Letters

Figure. Number of Medication Changes

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14

12

10

8

Older Veterans, % Older Veterans, 6

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0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 ≥20 Medication Changes, No.

needed. Nonetheless, the number of medication changes may preparation, review, or approval of the manuscript; and decision to submit the serve as a novel, valuable, and readily measurable marker of manuscript for publication. patients at high risk of medication-related problems and may Additional Contributions: The authors thank Kathy Z. Fung, MS, of the San Francisco VA Medical Center for her assistance compiling data for this manu- help identify patients who should be targeted for close atten- script and the residents of the Primary Medical Education Program (PRIME) at tion and follow-up. the University of California, San Francisco and the San Francisco VA Medical Center for their feedback on manuscript drafts. None of these persons received Khoa D. Lam, MD compensation for their assistance with this manuscript beyond that earned in the course of their standard academic duties. Yinghui Miao, MPH 1. Van Wijk BL, Klungel OH, Heerdink ER, de Boer A. The association between Michael A. Steinman, MD compliance with antihypertensive drugs and modification of antihypertensive drug regimen. J Hypertens. 2004;22(9):1831-1837. Author Affiliations: Department of Medicine, University of California, San 2. Choudhry NK, Fischer MA, Avorn J, et al. The implications of therapeutic Francisco (Lam, Steinman); San Francisco VA Medical Center, San Francisco complexity on adherence to cardiovascular medications. Arch Intern Med. (Lam, Miao, Steinman); Division of , University of California, San 2011;171(9):814-822. Francisco (Miao, Steinman). 3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events Corresponding Author: Michael A. Steinman, MD, San Francisco VA Medical occurring following hospital discharge. J Gen Intern Med. 2005;20(4):317-323. Center, 4150 Clement St, PO Box 181G, San Francisco, CA 94121 (mike.steinman @ucsf.edu). 4. George J, Phun Y-T, Bailey MJ, Kong DCM, Stewart K. Development and validation of the medication regimen complexity index. Ann Pharmacother. Published Online: June 10, 2013. 2004;38(9):1369-1376. doi:10.1001/jamainternmed.2013.7060. 5. Solem CT, Lee TA, Joo MJ, Lambert BL, Walton SM, Pickard AS. Complexity of Author Contributions: All authors had full access to all the data in the study medication use in newly diagnosed chronic obstructive pulmonary disease and take responsibility for the integrity of the data and the accuracy of the data patients. Am J Geriatr Pharmacother. 2012;10(2):110-122; e1. analysis. Study concept and design: Lam and Steinman. Acquisition of data: Steinman. Analysis and interpretation of data: Lam, Miao, and Steinman. Contraindicated Initiation of β-Blocker Therapy Drafting of the manuscript: Lam. in Patients Hospitalized for Heart Failure Critical revision of the manuscript for important intellectual content: Lam, Miao, To increase β-blocker treatment for patients with heart and Steinman. Statistical analysis: Miao. failure and left ventricular systolic dysfunction, re- Obtained funding: Steinman. cently updated performance measures recommend that Administrative, technical, and material support: Steinman. oral β-blocker therapy be started by the time of hospital Study supervision: Steinman. discharge in patients hospitalized for decompensated Conflict of Interest Disclosures: None reported. systolic heart failure.1 These performance measures Funding/Support: This research was supported by grant RC1-AG036377 from make clear that patients in whom a β-blocker therapy is the National Institute on Aging and grant 1K23-AG030999 from the National Institute on Aging and the American Federation for Aging Research. started Role of the Sponsors: The funders had no role in the design and conduct of the should not be hospitalized in an intensive care unit [ICU], study; collection, management, analysis, and interpretation of the data; and should have no or minimal evidence of fluid overload or vol-

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ume depletion, and should not have required recent treatment Figure. Potential Contraindications to Therapy with an intravenous positive inotropic agent.1(p2393) 50 Primary cohort To assess current patterns of β-blocker therapy initiation in 45 40 Age-restricted cohort these patients at risk for worsening clinical instability from 35 AMI-restricted cohort β-blocker use, we examined a large, contemporary cohort of 30 heart failure hospitalizations in the United States. 25 20 15

Methods | We conducted a retrospective cohort study using Per- Hospitalizations, % 10 spective, a voluntary, fee-supported database developed by 5 0 Premier Inc for measuring quality and health care utilization. ICU on Day IV Inotropes IV Diuresis Any Potential As of 2010, Perspective contained data on more than 130 mil- of Discharge During on Day of Contraindication Hospitalization Discharge lion cumulative hospital

discharges, representing Proportion of patients hospitalized for heart failure receiving a new β-blocker Editor's Note page 1549 approximately 20% of an- prescription at discharge despite potential contraindications to therapy. nual acute care hospitaliza- AMI indicates acute myocardial infarction; ICU, intensive care unit; and IV, intravenous. Supplemental content at tions in the United States. jamainternalmedicine.com In addition to the informa- tion available in the stan- dard hospital discharge file, Perspective contains a date- stamped log of all billed items at the patient level including the day of discharge, considered to reflect ongoing volume diagnostic tests, medications, and therapeutic services. Per- overload; and (3) after having received an intravenous ino- spective has been previously used to describe the pharma- trope including dobutamine, milrinone, or dopamine during cologic treatment of hospitalized patients.2,3 Perspective is hospitalization. not publicly available; access to the database was provided We calculated summary statistics using frequencies and under contract with Premier Inc. percentages with SAS version 9.2 software (SAS Institute Inc). The Yale University Human Investigation Committee re- viewed the protocol and determined that it was not consid- Results | We identified 217 550, 15 108, and 5154 heart failure ered human subjects research according to the Office of Hu- hospitalizations from the primary (P), age-restricted (A-R), man Research Protections. We included hospitalizations from and acute myocardial infarction–restricted (AMI-R) cohorts, 2009 and 2010 for patients 18 years or older with a principal respectively. In the 3 cohorts, the median patient age was 76 discharge diagnosis of heart failure by International Classifi- (P), 44 (A-R), and 76 (AMI-R) years (eTable 1 in the Supple- cation of Diseases, Ninth Revision, Clinical Modification (ICD- ment). Patients in the P cohort were similar to that of a large 9-CM) codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, heart failure registry.6 β-Blockers were administered in 404.13, 404.91, 404.93, and 428.xx. We excluded hospitaliza- 71.6% (P), 76.6% (A-R), and 73.4% (AMI-R) of hospitaliza- tions that involved transfers from another acute care facility tions in each cohort during the first 2 hospital days (eTable 2 or that had an unknown admission source because informa- in the Supplement). Following hospital day 2, β-blocker tion about treatment at the referring institution was unavail- therapy was started in 7.1% (P), 7.3% (A-R), and 10.7% able. We further excluded hospitalizations with a pediatric at- (AMI-R) of hospitalizations in each cohort. The hospitaliza- tending physician to concentrate on care patterns of physicians tions in which β-blocker therapy was started comprised who treat adults. For sensitivity analyses, we examined 2 ad- 24.9% (P), 30.9% (A-R), and 40.4% (AMI-R) of all heart fail- ditional heart failure cohorts with greater specificity for sys- ure hospitalizations potentially eligible for β-blocker tolic dysfunction4,5: (1) heart failure hospitalizations involv- therapy initiation. More than 40% of β-blocker therapy ing patients aged 18 to 49 years and (2) heart failure starters had at least 1 potential contraindication to treat- hospitalizations with acute myocardial infarction as a second- ment (Figure). Approximately one-third received concomi- ary ICD-9-CM discharge diagnosis. tant intravenous diuretics on the day of discharge, and up to For each cohort, we identified hospitalizations during one-fifth had received intravenous inotropes during hospi- which oral β-blocker therapy was started. β-Blocker therapy talization. Potential contraindications were higher among initiation was defined as (1) no evidence of oral β-blocker cohorts with higher specificity for systolic dysfunction. treatment during hospital days 1 to 2, and (2) oral β-blocker treatment on the day of hospital discharge. Length of stay Discussion | Even before performance measures encourage the was therefore 3 days or more for all patients. Oral β-blockers further use of β-blockers during hospitalization for heart fail- included metoprolol succinate, carvedilol, bisoprolol, and ure, there is evidence from a large, contemporary database that 13 non–guideline-approved agents. We calculated the per- these agents are frequently started in patients with markers centage of β-blocker therapy starters receiving these agents of clinical instability. Further research is needed to confirm in potentially contraindicated situations as defined by the these care patterns and examine the outcomes associated with following performance measures: (1) while being cared for β-blocker therapy initiation in settings with and without po- in an ICU; (2) while receiving intravenous loop diuretics on tential contraindications to treatment. In the interim, to avoid

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unintended consequences that may result from the unselec- Improvement. ACCF/AHA/AMA-PCPI 2011 performance measures for adults tive application of this performance measure,7,8 itmaybepru- with heart failure. Circulation. 2012;125(19):2382-2401. dent to explore metrics that also assess medication overuse to 2. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac avoid treating those at higher risk for adverse consequences surgery. N Engl J Med. 2005;353(4):349-361. of therapy. 3. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of Kumar Dharmarajan, MD, MBA treatment failure in acute exacerbation of chronic obstructive pulmonary Frederick A. Masoudi, MD, MSPH disease. JAMA. 2010;303(23):2359-2367. John A. Spertus, MD, MPH 4. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure, part I: diagnosis, prognosis, and measurements of diastolic Shu-Xia Li, PhD function. Circulation. 2002;105(11):1387-1393. Harlan M. Krumholz, MD, SM 5. Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection Author Affiliations: Division of Cardiology, Columbia University Medical Center, fraction: prevalence and mortality in a population-based cohort. JAmColl New York, New York (Dharmarajan); Division of Cardiology, University of Cardiol. 1999;33(7):1948-1955. Colorado Anschutz Medical Campus, Aurora (Masoudi); St Luke’s Mid America 6. Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW; Heart Institute/University of Missouri, Kansas City (Spertus); Center for ADHERE Scientific Advisory Committee and Investigators. Temporal trends Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, in clinical characteristics, treatments, and outcomes for heart failure Connecticut (Dharmarajan, Li, Krumholz); Section of Health Policy and hospitalizations, 2002 to 2004: findings from Acute Decompensated Administration, Yale School of Public Health, New Haven, Connecticut Heart Failure National Registry (ADHERE). Am Heart J. 2007;153(6):1021-1028 (Krumholz); Robert Wood Johnson Clinical Scholars Program and Section of . Cardiovascular Medicine, Department of Medicine, Yale University School of 7. Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired Medicine, New Haven, Connecticut (Krumholz). pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h Corresponding Author: Kumar Dharmarajan, MD, MBA, Center for Outcomes antibiotic administration rule. Chest. 2007;131(6):1865-1869. Research and Evaluation, Yale–New Haven Hospital, 1 Church St, Ste 200, New 8. Baker DW, Qaseem A; American College of Physicians’ Performance Haven, CT 06510 ([email protected]). Measurement Committee. Evidence-based performance measures: preventing Published Online: June 24, 2013. unintended consequences of quality measurement. Ann Intern Med. doi:10.1001/jamainternmed.2013.7717. 2011;155(9):638-640. Author Contributions: Drs Dharmarajan, Li, and Krumholz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Editor's Note Study concept and design: Dharmarajan, Krumholz. Performance Measures: Better Outcomes, Not Better Grades Acquisition of data: Li, Krumholz. Analysis and interpretation of data: Dharmarajan, Masoudi, Spertus, Li, Performance measures are widely used with the goal of Krumholz. improving care of patients with heart failure and other ill- Drafting of the manuscript: Dharmarajan, Li, Krumholz. Critical revision of the manuscript for important intellectual content: nesses. This study by Dharmarajan et al illustrates that per- Dharmarajan, Masoudi, Spertus, Krumholz. formance measures may sometimes have unintended con- Statistical analysis: Dharmarajan, Li. sequences. The authors show that in the enthusiasm to Obtained funding: Krumholz. achieve the measure of placing patients with heart failure Administrative, technical, and material support: Krumholz. Study supervision: Krumholz. on β-blocker therapy at hospital discharge, many patients Conflict of Interest Disclosures: Drs Masoudi and Spertus report serving on who should not receive β-blockers are getting them, while the writing committee for the development of the American College of Cardiol- others who meet the criteria are not. It is likely that there ogy Foundation/American Heart Association/American Medical Association– was more thoughtful discussion and decision making Physician Consortium for Performance Improvement 2011 Performance Mea- behind these decisions that is not captured in administra- sures for Adults With Heart Failure. Dr Masoudi also reports having contracts with the Oklahoma Foundation for Medical Quality and the American College of tive data used for this analysis. However, it must also be Cardiology Foundation. Dr Spertus reports that he serves on a cardiac scientific remembered that the purpose of performance measures is advisory board for UnitedHealth. Dr Krumholz reports that he is the recipient of to improve patient care, not to get high grades. Too much a research grant from Medtronic Inc through Yale University and is chair of a cardiac scientific advisory board for UnitedHealth. focus on meeting a target can distract us from the care of Funding/Support: This project was supported by grant DF10-301 from the the whole patient. Patrick and Catherine Weldon Donaghue Medical Research Foundation in West Hartford, Connecticut; grant UL1 RR024139-06S1 from the National Center for Rita F. Redberg, MD, MSc Advancing Translational Sciences in Bethesda, Maryland; and grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale Published Online: June 24, 2013. University) from the National Heart, Lung, and Blood Institute in Bethesda. doi:10.1001/jamainternmed.2013.7769. Dr Dharmarajan is supported by grant HL007854 from the National Heart, Lung, and Blood Institute and is also supported as a Centers of Excellence Scholar in Geriatric Medicine at Yale by The John A. Hartford Foundation and the American Federation for Aging Research. Hepatitis C Virus Screening and Prevalence Among Role of the Sponsors: The funding sponsors had no role in the design and US Veterans in Department of Veterans Affairs Care conduct of the study; in the collection, management, analysis, and From 2.7 to 3.9 million Americans are living with hepatitis C interpretation of the data; or in the preparation, review, or approval of the virus (HCV) , and 45% to 85% are unaware they are manuscript. infected.1-4 In August 2012, the Centers for Disease Control 1. Bonow RO, Ganiats TG, Beam CT, et al; American College of Cardiology Foundation; American Heart Association Task Force on Performance Measures; and Prevention (CDC) began recommending 1-time HCV American Medical Association-Physician Consortium for Performance screening for persons born from 1945 through 1965 because

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