Transcript GWTG HFSA Poster 2006 - Clinical Trial Results

Influence of Age on the Management of Heart Failure: Findings from Get With the Guidelines-HF
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DE Forman, CP Cannon, AF Hernandez, L Liang, CW Yancy, GC Fonarow
Brigham and Women’s Hospital, Boston, MA
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20
10
Background
Warfari
Lipid Low Rx
ASA
Nitrates
evidence-based therapy for the 5 standardized
GWTG-HF measures that were indicated
• Admission medications, In-hospital
procedures
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20
3
2
10
1
0
<0.0001
Discharged on Beta Blocker with
LVSD (%)
88.8
Discharge Instructions (%)
77.1
77.5
77.8
76.6
75.9
0.0063
Smoking Cessation Counseling (%)
87.1
88.7
86.3
84.0
74.4
<0.0001
90.9
88.4
88.0
82.7
<0.0001
Composite Performance Measure
84.7
(26.7)
85.7
(24.5)
85.0
(25.7)
84.8
(27.0)
82.7
(30.6)
0.2201
69.1
67.2
68.1
70.3
71.0
<0.0001
3.3
1.6
3.1
3.8
5.3
LOS
•Median 5.0
Days
5.0
5.0
5.0
5.0
Pt Died
(%)
<.0001
Limitations
• Data from medical chart review
• Voluntary participation in GWTG so may not be generalizable
• No socioeconomic assessment component
• Lack of post-discharge follow-up data
Dialysis
79.0
p
Value
R Hrt Cath
81.8
Age
>85
Conclusions
Age 76-85
IABP
84.3
Age76-85
Age 66-75
ICD
88.6
Age
66-77
Age<=65
Pacemaker
84.7
Age
< 65
Bi-Pace
Discharged on ACE or ARB with
LVSD (%)
Tot
Pop
CABG
• Multivariable regression analysis used to assess
the influence of age on therapeutic decisions and
in-hospital mortality, independent of common
confounders
Mortality and LOS
PCI
<0.0001
Univariate analysis shows age-related declines in
therapy. Multivariate regression analyses shows
Age>85
66-77 Age
persistent ageAge<=65
effects onAge
treatment
and 76-85
mortality
even
after accounting for confounding variables.
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Cath
89.4
Warfarin
92.8
Lipid Low Rx
93.1
ASA
93.8
Nitrates
p
Value
Diuretic
Age>85
N=10,860
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Digoxin
Age-76-85
N= 18,398
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Aldos Block
Age 66-77
N=12,488
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ARB
Age < 65
N=16245
Age<=65 Age 66-75 Age 76-85 Age>85
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defect-free composite measure: 100% of
92.6
Composite Performance Measure for
100% Compliance (%)
Diuretic

Documentation of LV function (%)
during the HF hospitalization
Composite Performance Measure
[Mean % (SD)]
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therapeutic interventions/circumstances
interventions indicated
Selected GWTG Performance and
Quality Measures
• Variables in the model included gender, race,
admission BMI, admission BP, anemia, CVA/TIA,
diabetes, HTN, hyperlipidemia, atrial
fibrillation/flutter, PVD, CRI, depression, smoking,
HF etiology,
insurance, and hospital
DISCLOSURE INFORMATION
The following relationships exist related to this presentation:
characteristics.
GWTG-HF is an American Heart Association Program sponsored program supported in part by GlaxoSmithKline
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opportunity composite measure: #
• Documented contraindications or intolerance were
used to exclude ineligible patients as determined
by providers, facilitating analysis of only eligible
HF patients.
• Generalized Estimating Equations (GEE) method
employed to account for within-hospital clustering.
Digoxin

GWTG Quality of Care Performance Measures
Total
Population
N=57,937
Hospital Procedures
Meds at Admission
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• LOS, in-hospital death
• Assessment of HF patients at admission, during
the course of HF hospitalizations, and at
discharge.
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ACE Inhib
Methods
• GWTG indices: (a) Performance; (b)
Quality; (c) composite scores:
•Patient characteristics and
management collected at admission
and discharge, and stratified by age.
•Prespecified GWTG performance
and quality indices.
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Aldos Block
The objectives of this study are to assess the
characteristics, treatment, quality of care, and
outcomes for patients hospitalized with HF as a
function of patient age.
•57,937 admissions from 1/05-4/07
from 257 hospitals participating in the
AHA’s Get With the Guidelines-HF
Program.
General Patterns of Management
in Relation to Age
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ARB
While patient complexities relating to age may
sometimes steer decisions to omit specific
guidelines-based therapies, in other instances
omissions may constitute deficiencies of care.
Measures
ACE Inhib
Heart failure (HF) in older adults is associated with
high morbidity and mortality. Underutilization of
evidence-based medications for older adults has
been reported previously.
Components
Age>85
•Older age is associated with lower rates of
guideline recommended therapies even
when confounders and contraindications
are considered.
•However, compared to prior studies, rates of
evidence-based therapies are now higher in
the very old in GWTG-HF hospitals.
•Rising use of evidence-based therapy
suggests there may be fundamental
changes in caregiver attitudes regarding
importance and efficacy of guidelines
recommended therapy for older HF patients.
- GWTG-HF may have catalyzed greater
utilization of evidence-based treatments,
even for those very old and with many
comorbidites.