title: Temporal Trends and Hospital Variation in Mineralocorticoid Receptor Antagonist Use in Veterans Discharged With Heart Failure.
abstract: BACKGROUND
  Despite 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.
  
  
  RESULTS
  We 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.
  
  
  CONCLUSIONS
  There 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.
authors.affiliation: Phoenix VA Medical Center, Phoenix, AZ (S.D.).
authors.forename: Sandesh
authors.initials: S
authors.lastname: Dev
authors.affiliation: Brown University, Providence, RI (M.E.L., W.C.W.) Providence VA Medical Center, Providence, RI (M.E.L., W.C.W.).
authors.forename: Mary E
authors.initials: ME
authors.lastname: Lacy
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.).
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Masoudi
authors.affiliation: Brown University, Providence, RI (M.E.L., W.C.W.) Providence VA Medical Center, Providence, RI (M.E.L., W.C.W.).
authors.forename: Wen-Chih
authors.initials: WC
authors.lastname: Wu
mesh_terms: D006333:Heart Failure / Q000188:drug therapy*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D010351:Patient Discharge; D010818:Practice Patterns, Physicians'; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000706:statistics & numerical data
chemical_list: D000451:Mineralocorticoid Receptor Antagonists
keywords: appropriateness criteria; quality of care; spironolactone; variation