title: Provider and hospital characteristics associated with geographic variation in the evaluation and management of elderly patients with heart failure.
abstract: BACKGROUND
  Rates of guideline-based care for elderly patients with heart failure vary by state, and overall are not optimal. Identifying factors associated with the lack of uniformly high-quality health care might aid efforts to improve care. We therefore sought to determine the extent to which provider and hospital characteristics contribute to small-area geographic variation in heart failure care after controlling for patient factors.
  
  
  METHODS
  We studied 30 228 Medicare patients who were older than 65 years and hospitalized with heart failure. We mapped rates for 2 quality measures-documentation of left ventricular ejection fraction and appropriate prescription of angiotensin-converting enzyme inhibitors-across the United States, using a Bayesian technique that smooths rates and enhances assessment for significant patterns of small-area variation. We used nonlinear hierarchical models to assess for associations between the the quality indicators and provider and hospital characteristics independent of patient characteristics.
  
  
  RESULTS
  Smoothed, unadjusted rates of left ventricular ejection fraction documentation ranged from 30.1% to 67.2% and of angiotensin-converting enzyme inhibitor prescription from 55.8% to 87.1% among hospital referral regions; regional patterns were apparent. After patient factors were controlled for, care at hospitals without a medical school affiliation, without invasive cardiac capabilities, or in a rural location, as well as not having a cardiologist as an attending physician, was significantly associated with lower rates of left ventricular ejection fraction documentation. Hospitalization at a nonteaching facility was significantly associated with failure to prescribe angiotensin-converting enzyme inhibitors.
  
  
  CONCLUSIONS
  Characteristics of providers and hospitals explain in part the geographic variation in guideline-based care for elderly patients with heart failure.
authors.affiliation: Denver Health Medical Center, Denver, CO 80204, USA. ehavrane@dhha.org
authors.forename: Edward P
authors.initials: EP
authors.lastname: Havranek
authors.forename: Pam
authors.initials: P
authors.lastname: Wolfe
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Masoudi
authors.forename: Saif S
authors.initials: SS
authors.lastname: Rathore
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.forename: Diana L
authors.initials: DL
authors.lastname: Ordin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001499:Bayes Theorem; D002303:Cardiac Output, Low / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013318:Stroke Volume; D016277:Ventricular Function, Left
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors