San Francisco VA Medical Center, San Francisco, CA 94121, USA.
J Gen Intern Med. 2011 Oct;26(10):1152-9. doi: 10.1007/s11606-011-1745-2. Epub 2011 May 21.
Older patients often receive less guideline-concordant care for heart failure than younger patients.
To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chart-documented reasons for non-adherence to guidelines.
Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program).
Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.
Among 2,772 patients, mean age was 73 +/- 10 years, 87% received an ACE inhibitor or ARB, and 82% received a beta blocker. When patients with explicit chart-documented reasons for not receiving these drugs were excluded, 95% received an ACE inhibitor or ARB and 89% received a beta blocker. In multivariable analyses controlling for a variety of patient and health system characteristics, the adjusted odds ratio for ACE-inhibitor and ARB use was 0.43 (95% CI 0.24-0.78) for patients age 80 and over vs. those age 50-64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI 0.48-0.93) between the two age groups. The magnitude of these associations was similar but not statistically significant after excluding patients with chart-documented reasons for not prescribing ACE inhibitors or ARBs and beta blockers.
A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.
老年患者接受心力衰竭治疗的方法往往与年轻患者不同，并不符合指南建议。
确定心力衰竭治疗中年龄差异是否可以用患者、医疗服务提供者和医疗体系特征以及不遵循指南的图表记录原因来解释。
对 2004 年全国范围内病历审查项目（VA 外部同行审查计划）中的 2772 例心力衰竭和左心室射血分数<40%的门诊退伍军人进行回顾性队列研究。
门诊使用血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂和β受体阻滞剂。
在 2772 例患者中，平均年龄为 73 ± 10 岁，87%的患者接受了血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂，82%的患者接受了β受体阻滞剂。当排除未接受这些药物的患者有明确图表记录的原因时，95%的患者接受了血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂，89%的患者接受了β受体阻滞剂。在多变量分析中，控制各种患者和医疗体系特征后，80 岁及以上患者接受血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂的调整比值比为 0.43（95%可信区间 0.24-0.78），与 50-64 岁年龄组相比，接受β受体阻滞剂的调整比值比为 0.66（95%可信区间 0.48-0.93）。在排除有图表记录的不使用血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂和β受体阻滞剂原因的患者后，这些关联的程度相似，但无统计学意义。
很大一部分退伍军人接受了心力衰竭的指南推荐药物。年龄较大的退伍军人接受这些药物的可能性始终较低，但在考虑到有图表记录的不使用这些药物的原因的患者后，这些差异不再显著。仔细评估老年人不处方的原因对于评估非治疗是否代表良好的临床判断或错失改善护理的机会至关重要。
