and Their Patients: Lessons From the Heart Failure Adherence. Retention Trial ... of Mathematics and Computer Science,3 Lake Forest College, Lake Forest, IL.
ORIGINAL
PAPER
Adherence to Evidence-Based Guidelines for Heart Failure in Physicians and Their Patients: Lessons From the Heart Failure Adherence Retention Trial (HART) James E. Calvin, MD;1 Sujata Shanbhag, MD;1 Elizabeth Avery, MS;2 John Kane, MS;2 Dejuran Richardson, PhD;3 Lynda Powell, PhD2 From the Section of Cardiology1 and the Department of Preventive Medicine,2 Rush University Medical Center, Chicago, IL; and the Department of Mathematics and Computer Science,3 Lake Forest College, Lake Forest, IL
The Heart Failure Adherence and Retention Trial (HART) provided an opportunity to determine adherence to evidence-based guidelines (EBG) in patients with heart failure (HF). Ten hospitals were the source of 692 patients with HF (EF < 40%). Physicians of patients with HF were classified as adherent to EBG if the patient chart audit showed they were on a beta-blocker, ACE-inhibitor (ACE-I), or angiotensin receptor blocker (ARB). Patients were classified as adherent to EBG if MEMS pill caps were used appropriately more than 80% of the time. Sixty-three percent of physicians prescribed evidence-based medications that were adherent to clinical practice guidelines. New York
Heart Association (NYHA) III patients were less likely to be adherent (P < 0.001), as were those with renal disease (P < 0.001) and asthmatics (P < 0.001). Nonadherent physicians were less likely to treat patients with beta-blockers (39% vs 98%, P < 0.001) and ACE-I or ARBs (71% vs 98% P < 0.001). Thirty-seven percent of patients prescribed evidence-based therapy failed to use the MEMS pill cap bottles appropriately and were more likely a minority or higher NYHA class. Adherence to evidence-based therapy is less than optimal in HF patients based on a combination of both physician and patient nonadherence. 2011 Wiley Periodicals, Inc.
Heart failure (HF) continues to be a major public health problem, affecting an estimated 5 million Americans, with an incidence of 550,000 new cases diagnosed annually.1 Its prevalence rises with age, affecting 1.5% to 2% of the population between the ages of 40 to 59 years and more than 10% of persons older than 60.1 HF is the most common diagnosisrelated group discharge in persons older than 65 years.2 This has two important public health concerns. First, HF carries substantial mortality when clinically evident. In 2004, the overall mortality for HF was 19.1%,1 with a sudden cardiac death rate 6 to 9 times that of the normal population.1 Second, HF also accounts for a large burden in rising health care expenditures, translating into 3.4 million office visits and 1 million hospital days per year.3 The indirect and direct costs of HF treatment in the United States are now $33.2 billion annually, siphoning off a significant portion of the cardiovascular budget.1 Because of the high mortality and tremendous costs associated with HF treatment, adherence to evidencebased therapy is critical. Evidence-based literature supports the value of medical therapy and lifestyle modification in delaying progression and improving
survival in patients with HF.4 However, patient adherence to these treatment regimens show high variability, with rates ranging from 10% to as high as 85%.5–8 The most common factors associated with patient nonadherence to HF treatment recommendations include complicated medical regimens, poor discharge instructions, lack of patient understanding, lower socioeconomic status, minority status, psychosocial variables, and younger age.6,7,9–11 The Heart Failure Adherence and Retention Trial (HART) was a National Institutes of Health–sponsored clinical trial designed to determine the efficacy of self-management training to improve clinical outcomes in patients with HF through improved patient adherence to evidence-based therapy.12 It featured a subgroup of 692 patients with mild to moderate systolic dysfunction (ejection fraction
