Transcript HF - Pharmacologic Management - South Carolina Society of Health

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
Objectives
• SCSHP Program agenda:
• Identify Characteristics of heart failure
patients and common factors that lead to
hospitalization of patients.
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 Related Events in Patients Enrolled in an Outpatient
Specialty Clinic in the VA System
• In progress
Heart Failure
• Key Concepts
– Complex clinical syndrome
• Dyspnea
• Fatigue
– Proven treatments
• Decrease morbidity and mortality
• Decrease health care expenditures
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–
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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
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
• 11,000 patients
– ACEI and BB
• 62 and 37%
Suboptimal treatment may lead to:
Increased mortality
Increased healthcare expenditures
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
American College of Cardiology
American 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
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
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•
•
•
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
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
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
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
HF - Pharmacologic Management
Beta-Blockers
Outcome
# of trials
Betablocker
Control
Relative
risk (95%
CI)
NNT (95%
CI)
Mortality
14
443/5366
682/4867
0.62 (0.550.69)
17 (14-22)
Mortality
or
Hospital
admission
9
1401/5035
1655/4610
0.81 (0.760.86)
12 (10-16)
Hospital
admission
13
613/5301
833/4827
0.67 (0.610.74)
17 (14-23)
Bandolier - http://www.jr2.ox.ac.uk/bandolier/booth/AF/betamort.html
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
HF
non-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
HF
non-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
HF
non-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 Care
Multidisciplinary
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;44:810-819
American Journal of Medicine 2001;110:378-84
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)
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
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
Advanced Heart Failure Program
(AHFP)
• 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
Drug Benefit Trends 2008;20:54-59
AHFP
HF Patients
NYHA Class III/IV
or AHA Class C/D
Enroll in HF Clinic
Initial Visit Every 2 Weeks for
2 Months,
Then Monthly Thereafter
PRN
Patient Monitoring
Weight
Blood Pressure
Peak Flow
Daily symptoms
Infusion Clinic
Clinic Monitoring
Labs
BNP
ICG
Episodic Management in Clinic
Emergency Department/
Readmission
Advanced Heart Failure Program
(AHFP)
• Once enrolled into AHFP
– Patients presented every 2 weeks for first 2 months
• Monthly thereafter
• Initial Visit
– Extensive evaluation
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•
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•
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Physical
Diagnostic
Laboratory
Medication
Quality of Life Evaluation
Drug Benefit Trends 2008;20:54-59
AHFP Costs
Initial Visit
$1051.92
Subsequent visits
$141.73
50 Week Cost
$3036.14
Drug Benefit Trends 2008;20:54-59
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
Patient Population
Local versus National
70
P
R
E
V
A
L
E
N
C
E
60
50
40
30
20
10
0
DM
HF
HTN
Columbia
Lipid
National
Obesity
COPD
AHFP - Results
Baseline Characteristics
Hospital Readmission Rates
per Patient
3.5
3
2.5
2
1.5
1
0.5
0
PreAHFP
PostAHFP
Drug Benefit Trends 2008;20:54-59
Drug Benefit Trends 2008;20:54-59
Objectives
• SCSHP Program agenda:
• Identify Characteristics of heart failure
patients and common factors that lead to
hospitalization of patients.
• Implications to clinicians