Clinical InvestigationHeart FailureFacility variation and predictors of serum potassium monitoring after initiation of a mineralocorticoid receptor antagonist in patients with heart failure
Section snippets
Patients
We identified all patients with an inpatient or outpatient diagnosis of HF who were dispensed an initial prescription of spironolactone or eplerenone from October 2003 to September 2013. Heart failure was characterized as having 2 or more outpatient or inpatient encounters with a HF diagnosis, or one primary discharge diagnosis of HF prior to the MRA prescription. To ensure that patients did not transfer their care to the VA while taking MRAs that were prescribed at a non-VA institution or were
Results
We identified 145,259 patients with a diagnosis of HF who were dispensed a new MRA prescription from 2003 to 2013 and had at least 1 medication filled and 1 laboratory value in 6 months prior to MRA dispensing in the VA system. We then excluded 2,379 (1.6%) patients who died within 14 days of MRA dispensing, allowing for a total study population of 142,880 patients. Baseline patient and facility characteristics are shown in Table I. In total 59,425 (41.6%) of patients had serum potassium
Discussion
This study demonstrates that within the VA Health System, patients with HF who are initiated on an MRA have a low frequency of serum potassium monitoring. Only about 41.6% of patients with HF prescribed an MRA had serum potassium monitoring within 14 days of medication dispensing. Significant variation with regard to frequency of monitoring was noted across VA facilities, ranging from more than 50% for some facilities to a low of 19% for others. Over time from 2003 to 2013, the frequency of
Limitations
There are several potential limitations of this study. First, we were unable to distinguish between whether providers failed to order laboratory monitoring or if patients failed to adhere to recommendations for laboratory monitoring. Next, although our population was primarily male, frequencies of monitoring were similar for the women included in our study. As this study was limited to VA facilities, the results may not be applicable to facilities outside the VA. Other studies, however, have
Conclusions
In a multicenter national sample of veterans with HF who received an MRA, we found a low frequency of serum potassium monitoring. In addition, there was a significant variation in serum potassium monitoring at the facility level. In order to promote safety with MRA prescriptions, targeted systems should be implemented to improve patient and provider adherence to monitoring guidelines.
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Sean van Diepen, MD served as guest editor for this article.