医疗保险受益人心力衰竭和糖尿病患者住院前、住院期间及出院后的药物治疗：遵循心力衰竭指南注册研究
Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines - Heart Failure Registry.
作者信息
Bhatt Ankeet S, Fonarow Gregg C, Greene Stephen J, Holmes Dajuanicia N, Alhanti Brooke, Devore Adam D, Butler Javed, Heidenreich Paul A, Huang Joanna C, Kittleson Michelle M, Linganathan Karthik, Joyntmaddox Karen E, McDermott James J, Owens Anjali Tiku, Peterson Pamela N, Solomon Scott D, Vardeny Orly, Yancy Clyde W, Vaduganathan Muthiah
机构信息
Kaiser Permanente San Francisco Medical Center and Division of Research, Oakland, CA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, CA.
出版信息
J Card Fail. 2024 Feb;30(2):319-328. doi: 10.1016/j.cardfail.2023.09.005. Epub 2023 Sep 25.
BACKGROUND
Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM.
METHODS
We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge.
RESULTS
Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%-49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%-82%; RASi: 51%-57%, MRA: 15%-28%, ARNI: 3%-6%, triple therapy: 8%-20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge.
CONCLUSIONS
In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.
背景
因心力衰竭（HF）和糖尿病（DM）住院的患者临床状况有恶化风险。关于住院期间治疗方案改变的频率知之甚少。我们对HF合并DM患者住院前、住院期间和出院后的药物治疗使用情况进行了描述。
方法
我们在“遵循指南-心力衰竭（GWTG-HF）”项目中确定了2014年7月至2019年9月期间住院且有D部分处方保险的医疗保险受益人。我们评估了7类降糖治疗药物（二甲双胍、磺脲类、胰高血糖素样肽-1受体激动剂[GLP-1RA]、钠-葡萄糖协同转运蛋白2抑制剂[SGLT2i]、二肽基肽酶-4抑制剂[DPP-4i]、噻唑烷二酮类和胰岛素）和4类HF治疗药物（循证β受体阻滞剂、血管紧张素转换酶抑制剂[ACEi]或血管紧张素受体阻滞剂[ARB]、醛固酮受体拮抗剂[MRA]和血管紧张素受体脑啡肽酶抑制剂[ARNI]）的使用趋势。在住院前6个月和3个月、出院时以及出院后3个月评估药物配药情况。
结果
在35165名医疗保险受益人中，中位年龄为77岁，54%为女性，76%为白人；11660名（33%）患有射血分数降低的心力衰竭（HFrEF，左心室射血分数[LVEF]≤40%），3700名（11%）患有射血分数中等降低的心力衰竭（HFmrEF，LVEF 41%-49%），19805名（56%）患有射血分数保留的心力衰竭（HFpEF，LVEF≥50%）。总体而言，胰岛素是HF住院后最常用的降糖药物（n = 12919，37%），其次是二甲双胍（n = 7460，21%）和磺脲类（n = 7030，20%）。GLP-1RA（n = 700，2.0%）和SGLT2i（n = 287，1.0%）的使用较少，且未随时间改善。在HFrEF患者中，HF住院前6个月循证β受体阻滞剂、肾素-血管紧张素系统抑制剂（RASi）、MRA和ARNI的配药率分别为63%、62%、19%和4%。配药率在住院前最初下降，但随后从住院前3个月到出院时上升（β受体阻滞剂：56%-82%；RASi：51%-57%，MRA：15%-28%，ARNI：3%-6%，三联疗法：8%-20%；所有P<0.01）。住院后3个月的处方率与出院时相似。
结论
在美国一个大型质量改进登记处的参与医院中，对HF合并DM患者进行院内药物治疗优化很常见。
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