7/19/2014

48th AnnualMeeting Heart Failure (HF)

HF is a complex clinical syndrome that can result from any structural or functional
cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
Chronic Heart Failure through REDUCED EJECTION FRACTION PRESERVED EJECTION FRACTION
(HFpEF)
Transitions of Care
(HFrEF)
EF typically defined as EF >50%
Shawn D. Anderson, Pharm.D., BCACP 40% diastolic dysfunction
Department of Veterans Affairs Inadequate cardiac
Gainesville, Florida output
Symptoms
Elevated BNP (NT-proBNP)

Navigating the Oceans of Opportunity 2013 ACCF/AHA Guideline for the Management of Heart Failure
4

Disclosure Heart Failure Facts

I do not have a vested interest in or affiliation with
any corporate organization offering financial
support or grant monies for this continuing education
activity, or any affiliation with an organization
whose philosophy could potentially bias my
presentation
More than 5 million people in the United States have
HF
An estimated 650,000 new diagnoses occur every
year
Primary diagnosis in over 1 million hospitalizations
yearly
Over 30 billion dollars spent of the management of
HF
1 in 9 deaths mentioned HF in the death certificate

American Heart Association Heart Disease and Stroke Statistics 2014 Update

Objectives Projected Prevalence of Heart Failure

Describe the impact of heart failure on morbidity

and mortality
Apply updated ACCF/AHA guidelines for
management of heart failure to patient care
throughout the health care continuum
Discuss the role of an acute care pharmacist
impacting CMS core measures
Recognize the impact of an ambulatory care
pharmacist in reducing readmissions

Heidenreich P, et al. Circ Heart Fail 2013

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Traditional Model of Heart Failure

Projected Costs of Heart Failure Care
Care

80% of costs The ED is an ineffective

related to point of triage for HF
patients
hospitalization Clinic
Concerns about ambulatory
follow up, and adverse
AHF events biases towards
admission
Home

Emergency
Department

Hospital
Heidenreich P, et al. Circ Heart Fail 2013

Hospitalization for HF Management is a

HF Vicious Cycle Sentinel Event

1.0 HF
Admission Initial diagnosis 1st admission (n = 14,374) P<0.0001
2nd admission (n = 3,358)
0.8
3rd admission (n = 1,123)
Cumulative mortality

4th admission (n = 417)

0.6

Ambulatory Acute HF
HF care care 0.4

0.2
1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%
Transition 0.0
from 0.0 0.5 1.0 1.5 2.0
hospital to
home Time since admission

Setoguchi S, et al. Am Heart J 2007;154:260-266.

Lifetime Risk for Readmissions in HF Stages in the Development of HFrEF

Desai AS, et al. Circulation 2012;126:501-506 2013 ACCF/AHA Guideline for the Management of Heart Failure

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HFrEF: Stage C treatment

Hospital Recommendations
algorithm

2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure

HFpEF: Treatment Recommendations Hospital Recommendations (cont)

2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure

Magnitude of Benefit Demonstrated

Recommendations for Discharge
in RCTs of HFrEF

2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure

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Recommendations for Discharge

CMS Core Measures
(cont)
Why do we need them?
Provides a measure of quality for our hospitals
Assures the community that our hospital is providing
high quality of care
Assures our hospital gets reimbursement from
Medicare

2013 ACCF/AHA Guideline for the Management of Heart Failure www.cms.gov

ACC/AHA/AMA-PCI Performance
Quality Improvement Initiatives
Measures (IP)
Inpatient HF Measure Description
Percentage of patients aged 18 y with a principal discharge diagnosis of HF
Core measures with documentation in the hospital record of the results of an LVEF assessment
2. LVEF assessment performed either before arrival or during hospitalization, OR documentation in the
Transition hospital record that LVEF assessment is planned after discharge

Percentage of patients aged 18 y with a diagnosis of HF with a current or prior

30 day readmission and mortality, Hospital to Home 6. Beta-blocker therapy for LVEF of <40% who were prescribed beta-blocker therapy with bisoprolol,
(H2H) initiative LVSD (outpatient and
inpatient setting)
carvedilol, or sustained-release metoprolol succinate either within a 12-mo period
when seen in the outpatient setting or at hospital discharge
Outpatient HF 7. ACE inhibitor or ARB Percentage of patients aged 18 y with a diagnosis of HF with a current or prior
therapy for LVSD LVEF of <40% who were prescribed ACE inhibitor or ARB therapy either within a
ACCF/AHA/AMA-PCI and GWTG (outpatient and inpatient 12-mo period when seen in the outpatient setting or at hospital discharge
setting)
Percentage of patients, regardless of age, discharged from an inpatient facility to
ambulatory care or home health care with a principal discharge diagnosis of HF
9. Postdischarge for whom a follow-up appointment was scheduled and documented, including
appointment for HF patients location, date, and time for a follow-up office visit or home healthcare visit (as
specified)

Bonow RO, et al. Circulation 2012;125:2382-2401

CMS Core Measures Pharmacist Opportunities

What are they? Across the continuum of HF care
Complete discharge instructions (6 components) Preventionof ADE and medications errors
- Activity level
Therapeutic drug monitoring
- Diet/fluid
- Medication reconciliation Medication reconciliation
- Follow up with physician Medication adherence and access
- Worsening symptoms
- Weight monitoring
Left ventricular function assessment
ACE inhibitor or ARB prescribed at discharge for left
ventricular systolic dysfunction
Adult smoking cessation counseling

www.cms.gov Mildred-LaForest SK, et al. Pharmacotherapy 2013;33:529-548

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Role of Pharmacist in Acute HF Transition of Care Quality Metrics

Involvement in interdisciplinary teams 30-day mortality

Potential interventions 30-day all-cause readmission
Drug information Why?
Therapeutic consultation Rates of unplanned readmission show whether a
Order clarification hospital is doing its best to prevent complications,
Formulary maintenance provide clear discharge instructions to patients, and
help patients make a smooth transition to their home or
Drug interaction avoidance
another setting such as a nursing home.
Duplication of therapy

Quality improvement

Mildred-LaForest SK, et al. Pharmacotherapy 2013;33:529-548 http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Medicare Hospital Readmission Reduction

Role of Pharmacist in QI Program

Why? ReadmissionsPenalties
HospitalReadmissionsReductionProgram
CMS core measure are high on discharge
Before admission, there is low utilization of HF-specific
medications and at sub-optimal doses
Opportunities
Involvement in interdisciplinary teams Policy inBrief: Medicares Hospital Readmissions Reduction Program

Medication reconciliation BeganonorafterOctober2012

TargetsDRGsreducedbyadjustmentfactorbasedonreadmissionsdeemedexcessive
Discharge education Adjustmentfactorcalculatedaspercentageofrevenuepaidforexcessivereadmissionsdividedby
totalrevenue
Projected$7.1Binreducedpayments(20132019)

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html 29
Mildred-LaForest SK, et al. Pharmacotherapy 2013;33:529-548

QI Evidence: Education and

Readmissions vs Mortality
Discharge Instructions
3857 Hospitals in CMS public
reporting database
Hospitalization
remains the best
option for
Hemodynamic
stabilization
Complex diagnostic
workup
Intensive monitoring
Complex
decisionmaking

Warden BA, et al. Am J Health-Syst Pharm 2014;71: 134-39 Gorodeski EZ, Starling RC, Blackstone EH. NEJM 2010;363(3):297-298.

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Trends in 30-day Rehospitalization and Mortality

in the VA Health Care System Transitional Care Opportunities
Discharge medication reconcilitation
Discharge education
Home-visiting programs
Structured telephone support
Telemonitoring
Outpatient HF clinic
Education
Others

Mildred-LaForest SK, et al. Pharmacotherapy 2013;33:529-548

Heidenreich et al. JACC 2010;56:362-368 Felter C, et al. Ann Intern Med 2014; epub

ACC/AHA/AMA-PCI Performance
Are Readmissions Avoidable?
Measures (OP)
Measure Description
Percentage of patients aged 18 y with a diagnosis of HF for whom the
quantitative or qualitative results of a recent or prior (any time in the past)
1. LVEF assessment
LVEF assessment is documented within a 12-mo period

Percentage of patient visits for those patients aged 18 y with a diagnosis of

3. Symptom and activity HF with quantitative results of an evaluation of both current level of activity
assessment and clinical symptoms documented

Percentage of patient visits for those patients aged 18 y with a diagnosis of

HF and with quantitative results of an evaluation of both level of activity AND
clinical symptoms documented in which patient symptoms have improved or
4. Symptom management remained consistent with treatment goals since last assessment OR patient
symptoms have demonstrated clinically important deterioration since last
assessment with a documented plan of care

Percentage of patients aged 18 y with a diagnosis of HF who were

5. Patient self-care education provided with self-care education on 3 elements of education during 1
visit within a 12-mo period

Van Walraven, et al. Journal of Evaluation in Clinical Practice 2012;18:12111218 Bonow RO, et al. Circulation 2012;125:2382-2401

ACC/AHA/AMA-PCI Performance
Factors that Precipitate AHF
Measures (OP)
Nonadherence with medication regimen, sodium and/or fluid restriction
Acute myocardial ischemia Measure Description
Uncorrected high blood pressure
Percentage of patients aged 18 y with a diagnosis of HF with a current or
AF and other arrhythmias 6. Beta-blocker therapy for LVSD prior LVEF of <40% who were prescribed beta-blocker therapy with
Recent addition of negative inotropic drugs (eg, verapamil, nifedipine, (outpatient and inpatient bisoprolol, carvedilol, or sustained-release metoprolol succinate either within a
diltiazem, beta blockers) setting) 12-mo period when seen in the outpatient setting or at hospital discharge

Pulmonary embolus
Percentage of patients aged 18 y with a diagnosis of HF with a current or
Initiation of drugs that increase salt retention (eg, steroids, 7. ACE inhibitor or ARB therapy prior LVEF of <40% who were prescribed ACE inhibitor or ARB therapy either
thiazolidinediones, NSAIDs) for LVSD (outpatient and within a 12-mo period when seen in the outpatient setting or at hospital
Excessive alcohol or illicit drug use inpatient setting) discharge

Endocrine abnormalities (eg, diabetes mellitus, hyperthyroidism,

hypothyroidism) 8. Counseling about ICD Percentage of patients aged 18 y with a diagnosis of HF with current LVEF
implantation for patients with 35% despite ACE inhibitor/ARB and beta-blocker therapy for at least 3 mo
Concurrent infections (eg, pneumonia, viral illnesses) LVSD receiving combination who were counseled about ICD implantation as a treatment option for the
Additional acute cardiovascular disorders (eg, valve disease endocarditis, medical therapy prophylaxis of sudden death
myopericarditis, aortic dissection)

2013 ACCF/AHA Guideline for the Management of Heart Failure Bonow RO, et al. Circulation 2012;125:2382-2401

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Pharmacist Outpatient HF Care

HF Observation Units
Opportunities
Criteria for OU Admit Intervention
Pharmacy-managed HF clinic Established HF Diagnosis Telemetry, weights, VS monitoring
Stable Vitals Serial labs/ECGs
Interdisciplinary HF clinic Likelihood of Stabilization within 24 hours Medical treatment (IV diuretics/nitrates/
Adequate Home Support electrolyte supplementation)
Others No Acute Comorbidities ECHO
HF/Smoking education
Ineligible
New Onset HF Criteria for Discharge
Unstable Vitals Subjective improvement
Acute Ischemia Stable vitals
Acute Cormorbities/New Medical Illness Stable laboratory parameters
Hb<8, BUN>40, Cr>3, Na<135 Adequate diuresis (> 1L urine, decrease in
Need for vasoactive therapy, ventilatory weight)
support Discharge checklist (ACEi, Beta-blocker,
Hypoperfusion HF/diet/smoking education, adequate
follow up)

Schrager J, et al. Acad Emerg Med 2013; 20:554-561.

Pharmacist Outpatient HF Care: HF Observation Unit Outcomes

Evidence

26.9%

P=NS

73.1%

Koshman, et al. Arch Intern Med. 2008;168:687-94 Schrager J, et al. Acad Emerg Med 2013; 20:554-561.

Evolved Model of Heart Failure Care Another Alternative Approach

CHRONIC ACUTE
MANAGEMENT MANAGEMENT

Home-Based
HF Clinic
Clinic Based
AMBULATORYHFTREATMENTCENTER
ED-Based (OU)
ORALMEDICATION
TITRATION
HOMECARELOOP ACUTETHERAPY
NURSE/PHARMACIST
DIRECTEDEDUCATION
EVALUATION,ACTIVE
Home REMOTE
MONITORING MULTIDISCIPLINARY
INTERVENTION,
ED HOSPITAL
HOME REASSESSMENT
Enhanced HFCLINIC
SELFTREATMENT
Ambulatory
SOCIALWORKSUPPORT
HF Treatment
ADVANCEDCARE
PLANNING

GENERAL
Emergency MEDICALHOME
Hospital
Department Desai AS, et al. Circulation 2012;126:501-506

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Our Program

Identify potential inpatient HF admissions daily (M-F)

from medical admissions pull list and loop diuretic list

Confirm likely HF admissions from brief EMR chart

review and submit an electronic consult

Complete inpatient consult

Optimize HF therapy
Discharge planning/HF education
Explain HF Team concept
Provide scale and BP/HR monitor

Enroll in the HF Team

Return to HF outpatient clinic within 3-14 days HF Care Coordination and Home
6 months of HF clinic for stable patients Telehealth management for
Long term HF clinic for complex patients appropriate patients
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In Summary
Heart failure prevalence and costs associated with
care are rising
A heart failure admission increases the risk of
readmission and death
Goals of therapy are well defined according to
evidence and HF Guidelines
Quality measures have been designed to improve
quality of HF care
Whether we agree with the measures or not, there
are many opportunities for pharmacy involvement