Background: Older patients often receive less guideline-concordant care for heart failure than younger patients.
Objective: 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.
Design and Patients: Retrospective cohort study of 2772 ambulatory veterans with heart failure and left ventricular ejection fraction less than 40% from a 2004 US nationwide medical record review programme (the US Veterans Administration External Peer Review Program).
Main Measures: Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers.
Results: Among 2772 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 to 0.78) for patients aged 80 and older vs those aged 50-64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI, 0.48 to 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.
Conclusions: 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.