title: Medication Initiation Burden Required to Comply With Heart Failure Guideline Recommendations and Hospital Quality Measures.
abstract: BACKGROUND
  Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described.
  
  
  RESULTS
  We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), β-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00).
  
  
  CONCLUSIONS
  A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care.
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.). larry.allen@ucdenver.edu.
authors: Larry A
authors: LA
authors: Allen
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Gregg C
authors: GC
authors: Fonarow
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Li
authors: L
authors: Liang
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Phillip J
authors: PJ
authors: Schulte
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Frederick A
authors: FA
authors: Masoudi
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: John S
authors: JS
authors: Rumsfeld
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: P Michael
authors: PM
authors: Ho
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Zubin J
authors: ZJ
authors: Eapen
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Adrian F
authors: AF
authors: Hernandez
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Paul A
authors: PA
authors: Heidenreich
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Deepak L
authors: DL
authors: Bhatt
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Eric D
authors: ED
authors: Peterson
authors: From Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora (L.A.A., F.A.M., J.S.R., P.M.H.); University of California Los Angeles Medical Center, Los Angeles (G.C.F.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., P.L.S., Z.J.E., A.F.H., E.D.P.); Veterans Affairs Medical Center, Denver, CO (J.S.R., P.M.H.); Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA (P.A.H.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).
authors: Harlan M
authors: HM
authors: Krumholz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D002317:Cardiovascular Agents / Q000145:classification / Q000627:therapeutic use*; D015897:Comorbidity; D000075202:Contraindications; D003430:Cross-Sectional Studies; D004342:Drug Hypersensitivity / Q000453:epidemiology; D011307:Drug Prescriptions / Q000592:standards* / Q000706:statistics & numerical data; D057915:Drug Substitution / Q000706:statistics & numerical data*; D004359:Drug Therapy, Combination; D004363:Drug Utilization; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006333:Heart Failure / Q000145:classification / Q000188:drug therapy* / Q000453:epidemiology; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D019338:Polypharmacy; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care
chemical_list: D002317:Cardiovascular Agents
keywords: heart failure; medication adherence; medication therapy management; prescribing patterns, physician; quality of health care