Schmedtje John F, Evans Gregory W, Byerly Wesley, King Mark, Goonan Kelly, Blastock-Glenn Camille, Croft Janet B, Goff David C
Wake Forest University School of Medicine, Winston-Salem, USA.
N C Med J. 2003 Jan-Feb;64(1):4-10.
Effective therapy for chronic heart failure (CHF) is underutilized despite a broad consensus regarding treatment recommendations.
As a quality improvement project designed to reduce preventable hospitalizations associated with CHF, we examined use of angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and beta-adrenergic receptor blockers (BB) in a population of patients enrolled in a managed care plan. Medicare and commercial enrollees were included. Patients with CHF were identified using claims data (International Classification of Disease 9th Clinical Modification code 428) covering January 1, 1998 through December 31, 1998. Drug utilization data were obtained from the plan's pharmacy benefits database. Data were available for 1220 patients.
The mean age (+/- SD) was 71 +/- 12 years, 53% were female, and 84% were Medicare enrollees. Prescriptions for ACEI, ARB and BB were filled by 52%, 9% and 25% of patients, respectively. Prescriptions for diuretics, digitalis preparations, and calcium channel blockers (CCB) were filled by 69%, 34%, and 32%, respectively. Therefore, almost half of patients with CHF were not receiving ACEI therapy, even though it had been proven to reduce morbidity and mortality related to CHF. Furthermore, three-quarters of patients were not receiving BB therapy, a similarly effective therapy. In contrast, CCB and digitalis have not been convincingly shown to reduce mortality in patients with CHF broadly defined. Utilization of CCB and digitalis exceeded that of BB.
Managed care organizations should develop, test, and implement network-level strategies designed to optimize the appropriate utilization of effective drug therapies for patients with CHF.
尽管对于慢性心力衰竭（CHF）的治疗建议已达成广泛共识，但有效治疗方法的使用仍未得到充分利用。
作为一项旨在减少与CHF相关的可预防住院的质量改进项目，我们研究了参加管理式医疗计划的患者群体中血管紧张素转换酶抑制剂（ACEI）、血管紧张素受体阻滞剂（ARB）和β-肾上腺素能受体阻滞剂（BB）的使用情况。纳入了医疗保险和商业保险参保者。通过涵盖1998年1月1日至1998年12月31日的理赔数据（国际疾病分类第9版临床修订本代码428）识别出CHF患者。药物使用数据来自该计划的药房福利数据库。共有1220名患者的数据可用。
平均年龄（±标准差）为71±12岁，53%为女性，84%为医疗保险参保者。分别有52%、9%和25%的患者开具了ACEI、ARB和BB的处方。利尿剂、洋地黄制剂和钙通道阻滞剂（CCB）的处方开具率分别为69%、34%和32%。因此，几乎一半的CHF患者未接受ACEI治疗，尽管已证明其可降低与CHF相关的发病率和死亡率。此外，四分之三的患者未接受BB治疗，而BB是一种同样有效的治疗方法。相比之下，对于广义定义的CHF患者，尚未有令人信服的证据表明CCB和洋地黄能降低死亡率。CCB和洋地黄的使用超过了BB。
管理式医疗组织应制定、测试并实施旨在优化CHF患者有效药物治疗合理使用的网络层面策略。
