Allen Larry A, Fonarow Gregg C, Liang Li, Schulte Phillip J, Masoudi Frederick A, Rumsfeld John S, Ho P Michael, Eapen Zubin J, Hernandez Adrian F, Heidenreich Paul A, Bhatt Deepak L, Peterson Eric D, Krumholz Harlan M
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.).
Circulation. 2015 Oct 6;132(14):1347-53. doi: 10.1161/CIRCULATIONAHA.115.014281. Epub 2015 Aug 27.
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.
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).
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.
心力衰竭（HF）指南建议在出院前开具指南指导的药物治疗处方；其中一些治疗方法包含在公开报告的绩效指标中。尚未描述个体患者使用新药的负担情况。
我们使用了2008年至2013年“遵循心力衰竭指南”注册登记数据，以描述血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β受体阻滞剂、醛固酮拮抗剂、肼屈嗪/硝酸异山梨酯和抗凝剂的处方、适应证及禁忌证。计算患者入院时的药物治疗方案与心力衰竭质量指标出院时推荐方案之间的差异。在271家医院的158922例主要出院诊断为心力衰竭的患者中，血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂的起始治疗适用于所有患者中的18.1%（出院时符合条件的患者中有55.5%在入院时未接受血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂治疗），β受体阻滞剂为20.3%（符合条件者的50.5%），醛固酮拮抗剂为24.1%（符合条件者的87.4%），肼屈嗪/硝酸异山梨酯为8.6%（符合条件者的93.1%），抗凝剂为18.0%（符合条件者的58.0%）。累积来看，0.4%的患者符合5种新药组的条件，4.1%符合4种新药组，9.4%符合3种新药组，10.1%符合2种新药组，22.7%符合1种新药组；15.0%因入院时处方恰当而不符合新药条件；38.4%不符合心力衰竭质量指标推荐的任何药物条件。与新适应证药物（平均1.45±1.23）相比，实际新处方较低（平均1.16±1.00）。
四分之一因心力衰竭住院的患者需要开始使用超过1种药物以达到心力衰竭质量指标。解决药物起始治疗和管理多重用药的系统对于心力衰竭过渡性护理至关重要。
