Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

BACKGROUND: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication. OBJECTIVE: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system. DESIGN: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics. RESULTS: Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p<0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p<0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p<0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p<0.05). CONCLUSION: Increasing opportunities for patient-physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

Cognitive deficits in chronic heart failure.

BACKGROUND: Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF. OBJECTIVES: : The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits. METHODS: A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF. RESULTS: Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample. DISCUSSION: HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.

Cognitive deficits and health-related quality of life in chronic heart failure.

BACKGROUND: Patients with chronic heart failure (HF) have cognitive deficits in memory, psychomotor speed, and executive function and poor health-related quality of life (HRQL), but the association between cognitive deficits and HRQL is unknown. OBJECTIVES: The objectives of this study were to (1) evaluate the relationship between HF severity, age, comorbidities, and cognitive deficits and HRQL among patients with chronic HF and (2) examine whether cognitive deficits mediated the relationship between HF severity and HRQL. DESIGN AND SAMPLE: This study was part of a larger explanatory study; 249 patients with HF completed face-to-face interviews. METHODS: Measures of HF severity, comorbidity (multiple comorbid conditions, hypertension, and depressive symptoms), cognitive function (domains of language, working memory, memory, psychomotor speed, and executive function), and HRQL were obtained. Clinical variables were abstracted from patients' records. Statistical analyses were conducted using descriptive statistics, Pearson correlation coefficients, and multiple linear regression analyses. RESULTS: Overall, the HRQL of patients was moderately poor. Heart failure severity, age, depressive symptoms, and total recall memory explained 55% of the variance in HRQL, but the contribution of memory was minimal (1%). Patients with more severe HF, younger age, and more depressive symptoms had poorer HRQL. Other cognitive function variables, multiple comorbidity, and hypertension were not significant explanatory variables for HRQL. Cognitive deficits did not mediate the relationship between HF severity and HRQL. CONCLUSIONS: Novel interventions targeted at improving HRQL continue to be urgently needed, particularly among younger patients and patients with depressive symptoms. Measures of HRQL are not sufficient as outcomes when investigating cognitive deficits in HF. Investigators need to include outcome measures of patients' actual abilities to perform daily activities and HF self-care.

Effect of advanced access scheduling on processes and intermediate outcomes of diabetes care and utilization.

BACKGROUND: The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied. OBJECTIVE: To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits). METHODS: We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes. RESULTS: Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to non-African Americans [OR 0.27 (CI: 0.21-0.36)]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 - 7.5). There were no differences by clinic type in any of the three health-care utilization outcomes. CONCLUSION: OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial.

The association of patient age with cardiovascular disease risk factor treatment and control in diabetes.

BACKGROUND: While inadequate treatment intensification may contribute to sub-optimal CVD risk factor control in older patients with diabetes, the relationship between patient age and treatment intensification is largely unexplored. OBJECTIVE: To examine differences in treatment intensification and control for blood pressure (BP), lipids and A1c in older vs. younger adults with diabetes. METHODS: A total of 161,697 Kaiser Permanente Northern California adult diabetes patients were stratified by age (<50, 50-64, 65-74 and 75-85) and assessed for control of A1c (<8%), LDL-c (<100 mg/dl) and SBP (<140 mmHg). Probit models assessed the marginal effects of patient age on treatment intensification and control for all three CVD risk factors. RESULTS: Patients aged 50-64 and 65-74 were significantly more likely to receive treatment intensification for elevated SBP than patients under 50 (74% and 76% vs. 71%) and significantly less likely to receive treatment intensification for elevated A1c (73% and 72% vs. 76%), with no differences noted for LDL-c treatment. Older patients had significantly worse SBP control, but better control of A1c and LDL-c. CONCLUSIONS: Both treatment intensification rates and control of BP, A1c and LDL cholesterol control varied somewhat by age, suggesting room for further improvement in treatment intensification and control.

Do cardioselective beta-adrenoceptor antagonists reduce mortality in diabetic patients with congestive heart failure?

BACKGROUND: The relative benefits of cardioselective beta-adrenoceptor antagonists (CSB) among patients with congestive heart failure (CHF) and diabetes mellitus are not firmly established. OBJECTIVE: To determine whether diabetic patients with CHF accrue the same mortality benefit from CSB therapy as non-diabetic patients. METHOD: Between October 1999 and November 2000 consecutive patients with CHF at the Veteran's Affairs Medical Center in Indianapolis, IN, USA, were enrolled in a randomized controlled trial and prospectively followed for 5 years. Disease severity and CHF-specific functional status were obtained from patients at baseline. Medical records were accessed for data regarding co-morbidities, medications, and mortality. Propensity-score analysis was used to balance co-variates because of the observational nature of CSB use, given this was a post hoc analysis. A multivariate Cox proportional hazards model was used to compare survival between diabetic and non-diabetic patients stratified by whether they were or were not receiving CSB therapy. RESULTS: Of the 412 evaluable patients, 222 (54%) had diabetes and 212 (51%) were taking a CSB. At 5-year follow-up, 186 (45%) patients had died. In the multivariate analysis, using propensity scores to balance co-variates, CSB therapy was an independent predictor of survival in patients without diabetes (hazard ratio 0.60; p = 0.054) only. CONCLUSIONS: These results extend prior observations that patients with diabetes and CHF may not accrue the same mortality benefit from CSB therapy as patients without diabetes, and warrant further prospective investigation.

The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure.

BACKGROUND: Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied. OBJECTIVE: To examine the process of care for diabetic patients with elevated triage blood pressure (> or =140/90 mm Hg) during routine primary care visits to assess whether a treatment change occurred and to what degree specific patient and provider factors correlated with the likelihood of treatment change. DESIGN: Prospective cohort study. SETTING: 9 Veterans Affairs facilities in 3 midwestern states. PARTICIPANTS: 1169 diabetic patients with scheduled visits to 92 primary care providers from February 2005 to March 2006. MEASUREMENTS: Proportion of patients who had a change in a blood pressure treatment (medication intensification or planned follow-up within 4 weeks). Predicted probability of treatment change was calculated from a multilevel logistic model that included variables assessing clinical uncertainty, competing demands and prioritization, and medication-related factors (controlling for blood pressure). RESULTS: Overall, 573 (49%) patients had a blood pressure treatment change at the visit. The following factors made treatment change less likely: repeated blood pressure by provider recorded as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded repeated blood pressure (13% vs. 61%; P < 0.001); home blood pressure reported by patients as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded home blood pressure (18% vs. 52%; P < 0.001); provider systolic blood pressure goal greater than 130 mm Hg versus 130 mm Hg or less (33% vs. 52%; P = 0.002); discussion of conditions unrelated to hypertension and diabetes versus no discussion (44% vs. 55%; P = 0.008); and discussion of medication issues versus no discussion (23% vs. 52%; P < 0.001). LIMITATION: Providers knew that the study pertained to diabetes and hypertension, and treatment change was assessed for 1 visit per patient. CONCLUSION: Approximately 50% of diabetic patients presenting with a substantially elevated triage blood pressure received treatment change at the visit. Clinical uncertainty about the true blood pressure value was a prominent reason that providers did not intensify therapy.

Current blood pressure self-management: a qualitative study.

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the"teachable moment" may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.

Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification.

BACKGROUND: Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved. OBJECTIVE: To examine the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target cardiovascular disease (CVD) risk factor levels. DESIGN: Cross-sectional assessment. PARTICIPANTS: In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study. MEASUREMENT: "Above target" was defined as most recent A1c >/=7.0% for hyperglycemia, LDL-c >/=100 mg/dL for hyperlipidemia, and SBP >/=130 mmHg for hypertension. Poor adherence was defined as medication gaps for >/=20% of days covered for all medications for each condition separately. Treatment intensification was defined as an increase in the number of drug classes, increased dosage of a class, or a switch to a different class within the 3 months before or after notation of above target levels. RESULTS: Poor adherence was found in 20-23% of patients across the 3 conditions. No evidence of poor adherence with no treatment intensification was found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients, and 36% of hypertension patients. Poor adherence or lack of therapy intensification was evident in 53-68% of patients above target levels across conditions. CONCLUSIONS: Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control.

Impact of provider self-management education, patient self-efficacy, and health status on patient adherence in heart failure in a Veterans Administration population.

To address the need for more information on predictors of adherence to heart failure (HF) self-management regimens, this study analyzed surveys completed by 259 HF patients receiving care at 2 Veterans Affairs hospitals in 2003. Linear multivariable regression models were used to examine general health status, HF-specific health status (Kansas City Cardiomyopathy Questionnaire) self-management education, and self-efficacy as predictors of self-reported adherence to salt intake and exercise regimens. Self-management education was provided most often for salt restriction (87%) followed by exercise (78%). In multivariable regression analyses, education about salt restriction (P=.01), weight reduction (P=.0004), self-efficacy (P=.03), and health status (P=.003) were significantly associated with patient-reported adherence to salt restriction. In a similar model, self-efficacy (P=.006) and health status (P< or = .0001), but not exercise education, were significantly associated with patient-reported exercise adherence. Findings suggest that provider interventions may lead to improved adherence with HF self-management and thus improvements in patients' health.

Research in patients with heart failure: challenges in recruitment.

BACKGROUND: Published studies of patients with heart failure may not include details about the challenges in the recruitment process. OBJECTIVES: To describe the recruitment process during the first 18 months of a study being conducted to evaluate cognitive deficits in patients with chronic heart failure. METHODS: Details of the recruitment process are described for 2 clinic sites. RESULTS: A total of 4,027 echocardiograms were screened at site 1 to evaluate eligibility. Of the 161 patients eligible, 61 (38%) were invited to participate, and 29 of the 61 (48%) completed the study. At site 2, four hundred thirty-seven medical records of patients were screened, resulting in 163 eligible patients (37%). The staff invited 70 of the 163 patients (43%) to participate, and 52 of the 70 (74%) completed the study. The refusal rate was 23% at site 1 and 21% at site 2. CONCLUSIONS: Successful recruitment in studies involving patients with heart failure often requires screening of a large group of patients.

A single health status question had important prognostic value among outpatients with chronic heart failure.

OBJECTIVE: Health status is an important marker of the impact of disease on function among patients with chronic heart failure (CHF). However, the prognostic value of CHF-specific health status on long-term mortality has not been adequately evaluated. Our objective was to assess CHF-specific health status and 5-year mortality among outpatients with CHF. STUDY DESIGN AND SETTING: We analyzed data from 494 Veterans Affairs outpatients with diagnoses of CHF and objective evidence of left ventricular dysfunction who enrolled in a quality improvement intervention. We extracted information about comorbid diagnoses, severity of illness (Charlson index), health care utilization, drug therapy, laboratory, and vital sign data along with generic and CHF-specific health status. We then identified multivariate correlates of subsequent mortality at 5 years. RESULTS: Five-year mortality was 44%. Age (chi2=26.1, hazard ratio [HR]=1.63, confidence interval [CI]: 1.35, 1.97; P<0.0001) and Charlson index (chi2=12.9, HR=1.39, CI: 1.16, 1.67; P=0.0003) were significantly associated with 5-year mortality. Controlling for clinical, lab, medication, and administrative data, a single-item assessing change in CHF-specific health status was independently associated with 5-year mortality (chi2=11.4, HR=0.87, CI: 0.80, 0.94, P=0.0007). CONCLUSIONS: Given the strength of the association with mortality, health care providers should routinely assess this single-item change in health status among outpatients with CHF to identify higher risk patients and guide therapy.

Decreased survival in diabetic patients with heart failure due to systolic dysfunction.

BACKGROUND: Prognosis of patients with heart failure (HF) has improved in recent years due to advances in therapy. Whether this is also true for diabetic subjects with HF in clinical practice has not been studied in a prospective manner. METHODS: All patients with HF and left ventricular systolic dysfunction attending the outpatient clinic at our Veteran's Hospital between October 1999 and November 2000 were enrolled in our study and followed prospectively. Electronic medical records were accessed for data on comorbid conditions, medications, echocardiogram results and mortality information. Mean follow-up was 2.7 years. RESULTS: Of 495 patients with HF due to systolic dysfunction enrolled in the study, 293 (59%) had diabetes. Prevalence of hypertension, diuretic use and angiotensin converting enzyme inhibitor use was higher among diabetics. Beta-blocker usage was equal and high in both groups (60%). On follow-up, 109/273 (37%) patients in the diabetic group died, compared with 49/202 (24%) in the non-diabetic group. Independent predictors of death were diabetes (p<0.005, OR=1.73), age at enrollment (p<0.0001, OR=1.06), serum creatinine (p<0.01, OR=1.44) and diuretic use (p=0.038, OR=1.85). Beta-blocker use was associated with a decreased risk of death on univariate analysis only. CONCLUSIONS: Our results show that diabetic patients with HF continue to have higher mortality than non-diabetic patients with HF despite advances in therapy.

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine.

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.

Diabetes status and racial differences in post-myocardial infarction mortality.

BACKGROUND: Prior studies regarding the effect of racial status on post-myocardial infarction (MI) in subjects with diabetes have yielded conflicting results. We evaluated the effect of diabetes status on racial differences in post-MI mortality and morbidity for a 7-year period, from 1990 through 1997. METHODS: All patients discharged with the primary diagnosis of acute MI from any Veterans Affairs Medical Center in the country between October 1990 and September 1997 were identified. Demographic, comorbid conditions, inpatient, outpatient, mortality, and readmission data were extracted. Mortality, revascularization, readmissions, and length of hospital stay for MI were compared for the group with diabetes and that without diabetes. Comparison was made between black and white patients. Independent predictors of survival using a Cox regression model were examined. RESULTS: We identified 67,889 patients with MI of whom 17,756 (26%) had diabetes. Race status was known for 66,506 subjects of whom 55,731 (84%) were white and 8437 (13%) were black. Regardless of the race, the diabetic patients tended to have higher mortality than nondiabetic patients. The post-MI mortality during the entire follow-up period tended to be similar between blacks and whites for the nondiabetic patients, whereas the mortality tended to be lower in blacks than in whites in diabetic patients. CONCLUSIONS: Mortality from post-MI is significantly lower in blacks with diabetes than in whites with diabetes. In contrast, no racial difference in long-term mortality was seen among subjects without diabetes. Thus, it appears that diabetes status determines racial variation in post-MI mortality. The reasons for better survival post-MI of blacks in general and among subjects with diabetes in particular need to be further investigated.

Secular trends in prevalence of diabetes among younger patients admitted with acute myocardial infarction.

BACKGROUND: Diabetes prevalence is increasing in the population, both in the young and the elderly. We assessed the impact of increasing prevalence of diabetes on admissions for acute myocardial infarctions (MI) from 1990 through 1997. METHODS AND RESULTS: We retrospectively identified all patients discharged with the primary diagnosis of MI from any Veteran's Affairs Medical Center (VAMC) in the country between October 1990 and September 1997. Patients were classified as having diabetes from the ICD-9-CM codes and stratified by age. Demographic data were extracted from the patient treatment files. Prevalence of diabetes among MI patients for the years 1990 through 1997 was compared to that in the general population obtained from the Center for Disease Control. We identified 67,889 patients with MI of whom 17,756 (26%) had diabetes. In the age group < or =44 years, the prevalence of diabetes remained at approximately 11.5% from 1991 to 1998. In the age group 45-64 years, the increase was from 23% to 28%--a 23% increase (p<0.001), while in the older age group over 65 years, it increased from 25% to 33.5%--a 34% increase (p<0.001). In the general population, prevalence of diabetes increased by 50%, 63% and 44% in the three age groups. CONCLUSIONS: Despite substantial increase in prevalence of diabetes among the younger population, it does not appear to be predisposing them to increased risk for MI. The prevalence of diabetes among older patients with MI paralleled the increase seen in the general population with the steepest increase seen in the group > or =65 years. These data are important in focusing our resources for preventive measures.

Similar decline in post-myocardial infarction mortality among subjects with and without diabetes.

BACKGROUND: Data from the 1970s and 1980s suggest that the rate of mortality from coronary disease for patients with diabetes has changed less than that for patients without diabetes. We evaluated trends in post-myocardial infarction mortality and morbidity in patients with and without diabetes over a 7-year period from 1990 through 1997, when substantial changes occurred in the management of coronary disease. METHODS: All patients discharged with the primary diagnosis of acute myocardial infarction (MI) from any Veterans Affairs Medical Center in the country between October 1990 and September 1997 were identified. Demographic, comorbid conditions, inpatient, outpatient, mortality, and readmission data were extracted. Mortality, trends in mortality over time, revascularization, readmissions, and length of hospital stay for MI were compared for the group with diabetes and the group without diabetes. Independent predictors of survival using a Cox regression model were examined. RESULTS: We identified 67,889 patients with MI, of whom 17,756 (26%) had diabetes. At 60 days post-MI, there was a 29% higher mortality rate in the group with diabetes (5.2% versus 4.0%, P < 0.001), which increased to 35% at 1 year (16.1% versus 11.9%, P < 0.001). Diabetes was independently associated with increased overall mortality. Age-adjusted 1-year post-MI mortality from 1991 to 1998 had a significant downward trend (4.9% decrease in odds of mortality per year, P < 0.001) regardless of diabetes status. CONCLUSIONS: Patients with diabetes showed a trend toward declining 1-year post-MI mortality rate that was not significantly different from that seen in patients without diabetes. Further work needs to be done to narrow the gap between the two groups.

Patient perception and provider assessment of severity of heart failure as predictors of hospitalization.

OBJECTIVE: To assess the agreement between 2 methods of assigning New York Heart Association (NYHA) functional class to patients with chronic heart failure (CHF): deriving NYHA class from self-report interview data versus clinician assignment. To then determine the ability of each method to predict all-cause hospitalization. METHODS: Adults with CHF > or = 50 years old from an urban health system in Indianapolis, Indiana, were administered the Kansas City Cardiomyopathy Questionnaire (a validated CHF symptom questionnaire) at baseline. Patient self-reported functional data were then used to derive NYHA class. Clinical providers who were blinded to patients' questionnaire data independently assessed NYHA functional class. We used a weighted kappa statistic to evaluate the agreement between the NYHA class from patient-derived and that from provider-assigned methods. We then assessed the ability of patient and provider NYHA to predict time to hospitalization using Cox proportional hazards models. RESULTS: Of 156 patients with complete 6-month follow-up (mean age 63 years +/- 9 SD, 53% African American, and 68% women), the correlation coefficient was 0.43 between the patient-derived and provider-assigned NYHA methods. The weighted kappa statistic was 0.278, and the 95% confidence interval was 0.18 to 0.37, indicating only slight agreement. Patients classified themselves in worse categories than did their providers. Provider-assigned NYHA was a better predictor of hospitalization (P = .06). CONCLUSIONS: There is only slight agreement between patient-derived and clinician-assigned NYHA functional class. A different approach with patients may be needed if providers hope to use patients' reports to identify those at risk for hospitalization.

A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure.

BACKGROUND: Heart failure is common and associated with considerable morbidity and cost, yet physician adherence to treatment guidelines is suboptimal. We conducted a randomized controlled study to determine if adding symptom information to evidence-based, computer-generated care suggestions would affect treatment decisions among primary care physicians caring for outpatients with heart failure at two Veterans Affairs medical centers. METHODS: Physicians were randomly assigned to receive either care suggestions generated with electronic medical record data and symptom data obtained from questionnaires mailed to patients within 2 weeks of scheduled outpatient visits (intervention group) or suggestions generated with electronic medical record data alone (control group). Patients had to have a diagnosis of heart failure and objective evidence of left ventricular systolic dysfunction. We assessed physician adherence to heart failure guidelines, as well as patients' New York Heart Association (NYHA) class, quality of life, satisfaction with care, hospitalizations, and outpatient visits, at 6 and 12 months after enrollment. RESULTS: Patients in the intervention (n = 355) and control (n = 365) groups were similar at baseline. At 12 months, there were no significant differences in adherence to care suggestions between physicians in the intervention and control groups (33% vs. 30%, P = 0.4). There were also no significant changes in NYHA class (P = 0.1) and quality-of-life measures (P >0.1), as well as no differences in the number of outpatient visits between intervention and control patients (6.7 vs. 7.1 visits, P = 0.48). Intervention patients were more satisfied with their physicians (P = 0.02) and primary care visit (P = 0.02), but had more all-cause hospitalizations at 6 months (1.5 vs. 0.7 hospitalizations, P = 0.0002) and 12 months (2.3 vs. 1.7 hospitalizations, P = 0.05). CONCLUSION: Adding symptom information to computer-generated care suggestions for patients with heart failure did not affect physician treatment decisions or improve patient outcomes.