Heart Failure among Older Home Care Clients: An Examination of Client Needs, Medication Use and Outcomes
Foebel, Andrea Dawn
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Population aging in Canada is associated with a rising burden of heart failure (HF), a condition associated with substantial morbidity, mortality and health service use. HF management involves pharmacotherapy, exercise, dietary restrictions and symptom monitoring. First-line combination pharmacotherapy for HF consists of an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) in conjunction with a β-adrenergic receptor blocker (β-blocker). This combination therapy can reduce mortality, improve symptoms and reduce health service use. However, evidence about the benefits of these therapies has been derived from randomized controlled trials in younger patients from acute care and specialty clinic settings. Little work has explored outcomes among older individuals and those in the community setting. In purposely studying an older cohort of individuals with HF, the goals of this research were three-fold: to comprehensively describe their sociodemographic, clinical and service use characteristics; to describe rates of usage of first-line HF pharmacotherapy and correlates of non-use; and to examine the outcomes of mortality, long-term care (LTC) admission, long-stay hospitalization, admission, new cognitive decline and new functional decline as well as predictors of these outcomes. To achieve these aims, this work made use of the extensive data available through the Resident Assessment Instrument – Home Care (RAI-HC) database in Ontario. The RAI-HC is mandated for use in Ontario to assess all long-stay home care clients (those expected to receive home care service for at least 60 days). This assessment contains over 300 items about sociodemographic and clinical characteristics, diagnoses, service use and geriatric conditions, such as functional abilities and cognition. The study samples included long-stay home care clients older than 65 years of age. The descriptive analyses (N=264,030) demonstrated that older home care clients with HF are a more complex group than home care clients without HF, with more comorbidity and higher use of medications and health care services. From the analyses examining pharmacotherapy use (N=176,860), rates of use of first-line pharmacotherapy were low, with only 30% of clients with HF receiving recommended combination first-line therapies, a similar proportion receiving no therapies and the remainder receiving at least one therapy. The multivariate analyses revealed that hypertension and diabetes mellitus diagnoses affect first-line therapy use. Regardless of clinical subgroup, use of these therapies was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Longitudinal analyses were done using Cox proportional hazards regression modeling (N=9,283) in which individuals were followed for nine months after each RAI-HC assessment. Results from these analyses showed that female gender and living alone reduced the risk of all outcomes except LTC admission, while age over 85 years generally increased the risk of all examined outcomes. Comprehensive clinical indicators, the Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale and Method for Assigning Priority Level (MAPLe) algorithm, increased the risk of all outcomes except new cognitive decline. ACE inhibitor use was protective of LTC admission and functional decline, but not mortality, long-stay hospitalizations or cognitive decline. The complexity of older individuals with HF could impair self-care abilities and points to the need for initiatives to help such individuals manage their care at home with appropriate support and services. The low rates of use of first-line pharmacotherapy among older home care clients with HF highlights the need for better understanding of which factors affect prescribing practices. Better evidence, that is more applicable to older individuals with HF, is needed about the therapeutic benefits of first-line therapies to help enhance the evidence base and improve patient care.