CHART: congestive cardiac failure in hospitals, an Australian review of treatment

A physician targeted intervention improves prescribing in chronic heart failure in general medical units

Background

Despite strong evidence for beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in chronic heart failure (CHF), they have been under-utilised especially in general medical units. We aim to evaluate the effectiveness and feasibility of a physician-targeted quality improvement intervention with education and feedback on the prescription of beta-blockers and ACEI/ARB for CHF management in an inpatient setting.

Methods

We conducted an interrupted time series study between January 2009 and February 2012. A two-stage intervention was implemented. Between November 2009 and January 2011, a structured physician-oriented education program was undertaken. From February 2011, quarterly performance feedback was provided to each medical unit by a senior clinician. Medical notes of patients admitted with CHF under general medical units before and during the intervention were prospectively audited. Main outcomes were beta-blockers and ACEI/ARB prescription rates, and 180-day readmission rates for CHF.

Results

Four hundred and sixty-eight patients were included in this study. Structured education program was associated with a significant rise in beta-blockers prescription rates from a baseline of 60 to 92% (p = 0.003), but a non-sustained rise in ACEI/ARB prescription. Regular performance feedback resulted in a further sustained increase in ACEI/ARB prescription rates from 62 to 93% (p = 0.028) and a positive trend for beta-blockers with rates maintained at 89%. There was a reduction in 180-day readmission rates that correlated with the improvements in beta-blocker (p = 0.030) and ACEI/ARB (p = 0.035) prescription.

Conclusion

Implementation of a structured education program with regular performance feedback was durable and was associated with improvements in appropriate prescribing and an observed decrease in CHF-related readmissions.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective

RATIONALE, AIMS, AND OBJECTIVES

The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients.

METHOD

A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6 months to examine their management.

RESULTS

The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on β-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input.

CONCLUSION

This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines.

Diabetes mellitus and the heart

Diabetes mellitus is a risk factor for the development of coronary artery disease and chronic heart failure. When carefully screened for, diabetes or prediabetic disorders, are present in the majority of patients with clinically manifest ischaemic heart disease, and confer a major adverse impact upon morbidity and mortality. Important therapeutic modifications are required in the management of coronary artery disease and chronic heart failure associated with diabetes, and vice versa. However, despite optimal management, aided by recent landmark trials solely recruiting patients with diabetes, outcomes for patients with diabetes and heart disease remain poor. This review outlines the epidemiology, pathogenesis and management of diabetic heart disease, along with highlighting the many gaps in the evidence-base and suggesting future research priorities.

Exploring the beliefs of heart failure patients towards their heart failure medicines and self care activities

AIM

To identify Heart Failure patients' beliefs towards their medications and how these beliefs relate to adherence.

METHOD

Patients attending a multi-disciplinary, community based heart failure clinic on the Gold Coast, Australia were interviewed using a questionnaire composed of fours parts: repertory grid technique; Beliefs About Medicines Questionnaire (BMQ); Medicines Adherence Reporting Scale (MARS); demographic details. Patients were divided into those categorised as adherent (MARS score ≥ 23) and those categorised as non-adherent (MARS score < 23). Necessity beliefs scores from BMQ and the frequency of statements generated from the repertory grid portion of the questionnaire were compared between these two groups.

RESULTS

Forty-three patients were interviewed with a mean age (±SD) of 64 (±17) years and thirty-six (83.7 %) were male. Thirty-seven (86.0 %) patients were categorised as adherent; the remaining six (14.0 %) as non-adherent. The 43 patients generated a total of 262 statements about their medicines. The three most common themes identified were Related to fluid (36.6 %), Helps the heart (31.7 %) and Related to weight (13.7 %). There was a significantly higher median necessity score in the adherent group compared to the non adherent group (22.0 vs. 19.5, p = 0.0272). Patients with a strong necessity score also had significantly higher self reported adherence compared to patients with a strong concerns score (21.5 vs. 18.0, p = 0.006).

CONCLUSION

This study suggests that patients with heart failure possessing a strong belief in the necessity of their treatment regimen are more likely to demonstrate better adherence.

The effect of evidence-based medication use on long-term survival in patients hospitalised for heart failure in Western Australia

OBJECTIVES

To examine trends and predictors of prescription medications on discharge after first (index) hospitalisation for heart failure (HF), and the effect on all-cause mortality of evidence-based therapy.

DESIGN

A retrospective multicentre cohort study, with medical record review.

SETTING

Three tertiary-care hospitals in Perth, Western Australia.

PATIENTS

WA Hospital Morbidity Data were used to identify a random sample of 1006 patients with an index admission to hospital for HF between 1996 and 2006.

MAIN OUTCOME MEASURES

Proportion of patients prescribed evidence-based therapy for HF on discharge from hospital; and 1-year all-cause mortality.

RESULTS

Among 944 patients surviving to hospital discharge, the prescription rate of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) (74.3%) and loop diuretics (85.5%) remained high over the study period, whereas that of beta-blockers and spironolactone increased (10.5% to 51.3% and 1.4% to 23.3%, respectively), and digoxin prescription decreased (38.1% to 20.7%). The temporal trends in use of beta-blockers, spironolactone and digoxin were in line with clinical trial evidence. Age > or = 75 years was a significant, negative predictor of beta-blocker and spironolactone prescription. In-hospital echocardiography, performed in 53% of patients, was associated with a significantly greater likelihood of treatment with ACE inhibitors/ARBs, beta-blockers and spironolactone. Both ACE inhibitors/ARBs and beta-blockers prescribed on discharge were associated with a lower adjusted hazard ratio (HR) for mortality at 1-year (HR, 0.71; P = 0.003; and HR, 0.68; P = 0.002, respectively).

CONCLUSION

ACE inhibitors/ARBs and beta-blockers, prescribed during initial hospitalisation for HF, are associated with improved long-term survival. Therapy became more evidence based over the study period, but echocardiography, an important predictor of evidence-based therapy, was underutilised.

Diabetic cardiomyopathy

Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy.

Review article: Diabetes mellitus and heart failure--an overview of epidemiology and management

Heart failure and diabetes mellitus are chronic complex medical conditions that are closely related and commonly coexist.Treatment options have varied over the years, but newer treatment modalities have developed which have improved prognosis and longevity of patients with these conditions. Unfortunately, despite these advances, the evidence base remains insufficient, and larger randomised control trials need to be conducted. Here we discuss the available evidence and treatment and management of these inter-related conditions.

Diabetes, left ventricular systolic dysfunction, and chronic heart failure

Chronic heart failure (HF) and diabetes mellitus (DM) commonly coexist. Each condition increases the likelihood of developing the other, and when they occur together in the same patient the risk of morbidity and mortality increases markedly. We discuss the epidemiological overlap and consider the complex patho-physiological pathways linking the two diseases. The treatment of each condition is made more problematic by the presence of the other. We review the evidence-based treatment strategies and discuss the common problems faced by physicians when treating patients with both conditions. This article forms a comprehensive overview of a fascinating intersection between two common diseases.