Hollywood, Fla. and Las Vegas—As part of the requirements of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) started imposing potential reimbursement penalties on hospitals based on their 30-day heart failure (HF) readmission rates beginning in October 2012. Concerned about these potential penalties, hospitals have ramped up efforts to forestall readmissions among those in this vulnerable target population, and several abstracts presented at recent pharmacy meetings suggest that pharmacist-led multidisciplinary efforts, including patient drug education and follow-up, can lower hospital readmission rates related to HF.
“Many institutions are trying their best to come up with methods to meet the requirements, and pharmacists are an integral part of the solution,” said Robert Lee Page II, PharmD, an associate professor of clinical pharmacy and a physical medicine clinical specialist in the Division of Cardiology at the University of Colorado School of Pharmacy and Medicine, in Aurora. “Every hospital has its own different case mix, but these studies show we can all learn from each other.”
A Coordinated Multidisciplinary Approach Works
Responding to the threat of possible financial penalties, researchers at The Nebraska Medical Center, in Omaha, conducted a study involving pharmacists, nurses and nutritionists to help lower readmission rates. The study included early identification of patients with HF upon admission, interdisciplinary education during the inpatient stay and interdisciplinary follow-up phone calls after discharge.
“I was surprised that our efforts not only improved the patients’ understanding of the disease process but also enhanced their resolve and commitment to take their medications and pay more attention to their symptoms,” said Brian Trevarrow, PharmD, the lead researcher, who presented the study at the American College of Clinical Pharmacy (ACCP) annual meeting.
The educational efforts—which focused on the pharmacologic effects on disease pathophysiology, possible side effects, dosing, regimen adherence, drug interactions and special instructions—were initiated in January 2011. Pharmacists, nurses and nutritionists all called patients four times: 24 to 48 hours after discharge, within one week, at three to four weeks and again after 30 days.
The team retrospectively analyzed the readmissions of 532 patients in 2010 (pre-education group) and prospectively analyzed the readmissions of 482 patients exposed to the education program in 2011. The two groups of patients had comparable comorbidities and demographics and were taking similar medications. The rate of all-cause readmission was significantly reduced after implementation of the multidisciplinary program, from 28% in 2010 to 20% in 2011. The incidence of HF readmissions also decreased from 12% to 5%.
The follow-up efforts were ambitious and rewarding, said Dr. Trevarrow, the coordinator of the Anticoagulation Stewardship and Heart Failure program at the medical center, and a clinical assistant professor at the University of Nebraska College of Pharmacy, in Omaha. “Patients [had been] taking medications for years just because they were told to,” said Dr. Trevarrow, noting that after the program was initiated, several patients thanked him for explaining how the medications work and why it was important to take them.
Patient Education and Follow-Up
A second study presented at the ACCP meeting also underscored the value of helping patients understand the importance of taking their medications and showed lower hospital readmission rates when pharmacists were involved in patient care during the hospital stay as well as after discharge.
During the study, investigators evaluated patients admitted to Atlanta Medical Center with a primary or secondary diagnosis of HF between Aug. 1, 2011 and Jan. 30, 2012, randomizing them into control (n=38) and intervention (n=22) groups. The baseline characteristics, which included ejection fraction, hospital length of stay and comorbidities, were similar between the populations. Control group patients received the standard of care. Intervention group patients received one-on-one medication and disease management discharge counseling from a pharmacist. Patients were called 14 and 28 days after discharge. The 30-day readmission rate for patients in the intervention group (9.5%) was approximately 50% lower than for the patients in the control group (21%).
“Heart failure patients are at risk for coming back to the hospital soon after discharge. Because of this pilot study, we now have a program where patients are screened for readmission risk,” said Pamela M. Moye, PharmD, the lead researcher and a clinical assistant professor in the Department of Pharmacy Practice at Mercer University, in
Atlanta. “All patients who are in the moderate to high–risk group will have a pharmacy consult and follow-up.”
A third related ACCP study dealt with the chronic problem of underdosing cardiac medications, such as angiotensin-converting enzyme inhibitors (ACEIs) and b-blockers in the treatment of HF. National guidelines recommend maximizing therapy to reduce mortality and the number of rehospitalizations. Pharmacists from the University of Illinois at Chicago (UIC) managed a clinic for a half-day every other week to help patients maximize their ACEIs and b-blockers. At each visit, the pharmacist reviewed vitals, symptoms, educational needs, laboratory results and medication regimens. ACEIs and b-blockers were titrated as tolerated.
Since the clinic opened in July 2011, the HF pharmacist has made 126 visits to 46 patients, and 64% of cardiologists referred their patients to the clinic
for medication optimization. The program was so successful that within a month, the half-day clinic had to operate every week.
“What’s unique is that it lets me work independently. I don’t need to call a physician before I make a medication adjustment,” said Vicki L. Groo, PharmD, the lead researcher and a clinical pharmacist at UIC. Prescriptions and the progress note are sent to the referring cardiologist for cosignature. The clinic pharmacist sees patients at two-week intervals, with a cardiologist available for additional consultation as needed.
Pharmacist services at the clinic are billed via a hospital-based facility fee model at a level 3 or 4 technical fee, depending on visit complexity. Dr. Groo said that because she was already working in the university’s Heart Center, the costs of implementing this new clinic were minimal.
The fact that UIC is getting “some reimbursement for pharmacy services … shows that their services are valued,” said Dr. Page, adding, “In order to sustain a program, you need reimbursement.”
VA Hospital Looks for Clues
A study presented at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting evaluated the factors leading to HF readmissions at the Jesse Brown Veterans Affairs Medical Center, in Chicago. At the VA medical center, like at UIC, underdosing was a factor contributing to HF readmissions. The VA team retrospectively evaluated patients with a HF diagnosis who were discharged from the medical center between Oct. 1, 2010 and March 1, 2011, comparing those who were readmitted within 30 days of discharge with those readmitted after 30 days or not at all.
Presenting the results at the ASHP meeting, Blair Kaplan, PharmD, BCPS, and Clare Bergman, PharmD, BCPS, inpatient clinical pharmacists at the VA medical center, reported that earlier and more frequent readmissions were more common among patients who received oral diuretic therapy for less than 24 hours before discharge; who were not prescribed an ACEI or angiotensin-receptor blocker and a β-blocker at discharge; and who were not compliant with medications or follow-up care.
Although the investigators noted that the rate of 30-day readmissions at the medical center was low, they acknowledged that the results “suggest that there is room for improvement.” Dr. Kaplan told Pharmacy Practice News, “We found that none of the patients who were readmitted during the study period of six months [had been] seen in the newly initiated heart failure pharmacist clinic. This gives us hope that over time, more patients will have the opportunity to receive medication education and optimization to prevent future hospital readmissions.”
Rural Health Care Approach
These programs can be incorporated even at small rural hospitals, according to another study presented at the ASHP meeting. In the study, conducted at Eastern Maine Medical Center (EMMC), in Bangor, Maine, pharmacists played an integral role within an interdisciplinary team that educated patients with HF and enhanced continuity of care, resulting in decreased readmission rates and improved reimbursement rates.
To be compliant with CMS reimbursement requirements, EMMC, which has six affiliated primary care clinics, established a Heart Failure Readmission Reduction Team, consisting of physicians, pharmacists, nurses and administrators from inpatient and outpatient settings. The Pharmacy Department was responsible for educating patients and establishing a screening criterion to better target patients with HF. Patients were targeted if they were on the cardiac telemetry unit, had a left ventricular ejection fraction less than or equal to 40% and had a primary care provider (PCP) within an affiliated provider group.
“We focused on the worst of the worst patients, those most likely to come back repeatedly,” said lead researcher
Dmitri Cohen, PharmD, BCPS, currently a critical care resident at the University Medical Center of Southern Nevada, in Las Vegas. “Before the study, they were getting very little education. During the study, we’d spend 30 minutes to an hour with each patient having detailed conversations.” During each session, patients were encouraged to take their blood pressure and weight on a daily basis and to notify their PCP of any significant changes. After the sessions, pharmacists emailed notes and suggestions to the PCP’s nurse case manager and pharmacist.
The initiative was implemented on Sept. 26, 2011. The team found that 30-day HF readmission rates fell significantly after implementation, from 17.6% to 19.5% before implementation (2008-2011 data) to 11.7% after (data from first three quarters of 2012), a 33% to 40% reduction (P=0.0327).
The special challenges of serving a rural area affected the study, noted Dr. Cohen. “It was a very unhealthy population of patients. For many of them, exercise was chopping wood once a week,” he said. “They hadn’t been educated. They didn’t know the symptoms of heart failure, so they were waiting too long before coming in.”
Patients’ Role Is Crucial
Getting patients to understand their medications, to be committed to taking them as prescribed, to weighing themselves and to taking their blood pressure daily is a huge step forward, according to C. Michael White, PharmD, the department head and a professor in the Department of Pharmacy Practice at the University of Connecticut in Storrs. “The addition of the safety measures is vitally important and new in this study,” he said. “The patients we see with 20 pounds of fluid overload are at greatest risk for intubation, nosocomial infections, arrhythmias and death. If they were caught with more than 2 pounds of weight loss on a single day or 5 pounds in a week, and treated at that point, their chances for success would be much better.”
These studies illustrate the need for pharmacists to play a more crucial role as hospitals become more responsible for reducing readmission rates, Dr. White noted. He predicted that finding clinical care and reimbursement models “that integrate all health care providers who add value to the team in a manner that best utilizes their skills and time availability” is going to be a core feature of a successful system.
—Additional reporting by Sarah Tilyou
Drs. Page, Trevarrow, Moye, Groo, Kaplan, Bergman, Cohen and White reported no relevant financial conflicts of interest.
Hollywood, Fla.—Albumin levels less than or equal to 3 g/dL signal worsening renal failure (WRF) in patients with acute decompensated heart failure (ADHF), according to a recent University of Michigan study presented at the ACCP annual meeting.
“Our study looked at baseline characteristics to help predict which patients receiving continuous infusions of loop diuretics were predisposed to develop WRF, whereas other research has studied what happened during infusion, when it may be too late to prevent WRF,” said Megan Barnes, PharmD, the lead researcher and a clinical pharmacy specialist in cardiology at West Penn Allegheny Health System, in Pittsburgh. Aggressive diuresis with loop diuretic infusions often is necessary for symptom relief in patients hospitalized for ADHF, said Dr. Barnes. But it can lead to development of WRF, which has been associated with increased mortality.
Dr. Barnes and her team performed a retrospective observational analysis of 177 patients with ADHF who were receiving continuous infusions of loop diuretics. The study included all patients who were admitted to the University of Michigan Health System with ADHF between January 2006 and June 2009 and received the infusions. WRF was defined as an increase of at least
0.3 mg/dL from the baseline serum creatinine value.
The mean patient age was 61 years and the median length of loop diuretic infusion was four days. Forty-eight patients (27%) experienced WRF and 34 (19%) died during hospitalization. A myriad of other factors were considered as predictors of WRF, including advanced age, severity of HF, baseline demographics, comorbidities and medications.
“It’s not surprising that low albumin would be a predictor, because it’s also indicative of nutritional status,” said Robert Page II, PharmD, MSPH, an associate professor of clinical pharmacy and a physical medicine clinical specialist in the Division of Cardiology at the University of Colorado School of Pharmacy and Medicine, in Aurora. “If patients are nutritionally depleted, it makes sense they may not fare well with high-dose diuretics.”
Drs. Barnes and Page reported no relevant financial conflicts of interest.