Online Appendix: Classification of reasons for not prescribing guideline-recommended drugs
- Appendix to: Steinman MA et al. Age and receipt of guideline-recommended medications for heart failure: a nationwide study of veterans. J Gen Intern Med 2011
Reason / EPRP definition / Computerized clinical data
ACE inhibitors / ARBs
Drug allergy or sensitivity / Specific reference in the record to ACE allergy or sensitivity. Also includes history of angioedema, hives, or rash with ACEI use; or
Specific reference in the record to ARB allergy or sensitivity. Also includes history of angioedema, hives, or rash with ARB use.
Recent serum potassium > 5.5 or creatinine > 2.5 / Creatinine >2.5 in past year in outpatient or inpatient setting; or
Potassium >5.5 in past year in outpatient or inpatient setting
Contraindicating comorbidities
Renal artery stenosis
Aortic stenosis / Diagnosis of bilateral renal artery stenosis (assessed only for ARB)
Diagnosis of aortic stenosis with the description of moderate or severe. Includes both a current finding or a history of moderate or severe aortic stenosis without mention of repair, replacement, valvuloplasty, or commissurotomy. / >=1 encounter ICD9 diagnosis of renal artery stenosis in inpatient or outpatient setting
Patient refusal / Patient's direct refusal to take ACE inhibitor documented in the record; or
Patient's direct refusal to take ARB documented in the record
Other reasons / Documentation by MD, NP, or PA which explicitly links the noted reason with non-prescription of an ACE inhibitor. (Examples of other reasons for not prescribing an ACEI are diagnosis of renal artery stenosis, chronic dialysis, pregnancy, serum potassium > 5.5 meq/L that cannot be reduced, or symptomatic hypotension, documented by the MD, NP, or PA as specific reasons for non-use of an ACEI.) If the patient is on hydralazine and nitrates or an ARB, and the record documents this drug therapy is a better option than ACEI for the patient, this documentation is to be accepted as "other reason" and will be considered a contraindication; or
Documentation by MD, NP, or PA which explicitly links the noted reason with non-prescription of an ARB. (Examples of other reasons for not prescribing an ARB are chronic dialysis, pregnancy, serum potassium > 5.5 meq/L that cannot be reduced, or symptomatic hypotension, documented by the MD, NP, or PA as specific reasons for non-use of an ARB.)
Beta Blockers
Drug allergy or intolerance / Specific reference in the record to allergy or intolerance to beta-blockers
Systolic blood pressure <90 mm Hg or heart rate <60 bpm not on beta blocker / Documented by a clinician as the reason for non-use of a beta blocker
Contraindicating comorbidities
Asthma
Sick sinus syndrome
Atrioventricular block
Chronic obstructive pulmonary disease
Post-heart transplant / Second or third degree heart block on ECG and does not have a pacemaker. The ECG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the ECG interpretation does not have to be linked specifically to contraindication to beta-blocker.
Post-heart transplant patient / >=1 encounter ICD9 diagnosis of asthma in inpatient or outpatient setting
>=1 encounter ICD9 diagnosis of sick sinus syndrome in inpatient or outpatient setting
>=1 encounter ICD9 diagnosis of 2nd or 3rd degree atrioventricular block in inpatient or outpatient setting
>=1 hospital admission for which admission diagnosis is chronic obstructive pulmonary disease (hospitalization as marker of disease severity)
Severely decompensated heart failure / Cardiac decompensation is marked by dyspnea, venous engorgement, and edema. Abstractor may not make this decision based on symptoms described in record; there must be specific notation or diagnosis by a clinician.
Patient refusal / At time beta blocker prescribed, patient stated he/she would not take this medication.
Other reasons / MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker. COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma