriptions within 90 days after discharge. We determined the median odds ratio (MOR), a measure of the relative odds of an MRA prescription for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. From 37 126 patients (n=131 hospitals), 9355 were ideal‐MRA candidates, and 4056 were non‐ideal candidates. Among ideal candidates, 36% received an MRA, but there was a decline in use (41% in 2003 to 31% in 2009, P<0.001). Of non‐ideal candidates, 27% received an MRA with a decline in use (34% in 2003 to 22% in 2009, P<0.001). Hospital MRA prescription ranged from 0% to 71% for ideal candidates and 0% to 100% for non‐ideal candidates. The median odds ratios of MRA prescription for ideal and non‐ideal candidates were 1.44 and 1.36, respectively; a median odds ratio >1.2 indicates significant practice‐level variation.ConclusionsThere was decreasing MRA use between 2003 and 2009 with wide institutional variation in MRA prescription, which suggests opportunities for improvement to stimulate MRA use in ideal candidates while further reducing use in those with contraindications.

Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure: A Mixed‐Methods Study

“…In addition, we do not have information on the survey respondents' individual MRA‐prescribing behaviors, which would be useful to correlate with their knowledge and awareness of MRAs. We know that our VA medical center has MRA‐prescribing rates (unpublished data) similar to national VA MRA prescribing rates; therefore, it may reasonably represent other VA medical centers. Finally, some participants may have been minimally involved in the care of patients with HF; however, all participants had clinical roles and would be expected to have basic knowledge of HF.…”

“…12 Of the survey participants, 42 elected to participate in focus groups (ie, 84% recruitment rate) ( Table 1). We convened 6 focus groups, stratified by stakeholder category so as to develop a comfortable group atmosphere and encourage discussion of shared experiences: (1) cardiology nurse practitioners and cardiologists, (2) cardiology fellows in training, (3) hospitalists, (4) clinical pharmacists, (5) internal medicine residents, and Community clinic-rural 3 (6) Total years in practice (including residency), median (IQR)* 9 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) Years in practice at Phoenix VA (including residency),* median (IQR) No response 2 (4) (6) primary care physicians and nurse practitioners. We developed a semistructured focus group guide based on the extant literature regarding barriers to MRA prescription and a preliminary analysis of the aforementioned survey data.…”

Mineralocorticoid receptor antagonist pattern of use in heart failure with reduced ejection fraction: findings from BIOSTAT‐CHF

“…Despite these remarkable improvements in morbidity and mortality, and class IA guideline recommendations, MRAs are still largely underused in routine clinical practice . This may be (at least partly) explained by an undue concern about inducing hyperkalaemia or worsening renal function, and the need for close monitoring of potassium and renal function, but also by a lack of education/promotion about these drugs and their indications …”

Awareness of physicians and pharmacists of aldosterone antagonists in heart failure and myocardial infarction in Jordan

“… 10 Recently, a national large cohort study revealed that aldosterone antagonists prescription decreased over time in patients with HF. 11 Factors contributing to the discrepancy between current practice and evidence-based guidelines are unclear. The assessment of physicians and pharmacists’ knowledge of guidelines is important to narrow the treatment gap for use of aldosterone antagonists.…”