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New threshold means new approaches
Prior to the efforts of a team at Cedars-Sinai Medical Care Foundation (CSMCF) in Beverly Hills, CA, antihypertensive medications were accounting for nine of the 20 drugs on which the most money was spent. Mary Denton, RN, chief administrative officer at CSMCF, says the foundation was spending $139,000 per quarter for one health plan contract covering 4,000 patients. The facility proposed an initiative based on the premise that significant cost reductions could be achieved if prescribing patterns could be adjusted. A task force was assembled, and preliminary data on its hypertension (HT) program show that clinical outcomes were maintained or improved and costs decreased by nearly $30,000 within six months:
· nifedipine decreased from $50,000 to $40,000;
· lisinopril decreased from $33,000 to $24,000;
· diltiazem decreased from $24,000 to $18,000;
· total costs, including lab, visit, and drugs, were $6.40 lower per patient per month in the program group.
The CSMCF team accomplished what it did by first creating an evidence-based HT guideline in early 1997 based on the recommendations of the 1992 Fifth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V).1 "The guideline has recently been updated to reflect the new JNC-VI criteria published late in 1997, but the changes are minimal," says Denton. (See story on JNC-VI guidelines for HT, p. 28.)
The team then reviewed charts and analyzed prescribing patterns of the most beneficial HT drugs. It contacted the physicians and, Denton says, took this approach: "According to the records, doctor, patient X is not totally controlled. Our guideline indicates these drugs or combinations. Would you be willing to try those?" Changing doctors' prescribing patterns had a substantial financial impact, she says.
The CSMCF guideline recommends beta blockers as first-line agents for patients with angina or a history of myocardial infarction, and angiotensin-converting enzyme inhibitors for patients with concurrent congestive heart failure or diabetes. Isolated systolic HT, it states, warrants the use of low-dose thiazide diuretics.
While chart reviews revealed that, thanks to the guideline, CSMCF's patients did better than national averages, the team saw room for improvement. It went on to design a comprehensive clinical management program involving pharmacists and emphasizing patient education and compliance.
The team soon realized that compliance with prescribed therapy is diminished by patients' perception of HT as an acute rather than chronic condition. In addition, the medications have side effects. Those stumbling blocks were overcome by having the clinical pharmacist see each patient each time he or she came in and provide education. "Patients come in more frequently, and their BP [blood pressure] is monitored more closely," says Denton. "We go through the steps of the guideline aggressively and quickly."
Only patients whose HT is uncontrolled are included in the program. At the time - before JNC-VI was released - that meant for the general population, the key measurement was a BP ³140/90 mmHg, and for patients over 65, BP ³160/90 mmHg. In a dedicated clinic that coordinates all necessary resources, a pharmacist gathers information about patients' meds, side effects, and compliance. Care plans are formulated based on the team's guideline, and cases are discussed with the attending physician.
Implementing the management program requires three steps:
· Guideline dissemination: Aids are placed on patient charts as well as throughout the facility.
· Physician education: One-on-one sessions prove most successful.
· Data feedback: This measures compliance and outcomes, assesses the program's performance, and identifies problems. Outcomes measures include morbidity, mortality, health status, quality of life, patient satisfaction, resource utilization, and cost of care.
"Today we're analyzing the clinical and financial outcomes data from the management program," says Denton. "The preliminary data look very favorable."
1. National High Blood Pressure Education Program. The fifth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V). Arch Intern Med 1993; 153:154-183.