title: Prescribing and up-titration in recently hospitalized heart failure patients attending a disease management program.
abstract: BACKGROUND
  Heart failure (HF) medications improve clinical outcomes, with optimal doses defined in clinical trials. Patient, provider and system barriers may limit achievement of optimal doses in real life settings, although disease management programs (HF-DMPs) can facilitate up-titration.
  
  
  RESULTS
  Secondary analysis of a prospective cohort of 216 participants recently hospitalized with systolic HF, attending 5 HF-DMPs in Queensland, Australia. Medication history at baseline (6weeks after discharge) and 6months provided data to describe prescription rates, dosage and optimal titration of HF medications, and associations with patient and system factors were explored. At baseline, 94% were on an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB), 94% on a beta-blocker (BB) and 42% on a mineralocorticoid receptor antagonist (MRA). The proportion of participants on optimal doses of ACEI/ARB increased from 38% (baseline) to 52% (6months, p=0.001) and on optimal BB dose from 23% to 49% (p<0.001). Significant barriers to ACEI/ARB up-titration were body mass index (BMI)<25, female gender, polypharmacy, previously diagnosed HF, and tertiary hospital. Significant barriers for BB up-titration were BMI<25, previously diagnosed HF and non-cardiologist care.
  
  
  CONCLUSIONS
  Effective up-titration in HF DMPs is influenced by patient, disease and service factors. Better understanding of barriers to effective up-titration in women, normal weight, and established HF patients may help provide targeted strategies for improving outcomes in these groups.
authors.affiliation: Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia. Electronic address: robert.carroll@uqconnect.edu.au.
authors.forename: Robert
authors.initials: R
authors.lastname: Carroll
authors.affiliation: Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia.
authors.forename: Alison
authors.initials: A
authors.lastname: Mudge
authors.affiliation: Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia.
authors.forename: Jessica
authors.initials: J
authors.lastname: Suna
authors.affiliation: Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia.
authors.forename: Charles
authors.initials: C
authors.lastname: Denaro
authors.affiliation: University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Atherton
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D054796:Drug Dosage Calculations; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006333:Heart Failure / Q000188:drug therapy; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011793:Queensland
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000451:Mineralocorticoid Receptor Antagonists
keywords: Disease management program; Heart failure; Uptitration