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

Effects of Multidisciplinary Care of Heart Failure Patients at High 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

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

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  1. Effects of Multidisciplinary Care of Heart Failure Patients at High 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

  2. Objectives • SCSHP Program agenda: • Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients.

  3. Research 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 & 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) 11th Annual International Meeting • Predicting Heart Failure RelatedEvents in Patients Enrolled in an Outpatient Specialty Clinic in the VA System • In progress

  4. Heart Failure • Key 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;112:1825-1852 NEJM 2003;348:2007-2018 Arch Intern Med 1999;159:1939-1945 Can J Cardiol 2004;20:1205-1211

  5. Key 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 11,000 patients ACEI and BB 62 and 37% Heart Failure Suboptimal treatment may lead to: Increased mortality Increased healthcare expenditures Circulation 2005;112:1825-1852 NEJM 2003;348:2007-2018 Arch Intern Med 1999;159:1939-1945 Can J Cardiol 2004;20:1205-1211

  6. 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;112:1825-1852 NEJM 2003;348:2007-2018

  7. American College of CardiologyAmerican Heart Association • Stage A: • a high risk HF in the future but no structural heart disorder; • Stage B: • a structural heart disorder but no symptoms at any stage; • Stage C: • previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment; • Stage D: • advanced disease requiring hospital-based support, a heart transplant or palliative care Circulation 2005;112:1825-1852 NEJM 2003;348:2007-2018

  8. Heart Failure • Common model of treatment • Reactive • Patient perceives problem and makes appointment with clinician. • Ideal model provides continuous care coordination and support • Current 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;112:1825-1852 NEJM 2003;348:2007-2018 Heart 2005;91:849-850

  9. HF - Pharmacologic Management • Angiotension Converting Enzyme Inhibitors • CONCENSUS • Enalapril versus placebo – NYHA IV • SOLVD • Enalapril versus placebo – NYHA II-IV • ATLAS • Low dose versus high dose lisinopril – NYHAII-IV NEJM 1987;316;1429-35 NEJM 1991;325:293-302 Circulation 1999;100:2312-8

  10. HF - Pharmacologic Management • Angiotension 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;1429-35 NEJM 1991;325:293-302 Circulation 1999;100:2312-8 Bandolier

  11. HF - Pharmacologic Management • Beta-Blockers - (Number needed to treat 14-22) • CIBIS-II • Bisoprolol versus placebo – NYHA III-IV • US Carvedilol Heart Failure Study • Carvediolol versus placebo – NYHA II-IV • Merit-HF • Metoprolol XL versus placebo – NYHA II-IV • COMET • Carverdilol versus metoprolol tartrate – NYHA II-IV • Only compared to immediate release metoprolol Lancet 1999;353:9-13 NEJM 1996;334:1349-55 Lancet 1999;353:2001-7 Lancet 2003:362:7-13

  12. HF - Pharmacologic Management Beta-Blockers Bandolier - http://www.jr2.ox.ac.uk/bandolier/booth/AF/betamort.html

  13. HF - Pharmacologic Management • Aldosterone Antagonists • RALES • Spironolactone versus placebo – NYHA III-IV • NNT (all-cause mortality) 10 • EPHESUS • Eplerenone versus placebo – acute MI with LV dysfunction • NNT (all-cause mortality) 44 NEJM 1999;341(10):709-17 NEJM 2003;348:1309-21

  14. HFnon-Pharmacologic Management • Multidisciplinary 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;91:899-906 Chest 2005;127:173:40-45

  15. HFnon-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

  16. HFnon-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

  17. Effects of Multidisciplinary Care Journal American College of Cardiology 2004;44:810-819 American Journal of Medicine 2001;110:378-84

  18. Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission 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)

  19. Advanced Heart Failure Program (AHFP) • Target Patients • High readmission rates • Risks are identified • Intervention 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

  20. Advanced Heart Failure Program (AHFP) • 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 Drug Benefit Trends 2008;20:54-59

  21. 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 Advanced Heart Failure Program (AHFP) Drug Benefit Trends 2008;20:54-59

  22. AHFP

  23. Advanced Heart Failure Program (AHFP) • 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 Drug Benefit Trends 2008;20:54-59

  24. AHFP Costs Initial Visit $1051.92 Subsequent visits $141.73 50 Week Cost $3036.14 Drug Benefit Trends 2008;20:54-59

  25. Advanced Heart Failure Program (AHFP) • 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 Medication Evaluation AHFP Medications (pending indications) Lisinopril Furosemide Carvedilol Spironolactone Other medications potentially utilized Digoxin Valsartan Potassium Chloride Drug Benefit Trends 2008;20:54-59

  26. Patient PopulationLocal versus National P R E V A L E N C E

  27. AHFP - Results Baseline Characteristics Hospital Readmission Rates per Patient Drug Benefit Trends 2008;20:54-59

  28. Drug Benefit Trends 2008;20:54-59

  29. Objectives • SCSHP Program agenda: • Identify Characteristics of heart failure patients and common factors that lead to hospitalization of patients. • Implications to clinicians

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