Program improves heart patients’ outcomes

Hospital pharmacists key to success

A discharge program that placed cardiovascular patients on appropriate medications and scheduled follow-up care not only reduced the patients’ risk of readmission to the hospital, but also significantly decreased their risk of death.

In 1998, researchers at LDS Hospital and Intermountain Health Care (IHC) in Salt Lake City instituted a new discharge form and protocol to ensure cardiovascular patients were being discharged with the necessary medications.

The six-year study of the program focused on the appropriate prescribing of aspirin, statins, beta-blockers, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge.

"Around 1996-1997, there was clear evidence in the literature that certain medications had significant benefit in long-term outcomes for coronary artery disease, atrial fibrillation, and heart failure," explains Donald Lappe, MD, chief of cardiology at LDS Hospital and one of the researchers. "Yet, both locally and around the nation, patients with those diseases were being treated with those appropriate medications only about 50% of the time."

The biggest impact is for secondary prevention, he says. "No one was really clearly defined as being accountable to achieve that treatment goal."

The researchers decided that the accountability occurs when a person is discharged from the hospital with heart problems. "The magic of that is we know the person has coronary artery disease, atrial fibrillation, or heart failure. It is a measurable time, and one when you typically have the patient’s attention," Lappe says.

The process included a mandatory checklist for physicians regarding the appropriate medications at discharge. The researchers compared 26,000 patients who were hospitalized with heart problems before 1998 with 31,465 heart patients who were discharged from 10 IHC hospitals after 1998.

Within a year, the health system went from about 60% overall achievement of the discharge medications for the appropriate diagnosis to above 90%, Lappe says. Those results have now been sustained for five to six years in a row.

"[Using our own database], we’ve tested the hypothesis that this would make a difference, and it certainly has. Thousands of lives were saved, readmissions were saved, and health care costs were saved — just through best practice treatments. There is not much out there that has showed such huge a reduction of adversities through relatively simple means."

Meet resistance head-on

After reviewing the literature, the researchers saw this was the "right place, right time, and right goals to set," Lappe says. It helped that a cardiovascular clinical program oversees cardiovascular services throughout IHC.

The researchers began with the 10 largest hospitals in the health system and quickly moved to the rest. The researchers engaged cardiologists, surgeons, and primary care doctors first to make sure they were well educated as to the importance of these clinical goals.

Doing this presented two challenges. One was determining who is responsible for the patients after the medications were prescribed at discharge. There was the typical disagreement over who would follow the patient: Who is going to be responsible to check the liver function test? Who is going to titrate it? The interventional cardiologist didn’t claim responsibility, but placed it on the primary care physician. The primary care physician, on the other hand, would say that since the cardiologist didn’t prescribe the medication, it must not be important.

To overcome the confusion, the researchers defined the roles of responsibility. "We communicated across all caregivers as to how the process will carry out and who has what accountability so the ball wasn’t dropped through this lapse of understanding," Lappe says.

An even more important cultural change among physicians entailed saying they were accountable to evidence-based health care practice, he continues. "There are clear evidence-based standards in these particular goals that say it is the right thing to do. That resistance was minor when we said these are national standards, not IHC dictating how you should carry out practice."

The researchers also provided some implementation tools for each hospital, such as cards that reminded people about the protocol, Lappe says. "Then we had a simple piece of paper, a data collection tool, and we fed the data back."

Pharmacists were an important part of the process, he says. "In some of the hospitals, the pharmacist would review the chart before the patient went home and remind the physician to prescribe the medicines if they hadn’t already been prescribed. The pharmacists were the primary ones responsible for the success. In the hospitals where we used nurses or discharge managers to fulfill this role, the pharmacists worked hand-in-hand to help them achieve it. They were indispensable in all of our facilities."

Lappe says he has learned from this experience that you need to communicate, to educate, and to align and engage all the different components of the health care process.

For instance, it was critical that the researchers get nursing on-line with the program. "Nurses can remind doctors without conflict if something didn’t occur."

Overall, Lappe thinks that you manage what you measure. These data were measured at the hospital level and resulted in the different institutions comparing results. "Doctors are competitive people," he says. "If one hospital was doing a better job, people could see that, and I think that enhanced the other hospitals so that internally they would try to manage themselves to achieve this goal."

The program has been a remarkable event, he says. "It’s unconscionable that everyone in the country does not achieve this level because it is so important. We need to start looking and delivering this level of excellence to the people we serve."