New research sheds light on improving discharge process for coronary patients

New therapies not always quickly adopted

Several new studies highlight the need for more thorough discharge planning in the care of coronary and congestive heart failure patients. Such patients often are elderly and susceptible to adverse events and drug-drug interactions from standard medication treatment.1

Also, there often is too long of a lag time from when new evidence leads to guidelines outlining a more optimal treatment to when the treatment is implemented by clinicians.2

This trend, in particular, is noted in the context of aldosterone antagonist use, in which less than one-third of eligible patients hospitalized for heart failure received aldosterone antagonist therapy as recommended in guidelines.3

The aldosterone antagonist-use study resulted from a review of the American Heart Association's heart failure database, says Nancy M. Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, director of nursing research and innovation in the Nursing Institute, and a clinical nurse specialist at the Kaufman Center for Heart Failure in Cleveland.

Investigators identified 12,565 patients eligible for aldosterone antagonist therapy out of a database of more than 43,000 heart failure patients. All of the eligible patients had been treated at hospitals that participated with the Get with the Guidelines Heart Failure Program by the American Heart Association, a quality improvement initiative to improve usage of recommended evidence-based therapies.3

Only 34% of eligible patients, at the end of 2007, had been given aldosterone antagonist therapy at discharge, Albert says.

Study findings reflect that physicians and discharge planners need to stay current with guidelines for managing heart failure, and they should develop systems or processes to enhance evidence-based practices, Albert says.

"They need to make sure patients are receiving optimal medical therapies that ultimately will improve survival and decrease hospitalization," she says.

Another study, published last fall in the American Journal of Geriatric Pharmacotherapy, showed that hospital clinicians generally were not offering medications that might be beneficial for elderly heart failure patients.1

For example, the use of ACE inhibitors in heart failure patients can be seen as an indicator of how well hospitals are taking care of these patients, says Judy W. M. Cheng, PharmD, MPH, FCCP, BCPS, RPh, professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences in Boston.

"And the percentage of use of ACE inhibitors is lower in elderly patients," Cheng says. "We don't know if these patients can't tolerate them, or if people are not as aggressive in treating their disease."

The problem with the drugs is they often cause patients' blood pressure to drop, or they might worsen kidney function, Cheng says.

"Because those patients are older, they're also more susceptible to experiencing orthostatic hypotension. When they change from lying down to sitting up, they get very dizzy, which is very common in older patients," she explains. "If patients are taking ACE inhibitors or beta blockers, which also impact blood pressure, then this will exacerbate this change in dropping blood pressure."

The aldosterone antagonist study's findings complement Cheng's research.

"It sometimes is difficult to add aldosterone antagonist, because people worry it will make patients' potassium levels dangerously higher," Cheng says.

"That makes physicians more reluctant to prescribe them," she adds. "So, a lot of times, they'll say, 'Let's discharge these patients and let the outpatient doctor take care of it.'"

Further research is looking at improving adherence to treatment guidelines for patients with cardiovascular disease.

The ongoing investigation suggests that hospitals can use electronic health records to rapidly identify patients who would benefit from medication adjustments, says Allen Kachalia, MD, JD, a medical director for quality and safety at Brigham & Women's Hospital in Boston.

In hospitals like Brigham & Women's Hospital, such electronic information could be communicated to physicians by e-mail, resulting in more rapid adherence to guidelines, he says.

"We're in the process of studying how effective this process is," Kachalia says. "This program was designed at Brigham to help Brigham primary care patients."

Investigators chose to communicate by having staff nurses e-mail physicians, because this method of communication doesn't disrupt doctors' workflow, he notes.

"In general, they all responded to us," Kachalia adds.

This particular study looks at how hospitals can improve the discharge process and reduce readmissions among patients with cardiovascular-related diseases, including diabetes, coronary artery disease, heart failure, stroke, and chronic kidney disease.2

"The discharge process represents an opportunity to identify people at high risk for readmission, and then we can plug them into a program that will help prevent readmission," Kachalia says.

The process employed by Brigham & Women's Hospital is relatively inexpensive, since it was done with 0.4 nursing FTEs and a little bit of Kachalia's time as medical director, he notes.

"I took the lead and looked at national guidelines, coming up with what the indications were," he explains. "Then, the team verified them, and for each disease, we went to a resident specialist and built in a list of what we'd screen people for and what medications to prescribe."

The specialists made sure the information was correct.

By engaging specialists in the process, the staff buy-in was easier to obtain, Kachalia says.

"We went to primary care physicians and would say, 'We looked at the guidelines, and our specialists say this is how we should operate,'" he says.

The primary care physicians agreed but made a suggestion: "They wanted e-mails sent much closer to when patients would come back to see them, rather than three months in advance," Kachalia says.

Hospital clinicians defer to primary care physicians on timing and ordering medications, but they follow cases continuously to make sure medications recommended in guidelines are prescribed, he says.

"We follow patients for three weeks after discharge and then follow indefinitely," he explains. "The idea is to have continuous monitoring, and we can do this with electronic charts."

The electronic health database can be programmed to provide reminders about checking up on patients or calling primary care physicians if there's a medication issue, Kachalia says.

The results of this process soon will be available.

"We're going to see what data show, and we hope we'll see a benefit that could result in a best practice," Kachalia says.

Clinicians involved in discharge planning should consider giving heart failure patients an ACE inhibitor to start, and The Joint Commission of Oakbrook Terrace, IL, wants documentation for reasons behind any decision not to prescribe ACE inhibitors when patients meet criteria for them, Cheng says.

In Cheng's research, this problem appears to be primarily in the care of elderly heart patients.

"I'm not sure why we're not meeting a high level of compliance," she says. "It's troubling."

If a hospital physician declines to prescribe an ACE inhibitor at discharge because he or she wants to leave the decision to the patient's community physician, then this can be a big mistake, she notes.

Hospital doctors might think the outpatient doctors will take care of these details, Cheng says.

But when patients see their community physicians, these doctors often think that if the hospital doctors didn't prescribe certain drugs, then maybe the patient doesn't need them, she adds.

The key is to improve discharge communication between hospital clinicians and patients, as well as between the hospital and community clinicians, Cheng says.

"I know it's easy to say and hard to do," she says. "I think if a hospital physician makes a conscious decision that the outpatient doctor might be able to take care of it once the patient is more stabilized, then the hospital doctor should communicate this very clearly to the outpatient doctor."

Another strategy would be for the hospital doctor to prescribe a very low dose of the new medication, just so the medication would be on the patient's profile, Cheng adds.

"This is so the outpatient doctor would be more likely to titrate the dose up rather than to not even think about starting the drug," she explains.

One strategy in improving discharge planning with cardiovascular patients is to list the recommended therapies on a discharge assessment sheet and physician order set, Albert suggests.

"When the patient is discharged, then we can pick up on any therapies that were not appropriate or were appropriate but not fully utilized," Albert adds.

Also, if a therapy is recommended but not prescribed at discharge, then the discharge paperwork will highlight this discrepancy.

The goal at discharge is to make sure patients receive the optimal medical therapies, so that they have the best chance of improved quality of life, that they have improved survival, and do not need early rehospitalization, Albert says.

References

1. Cheng JWM, Nayar M. A review of heart failure management in the elderly population. Am J Ger Pharmacotherapy. 2009; 7(5):1-17.

2. Gandara E, Moniz TT, Dolan ML, et al. Improving adherence to treatment guidelines. Crit Pathways in Cardiol. 2009;8(4):139-145.

3. Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.

SOURCES

For more information, contact:

• Nancy M. Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, Director, Nursing Research and Innovation, Nursing Institute; Clinical Nurse Specialist, Kaufman Center for Heart Failure, 9500 Euclid Ave., Mailcode J3-4, Cleveland, OH 44195. Telephone: (216) 444-7028. Fax: (216) 445-1776. Email: albertn@ccf.org.

• Judy Cheng, PharmD, MPH, FCCP, BCPS, RPh, Professor of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences; Clinical Pharmacist, Brigham and Women's Hospital, 179 Longwood Ave., Boston, MA 02115. Telephone: (617) 732-2868. Fax: (617) 732-2244. Email: judy.cheng@mcphs.edu.

• Allen Kachalia, MD, JD, Medical Director for Quality and Safety, Brigham and Women's Hospital, 179 Longwood Ave., Boston, MA 02115. Email: akachalia@partners.org.