Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. The Large State Peer Review Organization Consortium.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have been proved to reduce mortality, rates of hospitalization, and disease progression in patients with heart failure. Investigators have suggested that ACE inhibitors are underused in heart failure.
METHODS: We examined the use of ACE inhibitors and the documentation of cardiac ejection fractions (EFs) in Medicare patients admitted to acute care hospitals with a principal diagnosis of heart failure. A random sample of at least 600 medical records in each of 10 populous states was retrospectively abstracted by peer review organizations. A total of 6749 records were reviewed of patients aged 65 years and older who were discharged in 1993 and 1994. The review tool was adapted from the Heart Failure Guidelines disseminated by the Agency for Health Care Policy and Research. An ideal candidate cohort was created of patients most likely to benefit from ACE inhibitors on the basis of their EF values (< 40%), renal function, absence of hyperkalemia, and absence of other contraindications.
RESULTS: Fifty-five percent (95% confidence interval, 54%-56%) of patients received ACE inhibitors at discharge. In the ideal candidate group, 73% (95% confidence interval, 71%-75%) of patients received ACE inhibitors at discharge. The oldest group was least likely to have ACE inhibitors prescribed at discharge. The EF was documented in 59% (95% confidence interval, 58%-60%) of records.
CONCLUSIONS: Medicare chart review suggests under-use of ACE inhibitors in up to one quarter of patients who have no clear contraindications. A substantial number of patients without documented EF are also likely to benefit from the use of ACE inhibitors.