Colleen Roberts

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

Hyperglycemia predicts mortality after CABG: postoperative hyperglycemia predicts dramatic increases in mortality after coronary artery bypass graft surgery

OBJECTIVE Risk of morbidity and mortality after coronary artery bypass graft surgery (CABG) is higher in patients with clinical diabetes mellitus (DM). We evaluated whether outcomes are affected by postoperative hyperglycemia in CABG patients independent of preoperative DM diagnosis. RESEARCH DESIGN AND METHODS A total of 2297 consecutive CABG patients were studied. The first glucose value after surgery completion (mean 15 min) was tested as a predictor of outcome. Primary outcome variables were prolonged ventilation (>24 h), deep sternal wound infection, renal failure, permanent stroke, any reoperation, length of stay (>14 days) and mortality. All outcomes except for prolonged ventilation and length of stay were tracked out to 30 days postoperatively. Patients were stratified by glycemic control: Low (glucose <80), normal (referent, glucose 80-110), high (glucose 111-200) and very high (glucose >200 mg/dl). Multivariable logistic regression was used to determine the independent predictive value of glycemic groups, adjusted for outcome specific risk scores from the Society of Thoracic Surgeons model. RESULTS Patient distribution among groups low through very high were 44 (1.9%), 476 (20.7%), 1425 (62.0%) and 352 (15.3%). Greater complication rates were noted in the very high group when compared with the referent group: prolonged ventilation (adjusted odds ratio (OR)=2.66, P<.001), length of stay >14 days (adjusted OR=2.06, P=.004) and mortality (adjusted OR=7.71, P<.001). CONCLUSION Patients with blood glucose values >200 mg/dl immediately after CABG had an increased risk of complications, including mortality, independent of a clinical diagnosis of DM. This study documents the high risk associated with early postoperative hyperglycemia in this group, suggesting the need for prospective trials of glycemic control.

Automated identification and predictive tools to help identify high-risk heart failure patients: pilot evaluation

OBJECTIVE Develop and evaluate an automated identification and predictive risk report for hospitalized heart failure (HF) patients. METHODS Dictated free-text reports from the previous 24 h were analyzed each day with natural language processing (NLP), to help improve the early identification of hospitalized patients with HF. A second application that uses an Intermountain Healthcare-developed predictive score to determine each HF patients risk for 30-day hospital readmission and 30-day mortality was also developed. That information was included in an identification and predictive risk report, which was evaluated at a 354-bed hospital that treats high-risk HF patients. RESULTS The addition of NLP-identified HF patients increased the identification scores sensitivity from 82.6% to 95.3% and its specificity from 82.7% to 97.5%, and the models positive predictive value is 97.45%. Daily multidisciplinary discharge planning meetings are now based on the information provided by the HF identification and predictive report, and clinicians review of potential HF admissions takes less time compared to the previously used manual methodology (10 vs 40 min). An evaluation of the use of the HF predictive report identified a significant reduction in 30-day mortality and a significant increase in patient discharges to home care instead of to a specialized nursing facility. CONCLUSIONS Using clinical decision support to help identify HF patients and automatically calculating their 30-day all-cause readmission and 30-day mortality risks, coupled with a multidisciplinary care process pathway, was found to be an effective process to improve HF patient identification, significantly reduce 30-day mortality, and significantly increase patient discharges to home care.

Predicting readmission risk shortly after admission for CABG surgery

Reducing preventable hospital readmissions after coronary artery bypass graft (CABG) surgery has become a national priority. Predictive models can be used to identify patients at high risk for readmission. However, the majority of the existing models are based on data available at discharge. We sought to develop a model to predict hospital readmission using data available soon after admission for isolated CABG surgery.

Early inpatient calculation of laboratory-based 30-day readmission risk scores empowers clinical risk modification during index hospitalization

Background Improving 30‐day readmission continues to be problematic for most hospitals. This study reports the creation and validation of sex‐specific inpatient (i) heart failure (HF) risk scores using electronic data from the beginning of inpatient care for effective and efficient prediction of 30‐day readmission risk. Methods HF patients hospitalized at Intermountain Healthcare from 2005 to 2012 (derivation: n = 6079; validation: n = 2663) and Baylor Scott & White Health (North Region) from 2005 to 2013 (validation: n = 5162) were studied. Sex‐specific iHF scores were derived to predict post‐hospitalization 30‐day readmission using common HF laboratory measures and age. Risk scores adding social, morbidity, and treatment factors were also evaluated. Results The iHF model for females utilized potassium, bicarbonate, blood urea nitrogen, red blood cell count, white blood cell count, and mean corpuscular hemoglobin concentration; for males, components were B‐type natriuretic peptide, sodium, creatinine, hematocrit, red cell distribution width, and mean platelet volume. Among females, odds ratios (OR) were OR = 1.99 for iHF tertile 3 vs. 1 (95% confidence interval [CI] = 1.28, 3.08) for Intermountain validation (P‐trend across tertiles = 0.002) and OR = 1.29 (CI = 1.01, 1.66) for Baylor patients (P‐trend = 0.049). Among males, iHF had OR = 1.95 (CI = 1.33, 2.85) for tertile 3 vs. 1 in Intermountain (P‐trend < 0.001) and OR = 2.03 (CI = 1.52, 2.71) in Baylor (P‐trend < 0.001). Expanded models using 182–183 variables had predictive abilities similar to iHF. Conclusions Sex‐specific laboratory‐based electronic health record‐delivered iHF risk scores effectively predicted 30‐day readmission among HF patients. Efficient to calculate and deliver to clinicians, recent clinical implementation of iHF scores suggest they are useful and useable for more precise clinical HF treatment.

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. A MP

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