ACE underuse: What to do
ACE underuse: What to do
To encourage physicians to increase their prescribing of angiotensin-converting enzyme (ACE) inhibitors, Randall Stafford, MD, PhD, instructor in medicine at Harvard Medical School and Massachusetts General Hospital in Boston, offers several suggestions:
· Educate physicians on the benefits of ACE inhibitors and dealing with contraindications.
· Educate patients on the benefits of the drugs and the importance of compliance. Make greater use of pharmacy information to track compliance.
· Tie physicians' performance reviews to appropriate usage of medications.
· Implement a uniform approach to treating congestive heart failure (CHF) that follows the clinical guidelines.
When Wilmington, DE-based Stuart Disease Management Services began developing its CHF program, it analyzed data from several health plans, and the biggest issue that surfaced was underuse of ACE inhibitors. Practice patterns were not aligned with national guidelines, says Kenneth L. McDonough, MD, MS, vice president and medical director for Stuart. "We saw an opportunity to implement those guidelines to get increased use of appropriate medications and to get patients to more assertively self-manage their disease."
The firm began by convening panels of participating physicians who went over the guideline from the Agency for Health Care Policy and Research (AHCPR) in Rockville, MD, with a fine-toothed comb. A separate meeting was held to cover each chapter of the document, and the physicians were given the opportunity to make changes and give their stamp of approval. "If national guidelines meet local practice customs and are approved by the audience, they are much more apt to be examined and followed," McDonough says.
Once the guidelines were approved, physicians received copies and attended educational meetings that stressed such issues as prescribing ACE inhibitors. More importantly, they started receiving individualized reports on each patient that customized the guidelines to that situation.
Given the overwhelming evidence in favor of ACE inhibitors, why do physicians hesitate to prescribe them? Stafford and Prakash Deedwania, MD, chief of the cardiology division at the Veterans Affairs Medical Center in Fresno, CA, point out several possible reasons:
· Physicians may be unfamiliar with the contraindications. The benefits usually outweigh side effects. Besides, all medications have the potential to create difficult situations.
· Patients may have comorbidities that make dosing more complicated. Physicians may be hesitant to use the drugs when underlying kidney disease or other illness exists. "Physicians are hassled for time, and they want to prescribe drugs that are easier," Deedwania says. There's too much concern over exacerbating kidney disease, he says. In the early stages of kidney disease, more than likely kidney function will actually improve with ACE inhibitors.
· Patients are disturbed by the cough that sometimes accompanies the drugs. Stafford says, "Lots of patients probably get taken off ACE inhibitors because of a very mild cough that they probably could live with." Deedwania points out that CHF itself causes coughing, so it's hard to say if it's due to the ACE inhibitor.
· It is sometimes difficult to get patients to comply, since the preventive nature of the drugs means they might not feel better immediately. "People are leery of causing side effects with a medication when, on a next-day basis, it's difficult to see that it's doing some good," Stafford says.
· Digoxin and Lasix have a traditional role in the emergency department, and that mentality may carry over to CHF treatment. "Some physicians view the role of digoxin and Lasix in an acute situation as somehow making them better medications," Stafford says. "But the AHCPR guideline says ACE inhibitors should be first-line. Diuretics and digoxin should be reserved for people who don't get the maximum benefit on ACE inhibitors alone."
· Prescribing ACE inhibitors is not a priority. "Physicians are very busy trying to meet the expectations of their patients," Stafford says, "and if they spend too much time on issues outside of the reason the patient came in, some patients get upset."
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.