Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Electronic address: https://twitter.com/revanthsk12.
Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Electronic address: https://twitter.com/gcfmd.
JACC Heart Fail. 2023 Nov;11(11):1534-1545. doi: 10.1016/j.jchf.2023.06.010. Epub 2023 Aug 2.
The burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described.
This study evaluated variation nationally for prescription of GDMT within the Veterans Health Administration.
A cohort of Veterans with HFrEF had their address linked to hospital referral regions (HRRs). GDMT prescription was defined using pharmacy data between July 1, 2020, and July 1, 2021. Within HRRs, we calculated the percentage of Veterans prescribed GDMT and a composite GDMT z-score. National choropleth maps were created to evaluate prescription variation. Associations between GDMT performance and demographic characteristics were evaluated using linear regression.
Maps demonstrated significant variation in the HRR composite score and GDMT prescriptions. Within HRRs, the prescription of beta-blockers to Veterans was highest with a median of 80% (IQR: 77.3%-82.2%) followed by angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitors (69.3%; IQR: 66.4%-72.1%), sodium-glucose cotransporter-2 inhibitors (10.3%; IQR: 7.7%-12.8%), mineralocorticoid receptor antagonists (29.2%; IQR: 25.8%-33.9%), and angiotensin receptor-neprilysin inhibitors (12.2%; IQR: 8.6%-15.3%). HRR composite GDMT z-scores were inversely associated with the HRR median Gini coefficient (R = -0.13; P = 0.0218) and the percentage of low-income residents (R = -0.117; P = 0.0413).
Wide geographic differences exist for HFrEF care. Targeted strategies may be required to increase GDMT prescription for Veterans in lower-performing regions, including those affected by income inequality and poverty.
心力衰竭的负担正在增加。指南指导的医学治疗（GDMT）可降低射血分数降低的心力衰竭（HFrEF）的不良结局。心力衰竭的护理质量是否存在地域差异尚不清楚。
本研究评估了退伍军人事务部（VA）内 GDMT 在全国范围内的处方差异。
对 HFrEF 退伍军人的地址与医院转诊区（HRR）进行了链接。2020 年 7 月 1 日至 2021 年 7 月 1 日期间，通过药房数据来确定 GDMT 的处方。在 HRR 内，我们计算了处方 GDMT 的退伍军人比例和 GDMT 综合评分的 z 分数。创建国家专题地图来评估处方的差异。使用线性回归评估 GDMT 表现与人口统计学特征之间的关联。
地图显示 HRR 综合评分和 GDMT 处方存在显著差异。在 HRR 内，退伍军人使用β受体阻滞剂的处方率最高，中位数为 80%（IQR：77.3%-82.2%），其次是血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/血管紧张素受体脑啡肽酶抑制剂（69.3%；IQR：66.4%-72.1%）、钠-葡萄糖共转运蛋白 2 抑制剂（10.3%；IQR：7.7%-12.8%）、盐皮质激素受体拮抗剂（29.2%；IQR：25.8%-33.9%）和血管紧张素受体脑啡肽酶抑制剂（12.2%；IQR：8.6%-15.3%）。HRR 综合 GDMT z 评分与 HRR 中位数基尼系数（R = -0.13；P = 0.0218）和低收入居民比例（R = -0.117；P = 0.0413）呈负相关。
HFrEF 护理存在广泛的地域差异。可能需要针对处方率较低的地区（包括受收入不平等和贫困影响的地区）制定有针对性的策略，以增加 GDMT 的处方。
