effects of multidisciplinary care of heart failure patients at high risk for hospital admission

Effects of Multidisciplinary Care Effects of Multidisciplinary Care ofof

Heart Failure Patients at Heart Failure Patients at High Risk for Hospital AdmissionHigh Risk for Hospital Admission

S. Scott Sutton, Pharm.D.Associate Clinical Professor

South Carolina College of Pharmacy

University of South Carolina & Medical University of South Carolina

WJB Dorn Veterans Administration Medical Center

Columbia, South Carolina

http://www.sccp.sc.edu/

http://www.sc.edu/

http://www.musc.edu/

ObjectivesObjectives

• SCSHP Program agenda:

• Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients.

Research TeamResearch Team• S. Scott Sutton, Pharm.D.• Meg Franklin, Pharm.D., Ph.D.• C.E. (Gene) Reeder, RPh, Ph.D.• Frank Laws, M.D.

• HF Research - Abstracts / Posters & PublicationsHF Research - Abstracts / Posters & Publications:

– Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission

• American Heart Association• University of South Carolina School of Medicine / Palmetto Health Biomedical

Research Program• Drug Benefit Trends 2008;20:54-59

– Economic Evaluation of a Multidisciplinary Approach to Heart Failure Management

• International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 11 th Annual International Meeting

– Predicting Heart Failure Related Events in Patients Enrolled in an Outpatient Specialty Clinic in the VA System

• In progress

Heart FailureHeart Failure

• Key ConceptsKey Concepts

– Complex clinical syndrome• Dyspnea• Fatigue

– Proven treatments• Decrease morbidity and mortality• Decrease health care expenditures

– Angiotension converting enzyme inhibitors– Beta-blockers– Multidisciplinary care– Pharmacist

Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Arch Intern Med 1999;159:1939-1945Can J Cardiol 2004;20:1205-1211


• Key ConceptsKey Concepts

– Complex clinical syndrome• Dyspnea• Fatigue

– Proven treatmentsProven treatments• Decrease morbidity and

mortality• Decrease health care

expenditures– Angiotension converting

enzyme inhibitors– Beta-blockers– Multidisciplinary care– Pharmacist

• 11,000 patients– ACEI and BB

• 62 and 37%

Suboptimal treatment may lead to:Increased mortalityIncreased healthcare expenditures

Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Arch Intern Med 1999;159:1939-1945Can J Cardiol 2004;20:1205-1211

New York Heart Classification

• Class I: – no limitation is experienced in any activities; there are

no symptoms from ordinary activities. • Class II:

– slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.

• Class III: – marked limitation of any activity; the patient is

comfortable only at rest. • Class IV:

– any physical activity brings on discomfort and symptoms occur at rest.

Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018

American College of CardiologyAmerican College of CardiologyAmerican Heart AssociationAmerican Heart Association

• Stage AStage A: – a high risk HF in the future but no structural heart disorder;

• Stage BStage B: – a structural heart disorder but no symptoms at any stage;

• Stage CStage C: – previous or current symptoms of heart failure in the context of an

underlying structural heart problem, but managed with medical treatment;

• Stage DStage D: – advanced disease requiring hospital-based support, a heart

transplant or palliative care

Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018


• Common model of treatment

– ReactiveReactive• Patient perceives problem and makes appointment with

clinician.• Ideal model provides continuous care coordination and

support

– Current HF Treatment ModelCurrent HF Treatment Model• 12-15 million office visits• 6.5 million hospital bed days• More Medicare dollars than other single diagnosis• 27.9 billion in direct and indirect

Circulation 2005;112:1825-1852NEJM 2003;348:2007-2018Heart 2005;91:849-850

HFHF - Pharmacologic Management - Pharmacologic Management

• Angiotension Converting Enzyme InhibitorsAngiotension Converting Enzyme Inhibitors

– CONCENSUSCONCENSUS• Enalapril versus placebo – NYHA IV

– SOLVDSOLVD• Enalapril versus placebo – NYHA II-IV

– ATLASATLAS• Low dose versus high dose lisinopril – NYHAII-IV

NEJM 1987;316;1429-35NEJM 1991;325:293-302Circulation 1999;100:2312-8

HF - Pharmacologic Management

• Angiotension Converting Enzyme InhibitorsAngiotension Converting Enzyme Inhibitors

– Heart Failure – NYHA I-II• ACE Inhibitor x 1 year• 100 treated to prevent 1 death (number needed to treat - NNT)

– Heart Failure – NYHA IV• ACE Inhibitor x 1 year• 6 treated to prevent 1 death (NNT)

– Heart Failure – post MI• ACE Inhibitor• 18 treated to prevent 1 death (NNT)

NEJM 1987;316;1429-35NEJM 1991;325:293-302Circulation 1999;100:2312-8Bandolier


• Beta-Blockers - Beta-Blockers - (Number needed to treat 14-22)

– CIBIS-IICIBIS-II• Bisoprolol versus placebo – NYHA III-IV

– US Carvedilol Heart Failure StudyUS Carvedilol Heart Failure Study• Carvediolol versus placebo – NYHA II-IV

– Merit-HFMerit-HF• Metoprolol XL versus placebo – NYHA II-IV

– COMETCOMET• Carverdilol versus metoprolol tartrate – NYHA II-IV

– Only compared to immediate release metoprolol

Lancet 1999;353:9-13NEJM 1996;334:1349-55Lancet 1999;353:2001-7Lancet 2003:362:7-13


Outcome # of trials Beta-blocker

Control Relative risk (95% CI)

NNT (95% CI)

Mortality 14 443/5366 682/4867 0.62 (0.55-0.69)

17 (14-22)

Mortality or Hospital admission

9 1401/5035 1655/4610 0.81 (0.76-0.86)

12 (10-16)

Hospital admission

13 613/5301 833/4827 0.67 (0.61-0.74)

17 (14-23)

Beta-BlockersBeta-Blockers

Bandolier - http://www.jr2.ox.ac.uk/bandolier/booth/AF/betamort.html


• Aldosterone AntagonistsAldosterone Antagonists

– RALESRALES• Spironolactone versus placebo – NYHA III-IVSpironolactone versus placebo – NYHA III-IV• NNT (all-cause mortality) 10NNT (all-cause mortality) 10

– EPHESUSEPHESUS• Eplerenone versus placebo – acute MI with LV

dysfunction• NNT (all-cause mortality) 44

NEJM 1999;341(10):709-17NEJM 2003;348:1309-21

HFHF nonnon-Pharmacologic Management-Pharmacologic Management

• Multidisciplinary ClinicsMultidisciplinary Clinics

– Decrease mortality Rates• Mortality rate similar to that of ACE Inhibitors

– Reduce hospital admission rates• All cause hospital admission – 13%• HF admissions by 30%

– Decrease use of health-care resources

Heart 2005;91:899-906Chest 2005;127:173:40-45

HFHF nonnon-Pharmacologic Management-Pharmacologic Management• Home-based interventions

– Decreased:• All cause-admission• HF related admission• Mean days in the hospital

• Telephone-based interventions– Decreased:

• Mortality• HF admissions

Heart 2005;91:899-906

HFHF nonnon-Pharmacologic Management-Pharmacologic Management

• Randomized clinical trials based upon self-care:– Decreased:

• Readmission• Hospitalization days• Cost of care

• 2 key components– 1-to-1 patient education– Self-management recommendations

Heart 2005;91:899-906

Effects of Multidisciplinary CareEffects of Multidisciplinary CareMultidisciplinary Care

Trials Patients Intervention (% having event)

Control

(% having event)

Relative Risk (95% CI)

Number needed to Treat (95% CI)

All-cause mortality

12 2129 17 24 0.7 (0.6-0.9) 17 (11-38)

All-cause Admission

14 2273 41 51 0.8 (0.7-0.9) 10 (7-16)

HF Admission 9 1416 27 38 0.7 (0.6-0.8) 9 (6-17)

Journal American College of Cardiology 2004;44:810-819American Journal of Medicine 2001;110:378-84

Effects of Effects of Multidisciplinary Care of Multidisciplinary Care of Heart Failure Patients at Heart Failure Patients at

High Risk for Hospital High Risk for Hospital AdmissionAdmission

S. Scott Sutton, Pharm.D.Meg Franklin, Pharm.D., Ph.D.C.E. (Gene) Reeder, RPh, Ph.D.

Frank Laws, M.D.

Drug Benefit Trends 2008;20:54-59 (publication)

American Heart Association (abstract / poster presentation)

Advanced Heart Failure Program Advanced Heart Failure Program (AHFP)(AHFP)

• Target PatientsTarget Patients – High readmission rates – Risks are identified

• Intervention DescribesIntervention Describes– Strategy to improve outcomes of patients with

chronic HF at the Dorn Veterans Administration Medical Center in Columbia, South Carolina

Drug Benefit Trends 2008;20:54-59


• Developed to provide comprehensive multidisciplinary management to persons with advanced HF.

• Inclusion criteria:– ACC/AHA stage C/D or NYHA III/IV– Hospitalized 2 or more times in 1-year period



• Goals:

– Decrease hospital admission & readmission

– Decrease health-care expenditures

– Improve quality of life

• AHFP Team:• Cardiologist• Internal Medicine

Specialist• Nurse Practitioner• Nurse• Case Managers• Physician assistants• Pharmacists• Clinical Researchers


AHFPAHFPHF Patients

NYHA Class III/IV or AHA Class C/D

Enroll in HF Clinic

Initial Visit Every 2 Weeks for 2 Months,

Then Monthly ThereafterPRN

Infusion Clinic

Episodic Management in Clinic

Emergency Department/ Readmission

Patient MonitoringWeight

Blood PressurePeak Flow

Daily symptoms

Clinic MonitoringLabsBNPICG


• Once enrolled into AHFP– Patients presented every 2 weeks for first 2 months

• Monthly thereafter

• Initial Visit– Extensive evaluation

• Physical• Diagnostic• Laboratory• Medication• Quality of Life Evaluation



Initial Visit$1051.92Subsequent visits$141.7350 Week Cost$3036.14

AHFP CostsAHFP Costs


• Once enrolled into AHFP– Patients presented every 2 weeks for first 2 months

• Monthly thereafter

• Initial Visit– Extensive evaluation

• Physical• Diagnostic• Laboratory• MedicationMedication• Quality of Life Evaluation


Medication EvaluationMedication EvaluationAHFP Medications (pending indications)

LisinoprilFurosemideCarvedilolSpironolactone

Other medications potentially utilized DigoxinValsartanPotassium Chloride

Patient Population Local versus National

0

10

20

30

40

50

60

70

DM HF HTN Lipid Obesity COPD

Columbia National

PREVALENCE


AHFP - ResultsAHFP - Results

0

0.5

1

1.5

2

2.5

3

3.5

Pre-AHFP

Post-AHFP

Baseline CharacteristicsBaseline Characteristics Hospital Readmission Rates Hospital Readmission Rates per Patientper Patient

ObjectivesObjectives

• SCSHP Program agenda:

• Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients.

• Implications to clinicians

effects of multidisciplinary care of heart failure patients at high risk for hospital admission

Documents