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Original Investigation
November 10, 2021

Evaluation of Quality of Care for US Veterans With Recent-Onset Heart Failure With Reduced Ejection Fraction

Author Affiliations
  • 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
  • 2Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 3Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
  • 4Center for Digital Health, Stanford University, Stanford, California
  • 5Associate Editor, JAMA Cardiology
JAMA Cardiol. Published online November 10, 2021. doi:10.1001/jamacardio.2021.4585
Key Points

Question  What are the trends in guideline-directed medical therapy and mortality for patients with heart failure with reduced ejection fraction (HFrEF) in the US Department of Veterans Affairs (VA) health care system between July 1, 2013, and June 30, 2019?

Findings  In this cohort study of 144 074 patients with HFrEF, medical therapy rates increased slightly over the study period, but rates of mineralocorticoid receptor antagonist and angiotensin receptor-neprilysin inhibitor therapies remained below 30% in 2019, with substantial variation across VA facilities. A modest reduction in 1-year risk-adjusted mortality was also observed.

Meaning  This study found that, despite the availability of multiple therapies that were associated with reduced mortality among VA patients with HFrEF, treatment rates remained suboptimal, suggesting the need for new approaches to increase the uptake of evidence-based HFrEF treatment.


Importance  Multiple guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF) are available and promoted by performance measures. However, contemporary data on the use of these therapies are limited.

Objective  To evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among patients with recent-onset HFrEF.

Design, Setting, and Participants  This cohort study analyzed claims and electronic health record data of patients with recent-onset HFrEF diagnosed at US Department of Veterans Affairs (VA) health care system facilities from July 1, 2013, through June 30, 2019. Veterans who had a history of heart transplant or used a ventricular assist device were among the patients who were excluded.

Exposures  Guideline-directed medical therapy (any β-blocker, guideline-recommended β-blocker [bisoprolol, carvedilol, or metoprolol succinate], angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and hydralazine plus nitrate) and ICD.

Main Outcomes and Measures  Treatment rates for guideline-directed medical therapies and ICDs were calculated within 6 months of the index HFrEF date using medication fills, procedural codes for implantation and monitoring, and diagnosis codes. Risk-adjusted mortality was calculated after adjusting for baseline patient characteristics. For both treatment rates and risk-adjusted mortality, we evaluated the change over 3 periods (period 1: July 1, 2013, to June 30, 2015; period 2: July 1, 2015, to June 30, 2017; and period 3: July 1, 2017, to June 30, 2019) and variation across VA facilities.

Results  The final cohort comprised 144 074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. The cohort had a mean (SD) age of 71.0 (11.4) years and was mostly composed of men (140 765 [97.7%]). Overall, changes in medical therapy rates were minimal over time, with the use of a guideline-recommended β-blocker increasing from 64.2% in 2013 to 72.0% in 2019. Rates for mineralocorticoid receptor antagonist therapy increased from 23.9% in 2013 to 26.9% in 2019, and rates for hydralazine plus nitrate therapy remained stable at 24.2% over the study period. Rates for angiotensin receptor-neprilysin inhibitor therapy increased since its introduction in 2015 but only to 22.6% in 2019. Among patients with an ICD indication, early use rates decreased over time. Substantial variation in medical therapy rates persisted across VA facilities. Risk-adjusted mortality decreased over the study period from 19.9% (95% CI, 19.6%-20.2%) in July 1, 2013, to June 30, 2015, to 18.4% (95% CI, 18.0%-18.7%) in July 1, 2017, to June 30, 2019 (OR, 0.96 per additional year; 95% CI, 0.96-0.97).

Conclusions and Relevance  This study found only marginal improvement between 2013 and 2019 in the guideline-recommended therapy and mortality rates among patients with recent-onset HFrEF. New approaches to increase the uptake of evidence-based HFrEF treatment are urgently needed and could lead to larger reductions in mortality.

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