Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission
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Transcript of Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission
Effects of Multidisciplinary Care Effects of Multidisciplinary Care ofof
Heart Failure Patients at Heart Failure Patients at High Risk for Hospital AdmissionHigh Risk for Hospital Admission
S. Scott Sutton, Pharm.D.Associate Clinical Professor
South Carolina College of Pharmacy
University of South Carolina & Medical University of South Carolina
WJB Dorn Veterans Administration Medical Center
Columbia, South Carolina
ObjectivesObjectives
• SCSHP Program agenda:
• Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients.
Research TeamResearch Team• S. Scott Sutton, Pharm.D.• Meg Franklin, Pharm.D., Ph.D.• C.E. (Gene) Reeder, RPh, Ph.D.• Frank Laws, M.D.
• HF Research - Abstracts / Posters & PublicationsHF Research - Abstracts / Posters & Publications:
– Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission
• American Heart Association• University of South Carolina School of Medicine / Palmetto Health Biomedical
Research Program• Drug Benefit Trends 2008;20:54-59
– Economic Evaluation of a Multidisciplinary Approach to Heart Failure Management
• International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 11 th Annual International Meeting
– Predicting Heart Failure Related Events in Patients Enrolled in an Outpatient Specialty Clinic in the VA System
• In progress
Heart FailureHeart Failure
• Key ConceptsKey Concepts
– Complex clinical syndrome• Dyspnea• Fatigue
– Proven treatments• Decrease morbidity and mortality• Decrease health care expenditures
– Angiotension converting enzyme inhibitors– Beta-blockers– Multidisciplinary care– Pharmacist
Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Arch Intern Med 1999;159:1939-1945Can J Cardiol 2004;20:1205-1211
Heart FailureHeart Failure
• Key ConceptsKey Concepts
– Complex clinical syndrome• Dyspnea• Fatigue
– Proven treatmentsProven treatments• Decrease morbidity and
mortality• Decrease health care
expenditures– Angiotension converting
enzyme inhibitors– Beta-blockers– Multidisciplinary care– Pharmacist
• 11,000 patients– ACEI and BB
• 62 and 37%
Suboptimal treatment may lead to:Increased mortalityIncreased healthcare expenditures
Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Arch Intern Med 1999;159:1939-1945Can J Cardiol 2004;20:1205-1211
New York Heart Classification
• Class I: – no limitation is experienced in any activities; there are
no symptoms from ordinary activities. • Class II:
– slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: – marked limitation of any activity; the patient is
comfortable only at rest. • Class IV:
– any physical activity brings on discomfort and symptoms occur at rest.
Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018
American College of CardiologyAmerican College of CardiologyAmerican Heart AssociationAmerican Heart Association
• Stage AStage A: – a high risk HF in the future but no structural heart disorder;
• Stage BStage B: – a structural heart disorder but no symptoms at any stage;
• Stage CStage C: – previous or current symptoms of heart failure in the context of an
underlying structural heart problem, but managed with medical treatment;
• Stage DStage D: – advanced disease requiring hospital-based support, a heart
transplant or palliative care
Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018
Heart FailureHeart Failure
• Common model of treatment
– ReactiveReactive• Patient perceives problem and makes appointment with
clinician.• Ideal model provides continuous care coordination and
support
– Current HF Treatment ModelCurrent HF Treatment Model• 12-15 million office visits• 6.5 million hospital bed days• More Medicare dollars than other single diagnosis• 27.9 billion in direct and indirect
Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Heart 2005;91:849-850
HFHF - Pharmacologic Management - Pharmacologic Management
• Angiotension Converting Enzyme InhibitorsAngiotension Converting Enzyme Inhibitors
– CONCENSUSCONCENSUS• Enalapril versus placebo – NYHA IV
– SOLVDSOLVD• Enalapril versus placebo – NYHA II-IV
– ATLASATLAS• Low dose versus high dose lisinopril – NYHAII-IV
NEJM 1987;316;1429-35NEJM 1991;325:293-302Circulation 1999;100:2312-8
HF - Pharmacologic Management
• Angiotension Converting Enzyme InhibitorsAngiotension Converting Enzyme Inhibitors
– Heart Failure – NYHA I-II• ACE Inhibitor x 1 year• 100 treated to prevent 1 death (number needed to treat - NNT)
– Heart Failure – NYHA IV• ACE Inhibitor x 1 year• 6 treated to prevent 1 death (NNT)
– Heart Failure – post MI• ACE Inhibitor• 18 treated to prevent 1 death (NNT)
NEJM 1987;316;1429-35NEJM 1991;325:293-302Circulation 1999;100:2312-8Bandolier
HF - Pharmacologic Management
• Beta-Blockers - Beta-Blockers - (Number needed to treat 14-22)
– CIBIS-IICIBIS-II• Bisoprolol versus placebo – NYHA III-IV
– US Carvedilol Heart Failure StudyUS Carvedilol Heart Failure Study• Carvediolol versus placebo – NYHA II-IV
– Merit-HFMerit-HF• Metoprolol XL versus placebo – NYHA II-IV
– COMETCOMET• Carverdilol versus metoprolol tartrate – NYHA II-IV
– Only compared to immediate release metoprolol
Lancet 1999;353:9-13NEJM 1996;334:1349-55Lancet 1999;353:2001-7Lancet 2003:362:7-13
HF - Pharmacologic Management
Outcome # of trials Beta-blocker
Control Relative risk (95% CI)
NNT (95% CI)
Mortality 14 443/5366 682/4867 0.62 (0.55-0.69)
17 (14-22)
Mortality or Hospital admission
9 1401/5035 1655/4610 0.81 (0.76-0.86)
12 (10-16)
Hospital admission
13 613/5301 833/4827 0.67 (0.61-0.74)
17 (14-23)
Beta-BlockersBeta-Blockers
Bandolier - http://www.jr2.ox.ac.uk/bandolier/booth/AF/betamort.html
HF - Pharmacologic Management
• Aldosterone AntagonistsAldosterone Antagonists
– RALESRALES• Spironolactone versus placebo – NYHA III-IVSpironolactone versus placebo – NYHA III-IV• NNT (all-cause mortality) 10NNT (all-cause mortality) 10
– EPHESUSEPHESUS• Eplerenone versus placebo – acute MI with LV
dysfunction• NNT (all-cause mortality) 44
NEJM 1999;341(10):709-17NEJM 2003;348:1309-21
HFHF nonnon-Pharmacologic Management-Pharmacologic Management
• Multidisciplinary ClinicsMultidisciplinary Clinics
– Decrease mortality Rates• Mortality rate similar to that of ACE Inhibitors
– Reduce hospital admission rates• All cause hospital admission – 13%• HF admissions by 30%
– Decrease use of health-care resources
Heart 2005;91:899-906Chest 2005;127:173:40-45
HFHF nonnon-Pharmacologic Management-Pharmacologic Management• Home-based interventions
– Decreased:• All cause-admission• HF related admission• Mean days in the hospital
• Telephone-based interventions– Decreased:
• Mortality• HF admissions
Heart 2005;91:899-906
HFHF nonnon-Pharmacologic Management-Pharmacologic Management
• Randomized clinical trials based upon self-care:– Decreased:
• Readmission• Hospitalization days• Cost of care
• 2 key components– 1-to-1 patient education– Self-management recommendations
Heart 2005;91:899-906
Effects of Multidisciplinary CareEffects of Multidisciplinary CareMultidisciplinary Care
Trials Patients Intervention (% having event)
Control
(% having event)
Relative Risk (95% CI)
Number needed to Treat (95% CI)
All-cause mortality
12 2129 17 24 0.7 (0.6-0.9) 17 (11-38)
All-cause Admission
14 2273 41 51 0.8 (0.7-0.9) 10 (7-16)
HF Admission 9 1416 27 38 0.7 (0.6-0.8) 9 (6-17)
Journal American College of Cardiology 2004;44:810-819American Journal of Medicine 2001;110:378-84
Effects of Effects of Multidisciplinary Care of Multidisciplinary Care of Heart Failure Patients at Heart Failure Patients at
High Risk for Hospital High Risk for Hospital AdmissionAdmission
S. Scott Sutton, Pharm.D.Meg Franklin, Pharm.D., Ph.D.C.E. (Gene) Reeder, RPh, Ph.D.
Frank Laws, M.D.
Drug Benefit Trends 2008;20:54-59 (publication)
American Heart Association (abstract / poster presentation)
Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)
• Target PatientsTarget Patients – High readmission rates – Risks are identified
• Intervention DescribesIntervention Describes– Strategy to improve outcomes of patients with
chronic HF at the Dorn Veterans Administration Medical Center in Columbia, South Carolina
Drug Benefit Trends 2008;20:54-59
Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)
• Developed to provide comprehensive multidisciplinary management to persons with advanced HF.
• Inclusion criteria:– ACC/AHA stage C/D or NYHA III/IV– Hospitalized 2 or more times in 1-year period
Drug Benefit Trends 2008;20:54-59
Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)
• Goals:
– Decrease hospital admission & readmission
– Decrease health-care expenditures
– Improve quality of life
• AHFP Team:• Cardiologist• Internal Medicine
Specialist• Nurse Practitioner• Nurse• Case Managers• Physician assistants• Pharmacists• Clinical Researchers
Drug Benefit Trends 2008;20:54-59
AHFPAHFPHF Patients
NYHA Class III/IV or AHA Class C/D
Enroll in HF Clinic
Initial Visit Every 2 Weeks for 2 Months,
Then Monthly ThereafterPRN
Infusion Clinic
Episodic Management in Clinic
Emergency Department/ Readmission
Patient MonitoringWeight
Blood PressurePeak Flow
Daily symptoms
Clinic MonitoringLabsBNPICG
Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)
• Once enrolled into AHFP– Patients presented every 2 weeks for first 2 months
• Monthly thereafter
• Initial Visit– Extensive evaluation
• Physical• Diagnostic• Laboratory• Medication• Quality of Life Evaluation
Drug Benefit Trends 2008;20:54-59
Drug Benefit Trends 2008;20:54-59
Initial Visit$1051.92Subsequent visits$141.7350 Week Cost$3036.14
AHFP CostsAHFP Costs
Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)
• Once enrolled into AHFP– Patients presented every 2 weeks for first 2 months
• Monthly thereafter
• Initial Visit– Extensive evaluation
• Physical• Diagnostic• Laboratory• MedicationMedication• Quality of Life Evaluation
Drug Benefit Trends 2008;20:54-59
Medication EvaluationMedication EvaluationAHFP Medications (pending indications)
LisinoprilFurosemideCarvedilolSpironolactone
Other medications potentially utilized DigoxinValsartanPotassium Chloride
Patient Population Local versus National
0
10
20
30
40
50
60
70
DM HF HTN Lipid Obesity COPD
Columbia National
PREVALENCE
Drug Benefit Trends 2008;20:54-59
AHFP - ResultsAHFP - Results
0
0.5
1
1.5
2
2.5
3
3.5
Pre-AHFP
Post-AHFP
Baseline CharacteristicsBaseline Characteristics Hospital Readmission Rates Hospital Readmission Rates per Patientper Patient
Drug Benefit Trends 2008;20:54-59
ObjectivesObjectives
• SCSHP Program agenda:
• Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients.
• Implications to clinicians