Drug Criteria & Outcomes-New practice modes can involve pharmacists
Last fall, Marc Silver, MD, a cardiologist who runs the congestive heart failure (CHF) center at Christ Hospital in Chicago, invited cardiologists and primary care physicians from the entire Advo cate Healthcare System in Oakbrook, IL, to spend a day talking about CHF and how care could be improved. About 100 people attended the "round table," which was held at nearby McDonald's corporate headquarters — Hamburger U.
"The purpose of the roundtable," explains Silver, "was to update everyone on where we stood with CHF initiatives across our system and to let them know how best to improve the outcomes of their patients with heart failure." While the cardiologist tried to get generalist physicians into the CHF treatment loop, many of the initiatives discussed can involve the hospital pharmacy department as well. Here are some highlights of the discussion and some suggestions on how to organize such an event in your facility.
- Prevention: Prevention is the "ultimate" solution and should be a daily practice. The presenters talked about the many secondary prevention measures. "We discussed preventing the diseases that cause CHF — diabetes and hypertension," says Silver. "We also talked about screening patients at high risk for developing CHF."
- Using the systemwide resources at Advocate: There are educational materials, home nursing, health advisors, support groups, and research and clinical trials. "We wanted to make sure cardiologists and primary care physicians alike know that there are CHF coordinators and CHF educational programs in place throughout this health system," says Silver. "We wanted to make sure they know that there's a lot of clinical research trials going on in CHF throughout the system, and they are available." Advocate also has a patient program called Health Advisor. Patients who sign up receive regular phone calls after discharge asking how their heart failure management is going. By virtue of those calls, Silver says, patients can improve their care at home.
- Tidbits: In this segment, the presenters talked about digoxin (Glaxo Wellcome's Lanoxin) and about spironolactone (Searle's Aldactone) and the Randomized Aldactone Evaluation Study (RALES) trial. They also discussed when to use angiotensin II receptor antagonists, the role of statins in CHF, salt restriction, and exercise. "These other modalities may be very helpful. Heart failure, like all chronic disease, is focused in the details."
- Using beta blockers at target dose: Clinical trials in more than 10,000 patients confirm that long-term treatment with beta blockers improves symptoms and clinical status and prevents hospitalization and death. This drug therapy can begin at the generalist's office visits. Doses are titrated slowly but progressively, with volume status evaluated.
- Using ACE inhibitors at target dose: All patients with CHF due to left ventricular dysfunction should receive an ACE inhibitor unless they have been shown to be intolerant, are elderly, or have a contraindication such as hypotension, renal insufficiency, hyperkalemia, or cough. ACE inhibitors also can decrease the risk of developing heart failure in asymptomatic patients with left ventricular dysfunction. Document their use (or adverse effect). Titrate up to target doses.
- Using standing orders: "A lot of the guidelines and consensus statements address outpatient care, but not so much that of inpatients," Silver says. "We decided to put our ideas into a set of working orders that tell people what steps to take to improve patient care." Standing orders for CHF patients are developed to make your life easier, to make documentation better, to guide proper therapy, and to help our patients. "We talked about the impetus to develop them, what they contain, and the importance of using them. We tried to get people to buy into using them in a consistent fashion and get their feedback on them."
- Using the emergency department: Estimates are that nearly half of the patients admitted can be safely discharged from the ED if the staff can be encouraged to use standing orders and work toward observation areas. Advocate's CHF orders initiate care right away in the ED — "It's fairly aggressive," he says. "In our Christ Hospital, where the CHF Institute is centered, we have a program in place to rapidly diurese people in the ED, and we're hoping to discharge at least 30% to 40% of patients who normally get admitted directly from the ED."
What's next? "The next step is to go back to each of the individual hospitals and revisit the same topics," Silver says. "We'll keep reinforcing them. Interest in this roundtable has been a very strong message from our system that CHF is a common problem that's not going away. In fact, the numbers are growing."
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