Roundtable spreads the word on CHF’s Top 10’
PCPs and cardiologists share practice modes
Last fall, Marc Silver, MD, a cardiologist who runs the CHF center at Christ Hospital in Chicago, invited cardiologists and primary care physicians from the entire Advocate Healthcare System in Oakbroak, IL, to spend a day talking about CHF and how care could be improved. About 100 people attended the roundtable 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." Several initiatives are going on at Advocate to improve the quality of care of heart failure patients regardless of where they enter Advocate’s diverse system.
"One of our goals was to make primary care doctors recognize that they are extremely important in helping CHF patients. They have to realize it’s not just the cardiologists," says Silver. "The primary care doctors have to do the right thing in their offices, and we’re here to help them. We’re here to provide them with the technology and research opportunities for their patients in their offices and in the hospitals."
This was the kickoff, but prior to the roundtable, Silver and his team had been strengthening the CHF infrastructure throughout the system. They made sure that in each of Advocate’s hospitals there is a nurse coordinator whose primary responsibility is to educate and train the staff and coordinate heart failure activities. There are also physicians who have volunteered to be physician leaders for the heart failure initiative. In addition, and most important, he says, "Over the past year, we have worked on creating a standard set of orders that cover heart failure admissions through all our hospitals. They have been agreed upon and now are being used in all Advocate venues. No matter if a patient comes in through an emergency department [ED], or directly to the floor, or to a critical care unit, a standard admission evaluation and treatment can be done on all patients with heart failure."
Heart failure, he says, is one area where there’s a tremendous diversity in how patients receive care, particularly on the inpatient side. "A lot of the guidelines and consensus statements address outpatient care, but not so much that of inpatients. We decided to put our ideas into a set of working orders that tell people what steps to take to improve patient care.
"Our first goal is to improve the care of these patients. But in doing that, we have standardized the product we deliver. The managed care organizations are aware of what we’re delivering, how we’re delivering it, and the fact that we’re measuring to see what the outcomes are. If it’s a good process, the outcomes will be good. If they are not, we’ll change it."
Throughout the roundtable day, Silver and his colleagues addressed the following "Top 10" items (not presented in order of importance):
1. Prevention. Prevention is the "ultimate" solution. The presenters talked about the many secondary prevention measures and how to make prevention a daily practice. "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."
2. "Doctor means teacher. Education from the physician or nurse has the greatest impact," says Silver.
3. 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 software program called Health Advisor that calls patients on a regular basis asking them questions about their heart failure. By virtue of those phone calls, Silver says, patients can improve their care at home.
4. Tidbits. 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. Those are all accessories that can make a big difference in how doctors can alter prognosis in CHF," says Silver.
5. Using beta-blockers at target dose. Clinical trials in over 10,000 patients confirm that long-term treatment with beta-blockers improves symptoms and clinical status, and prevents hospitalization and death. Start in your office. Titrate slowly, but progressively. Evaluate volume status. Ask for help if needed. "We tried to make the drugs understandable so the primary care physician would feel comfortable using them in a wider spectrum of patients."
6. 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 or have a contraindication. ACE inhibitors can also 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. Why ACE inhibitors are not used:
— renal insufficiency;
"Our rationale was the outcome measures associated with proper use of ACE inhibitors," says Silver. "We talked about why they are not used as much as they should be and about ways to circumvent that. Basically, we tried to allay fears about using them."
7. Using the standing orders. Standing orders for CHF patients are developed to make 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," says Silver. "We tried to get people to buy into using them in a consistent fashion and get their feedback on them."
8. Using the emergency department. Estimates are that nearly half of the patients admitted can be safely discharged from the ED. Encourage your ED teams to use standing orders, and work towards observation areas. Avoid unneeded testing. "Most hospitals across the country admit 80% of their patients through the ED," says Silver, "and I talked about what can be done there." 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."
9. Measuring and recording ejection fraction (EF). EF helps to stratify causes of heart failure and may help to alert patient and physician of disease status and severity. Measure EF when stable; document the EF. "That distinguishes between systolic and diastolic dysfunction, and the treatments are different," says Silver. "I emphasize the importance of recording the ejection fraction so it doesn’t need to be repeated admission after admission. There’s no need for routine serial determinations."
If EF is low, indicating systolic dysfunction, explains Silver, and something happens — CHF worsens or the patient has an acute myocardial infarction (AMI) — it is likely only to be lower and therefore not useful to measure. Occasionally if a patient has normal LVEF and then has an AMI or the heart failure is unresponsive, you may repeat. One of the issues is whether routine repeats of the echo, to evaluate the effectiveness of beta-blocker therapy, for example, is valid. Here the experts are split, he says, but generally this is an expensive approach for the majority of patients.
Determining why patients have heart failure
10. Determining an etiology for the heart failure. Common etiologies of heart failure are coronary artery disease, hypertension, alcohol, and valvular arrhythmia. Simply determining the cause(s) of a patient’s heart failure can set you on the proper therapeutic course. Document your search. "It’s important to know why someone has the disease mainly because some of the causes are potentially reversible," says Silver.
The existing guidelines mandate making sure patients have or don’t have ischemic heart disease, he says. "Sometimes it’s known when the patient comes into the hospital, and sometimes it’s not known. If it’s not known, it’s worth spending time in the hospital figuring out etiology because it will guide therapy and may even prevent future admission."
The presenters used an interactive keypad system so they could see people’s responses to each of the 10 areas before they were discussed. "That kept people integrated and involved in the program. No one fell asleep," says Silver.
What’s next? "The next step is to go back to each of the individual hospitals and revisit the same topics," he 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."