Benjamin Horne

Improvements in 1-Year Cardiovascular Clinical Outcomes Associated with a Hospital-Based Discharge Medication Program

Context Despite evidence to support the effectiveness of a variety of interventions for the secondary prevention of cardiovascular disease, many eligible patients do not receive these interventions. Contribution Compared with a baseline period, patients hospitalized with cardiovascular disease who received an intervention that focused on discharge medications had higher rates of prescription of aspirin, -blockers, statins, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge. The risk for death and readmission was lower in the intervention period than in the baseline period. Cautions The prepost design of this study does not permit conclusions about a causal relationship between the intervention and the observed improvements. The Editors Cardiovascular disease remains the most common source of morbidity and mortality in western countries (1). During the past 2 decades, a variety of significant medical advances have been made in the treatment and prevention of complications associated with major cardiovascular disorders, including coronary artery disease, congestive heart failure (CHF), and atrial fibrillation. Many of these advances in secondary prevention relate simply to the appropriate use of certain medications, for example, aspirin and statins for coronary artery disease, -blockers and angiotensin-converting enzyme inhibitors for CHF, and warfarin for prevention of stroke and other embolic events in patients with atrial fibrillation. Each of these medical therapies has been proven in large, multicenter, randomized, double-blind, placebo-controlled trials to save lives under appropriate circumstances (2-7). However, despite the overwhelming evidence supporting the benefit of these medications, many studies have documented a significant treatment gap. Often, far fewer than 50% of potential beneficiaries actually receive treatment (8-13), and studies from our institution and others have shown that many patients do not receive indicated medications at hospital discharge (14, 15). On the other hand, the chances of long-term adherence are significantly higher when medications are provided at hospital discharge, and this difference is associated with decreased mortality rates (13, 16). Hospital discharge is a critical juncture in the process of care. Patients are available for consultation and are often more disposed to adopt health care recommendations. A hospital dischargebased intervention could be more easily implemented, more effectively managed and measured, and more cost-effective than other potential outpatient intervention strategies. Consequently, there is substantial justification for focusing on hospital discharge as the ideal time to improve prescription of medications for secondary prevention of cardiovascular disease. In the current study, our objectives were to 1) determine the feasibility of implementing a comprehensive quality improvement initiative in a large multihospital network to significantly increase rates of prescription at discharge of evidence-based, secondary prevention medications for life-threatening cardiovascular diseases; 2) ascertain the effect of such a program on long-term clinical outcomes; and 3) determine whether good adherence to such an initiative is sustainable. Methods Intermountain Health Care (IHC) is a nonprofit, integrated health care system including 20 hospitals, a system of health plans, and both employed and affiliated physicians. The approximately 400 employed physicians mainly practice primary care, and the approximately 2500 affiliated physicians are mostly specialists. Intermountain Health Care serves approximately 60% of the population of Utah and southern Idaho. The systems 10 largest hospitals were included in the quality improvement initiative, accounting for more than 90% of the total population of cardiovascular patients. The major intent of this initiative was to ensure that appropriate secondary prevention medications were prescribed at discharge to all patients (excluding those with documented contraindications) who were hospitalized with a principal cardiovascular diagnosis of acute myocardial infarction (MI), coronary heart disease (CHD), CHF, or atrial fibrillation. Table 1 shows the guidelines that were developed for each of the diagnostic categories, and Appendix Figure 1 shows the reference card that was developed to aid physicians and clinical staff. All of the guidelines were based on the current class IA American Heart Association/American College of Cardiology recommendations, except for the recommendation of a statin in all patients with CHD, including those with a low-density lipoprotein cholesterol level less than 2.59 mmol/L (<100 mg/dL). Our research (17) showed that a statin provided significant benefit in this population, a notion that has since been supported by a large clinical trial (18). -Blocker therapy for patients with CHF was deferred until after discharge. Table 1. Discharge Medication Guidelines for the Secondary Prevention of Cardiovascular Disorders Design and Implementation of the Quality Improvement Program In 1998, before the new discharge medication program (DMP) was initiated, a new institution-wide database was developed to assist in its implementation and long-term management. Simultaneously, all participating institutions began prospectively tracking prescription of applicable discharge medications for all cardiac patients discharged from their respective cardiovascular departments (Appendix Figure 2). The DMP was implemented on 1 January 1999, and tracking of discharge prescriptions continued. Maintenance of the discharge medication database is ongoing, and information through February 2002 was included in this study. Appendix Figure 2. Data collection form for the discharge medication program. Implementation of the DMP required support and commitment from every level of the health care system, including administration, physicians, nurses, and other staff. To gain this support, the IHC Cardiovascular Clinical Program leadership conducted an extensive education campaign in all participating hospitals. Before the actual initiation of the DMP, this group conducted an extensive tour to engage physicians, residents, and nurses with the program, its goals, and its rationale. The actual DMP implementation and documentation process varied from hospital to hospital but always included the essential core elements. The appropriate indication for each medication was printed directly on the patient discharge form, so physicians needed only to check the correct box or record the specific contraindication (Appendix Figure 3). This form served as a project management and data collection tool. When an appropriate medication was not prescribed, the discharge-planning nurse contacted the attending physician or resident directly, after which the missing medication could be added to the discharge prescriptions or an appropriate contraindication for its use could be documented. All information was entered into a computerized database for tracking. Other than the additional resources for data management, the DMP used existing hospital personnel. No organized effort was made to guarantee long-term adherence to prescribed medications after discharge. Appendix Figure 2. Discharge orders form.. Documentation of Short-Term Success of the Program To measure and manage the short-term success of the program, monthly reports were generated showing the proportion of cardiovascular patients discharged with prescriptions for the indicated secondary prevention medications at each of the 10 hospitals. These reports were shared extensively with all participating health care providers from each contributing institution in an effort to further increase adherence. Long-Term Follow-up To monitor the effect of DMP implementation on long-term clinical outcomes, the baseline characteristics (age, sex, and discharge diagnosis) of each cardiovascular patient discharged from the 10 participating facilities were compiled from the centralized IHC informatics database. Each patient was followed prospectively for up to 1 year for hospital readmission due to a cardiovascular indication or for death. If no evidence of hospital readmission or death could be found for a patient, we assumed that the patient had not experienced either event. Information was included from 1996, 3 years before DMP initiation, to February 2002, more than 3 years afterward. Rehospitalizations (cardiovascular only) were determined through the IHC informatics systems electronic data warehouse, and death was ascertained by using the IHC system and the Social Security Administrations death records. Such electronic follow-up, in our experience (16), has proven more thorough and accurate than telephone surveys. Although a limited proportion of patients may have been readmitted to other hospitals for subsequent care, they were probably randomly distributed between the pre-DMP and DMP samples. Characteristics of patients admitted before (1996 to 1998) and after (1999 to 2002) DMP implementation were evaluated separately and compared. Statistical Analysis The chi-square test was used to evaluate differences in the proportions of patients receiving appropriate discharge prescriptions in the pre-DMP and DMP groups. To evaluate the effect of the DMP, we formed 4 mutually exclusive diagnostic or procedural categories for patients with the following index admissions: CHD without CHF, MI, or coronary artery bypass grafting (CABG); CHF without MI or CABG; MI without CABG; and CABG. The category of atrial fibrillation was not mutually exclusive of the other 4 categories. These categories reflected different patient samples and were not designed to evaluate groups on the basis of indications for each separate medication, since more than 1 medication could have been indicated in any given patient. Differences between baseline characteristics of the pre-DMP and DMP groups were eva

Evidence for a Heritable Component in Death Resulting From Aortic and Mitral Valve Diseases

Background—Cardiac valvular diseases contribute to >42 000 deaths yearly in the United States, but the role of genetics in these deaths is unknown. This study evaluated the familiality of death resulting from aortic, mitral, and all valvular diseases using a population-based genealogy linked to death records. Methods and Results—The Utah Population Database contains >2 million individual records with genealogy data and 250 000 linked death certificates. Nonrheumatic aortic (n=932), mitral (n=1165), and all valvular (n=2504) disease deaths and rheumatic heart disease deaths (n=4713) were studied. Familial relative risks (FRRs) were assessed for first- and second-degree relatives. Familiality was also evaluated with the genealogical index of familiality, which considers all relationships in the Utah Population Database. FRRs were increased only for mitral valve death in both first-degree (FRR, 2.55; P<0.0001) and second-degree (FRR, 1.67; P<0.0001) relatives. Genealogical index of familiality analysis showed significant excess relatedness for all groups (P<0.001). Genealogical index of familiality results (P<0.001) for early age at death cases showed higher mean relatedness, a common characteristic of heritable disorders. Excess familiality extended to distant relatives for mitral (second-degree relatives) and aortic (beyond second-degree relatives) valve death. Conclusions—Deaths resulting from nonrheumatic mitral and aortic diseases clustered among both close and distant relatives, especially among early age at death cases, suggesting a significant genetic component in death resulting from valvular diseases. Future studies should focus on gene discovery.

Less affluent area of residence and lesser-insured status predict an increased risk of death or myocardial infarction after angiographic diagnosis of coronary disease.

PURPOSEnLow socioeconomic status (SES) predicts coronary artery disease (CAD) onset, but its value among patients with CAD is uncertain. Geographic measures (e.g., residential neighborhood) may predict risk, but this requires further evaluation.nnnMETHODSnA cohort of 3410 patients with significant, angiographically-defined CAD (> or =1 lesion of > or =70% stenosis) joined a registry during the period between 1993 and 2000 and was followed for 6.7 years (median 3.7 years). A geographic SES measure-residential economic status (RES)-and insurance type were examined for association with mortality or myocardial infarction (MI).nnnRESULTSnIn Cox regression adjusting for 17 covariates, lower RES quartile was associated with increased death/MI (p-trend<0.001), death (p-trend=0.001), and MI (p-trend=0.07). First RES quartile (vs. fourth) predicted death/MI (hazard ratio [HR]=1.32, 95% confidence interval [CI]=1.07-1.62, p=0.01) and death (HR=1.46, CI=1.12-1.91, p=0.006), but not MI (HR=1.18, p=0.31). Compared with private insurance, self-pay (HR=1.88, p=0.053), charity care (HR=1.71, p<0.001), and Medicaid (HR=1.43, p=0.24), but not Medicare (HR=0.95, p=0.68), were associated with death/MI.nnnCONCLUSIONSnBoth geographic (RES) and economic (insurance) measures of SES independently predicted risk of death/MI in a large population with angiographically-defined CAD. This suggests that SES remains a significant predictor of health outcomes after CAD has developed, and that geographic measures of SES deserve further evaluation.

Addressing Air Quality and Health as a Strategy to Combat Climate Change

Poor air quality contributes to and is a consequence of global warming. The burning of fossil fuels to power our homes, businesses, and automobiles contributes to air pollution. When released into our atmosphere, some forms of pollution trap heat, leading to temperature elevation, and air pollution has direct effects on health, such as worsening cardiopulmonary disease (1). In this weeks Annals, the American College of Physicians calls for action to combat climate change and its effects on health, including governmental action to reduce greenhouse gas emissions, health care sector implementation of environmentally sustainable and energy-efficient practices, physician advocacy for policies and practices that reduce emissions, and expanded education and research funding on climate change and its effects on health (2). Combating climate change is a geopolitical issue involving the highest levels of government, with complex international negotiations and treaties. Can individual health care providers and institutions really do something meaningful? We began asking ourselves this question not long ago. Because of Utahs mountainous geography, our region (the Wasatch Front) is subject to winter temperature inversions, where the trapping of colder air below a warmer cap impedes atmospheric flow and results in the accumulation of air pollutants (Figure). Levels of particulate matter, nitrogen oxides, sulfur dioxide, carbon monoxide, and ground-level ozone increase, frequently exceeding the safe level designated by the U.S. Environmental Protection Agency, as reflected in an elevated Air Quality Index (>100). Winter inversions last an average of 14 days but can range from 1 to more than 30 days. In the summer, sunlight drives the creation of ground-level ozone from nitrogen oxides and volatile organic compounds; it is generally worse in hot, sunny weather and later in the day. Figure. Inversion layer over Salt Lake City, Utah. Ozone exposure results in airway inflammation and places patients with established respiratory disease at particularly high risk for harm. Particulate matter causes pulmonary and systemic inflammation and oxidative stress and is associated with adverse cardiovascular effects, including vascular and endothelial dysfunction, alterations in heart rate variability, coagulation, and cardiac autonomic function (3). Thus, changes in air quality are routinely palpable in our community. What could we do? Mounting evidence linking poor air quality with adverse health outcomes, coupled with the distinctly visible effect of air pollution on our community, prompted our health care system to form the Intermountain Air Quality and Health Workgroup in 2014 to achieve 3 aims: support ongoing research to further our understanding of air pollution exposure and health outcomes, expand sustainability efforts to reduce Intermountains environmental impact on the community, and address physician and patient education about outdoor air quality and health outcomes. Studies in the Wasatch Front community by members of our workgroup have further evaluated the effect of air pollution on cardiovascular outcomes in our patients; specifically, the likelihood of myocardial infarction and unstable angina increases by 4.5% for every 10g/m3 increase in fine particulate matter level. Of note, this risk was primarily identified among patients with existing coronary artery disease (4). The occurrence of ST-segment elevation myocardial infarction and decompensated heart failure requiring hospitalization also seems to be increased in association with increasing fine particulate matter levels in our community (5, 6). The second prong of our systems efforts, aimed at addressing climate change and air quality, began with a charge from our chief executive officer: We must limit our own health systems effect on our environment. In response, Intermountain is transitioning its automobile fleet from gasoline to natural gas, hybrid, and electric. Driver tracking devices on fleet vehicles have reduced idling by more than 500 hours per year. Employee use of public transportation has contributed to a reduction in emissions of 3.5 million pounds. The addition of rooftop solar panels has saved an additional 45 tons of carbon. In addition, Intermountain set a goal for all new facilities to achieve Leadership in Energy and Environmental Design Silver certification and be Energy Starcertified. The Office of Sustainability also addresses medical waste, water quality, and water conservationall areas of concern for the local community (7). What can we teach individual physicians about air quality that can be used to protect individual patients? Educating our physicians and patients about our communitys air quality and the actions that might help maintain good health has involved a multidisciplinary team of physicians, researchers, administrators, and writers working together to develop the Outdoor Air Quality and Health care process model (CPM) (https://intermountainphysician.org/_layouts/Custom/Know ledgeRepository/KrDocumentFetch.aspx?target=document&ncid=527926681&tfrm=default). The CPM provides evidence-based guidelines on the health effects of air quality and is primarily intended to help providers counsel patients about outdoor physical activity when air quality is poor. It is based on guidelines from the U.S. Environmental Protection Agency, current research on air quality and health, and advice from Intermountain experts. Included are an overview of common air pollutants, the health effects of poor air quality, and specific patient counseling recommendations. The CPM includes patient fact sheets for many conditions (https://intermountainhealthcare.org/health-information/health-library/patient-handouts/search-results/?Search Term=air%20quality) that are intended for distribution to patients at the point of care or community members accessing our patient education Web site. For example, a physician seeing a child with asthma could review the CPM to learn that even short-term exposure to air pollution is associated with disease exacerbation. If the Air Quality Index enters the moderate zone (51 to 100), the recommendation is to limit outdoor play time (or to play indoors if the child is symptomatic) and consider keeping a fast-acting inhaler nearby. If the Air Quality Index tops 100, the recommendation is to play indoors. Our research efforts, our initiatives to reduce our own carbon footprint, and the educational tools and programs represent the practical actions that one health care systemand the people within itcan take to address climate change and poor air quality. Success has been possible due to the support and encouragement from our highest level of leadership, a passionate and committed Air Quality and Health committee, and deliberate collaboration and alignment with community partners. Future efforts will focus on dissemination of patient and provider educational materials along with adoption and implementation of the CPM and fact sheets across the continuum of care. Finally, we hope that efforts focused on energy conservation will serve as an example to other businesses in our local community and in the broader health care community to reduce the effect of health care on the environment while adapting to the challenges of climate change. Combating climate change requires initiatives beyond the control of individual health care systems, clinicians, and patients, but we, as health care systems, clinicians, and patients, can bring about meaningful change if we act locally.

HIGH RISK HEART FAILURE PATIENT MULTIDISCIPLINARY CARE PATHWAY: IMPROVING CARE AND OUTCOMES

Heart failure (HF) patients at high risk (hr) for poor outcomes are a national focus. Multidisciplinary protocols (MP) for hospitalized HF patients have variable results. The purpose of this study was to test a MP in hrHF patients in a center with low readmission rates and to report outcomes.nnA MP

HEART FAILURE PATIENTS EVALUATED IN THE EMERGENCY DEPARTMENT: PERSONALIZATION OF CARE USING THE INTERMOUNTAIN HF READMISSION RISK SCORE

About three-fourths of heart failure (HF) patients who present to the emergency department (ED) are admitted to inpatient care, although some can be safely discharged home or managed in observation units. Risk-prediction tools that assist in avoiding unnecessary admissions are lacking. Using the

UPSTREAM USE OF ELECTRONIC DATA TO DISCOVER PATIENTS ELIGIBLE FOR ADVANCED HEART FAILURE THERAPIES

About 5% - 10% of heart failure (HF) patients have advanced disease, some of whom may be candidates for advanced HF therapies including heart transplantation and left ventricular assist devices (LVAD). To guide the appropriate recognition and timely referral of these patients, we evaluated the