More continuity needed in heart failure management

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 - Stethoscope heart

There are numerous medication therapy strategies along the continuum of managing heart failure (HF), and the authors of a review article published online Oct. 10 in The American Journal of Pharmacy Benefits argued that these various medication therapies need to be coordinated in a way that allows for continuity of care through each stage of treatment.

“Recently, Medicare and JCAHO [the Joint Commission on Accreditation of Healthcare Organizations] in the United States and the National Health Service and NICE [National Institute for Health and Care Excellence] in the United Kingdom have focused on whether these therapies are linked into an orderly care process to optimize physical function and quality of life (QOL) for patients, and to decrease avoidable readmissions,” wrote the authors, led by Lori Wetmore, PharmD, of Visante, Inc., a healthcare consulting firm in St. Paul, Minn.

According to established guidelines, patients with HF-related congestion are treated with loop diuretics, which can improve symptoms, but ultimately do not improve mortality. Patients with class A or B HF are managed with medications that can treat comorbid conditions and reduce risk factors such as hypertension, obesity and coronary artery disease. In addition, class B patients receive treatment that improves HF symptoms and may also undergo revascularization.

As they move toward class C, treatment should focus on reducing morbidity and mortality and typically involve diuretics, ACE inhibitors and ARBs. Key to this stage is carefully monitoring medication dose, which requires close collaboration between hospital and outpatient providers as well as a follow-up visit within one to two weeks of discharge. At this stage, patient education about the importance of follow-up is crucial.

Stage D management should focus on palliative or end-of-life care and the heart’s fragile condition requires careful use of medications. Close collaboration between hospitals, outpatient providers, advanced cardiac care centers and hospices can help patients transition.

The authors outlined several strategies for managing HF across the stages. There should be an evidence-based formulary with the HF drugs proven to be more effective and safer than other HF drugs.

Providers should also focus on evidence-based therapy. The effectiveness of drug therapy is often based on the number needed to treat, which is the number of people that need to be treated to prevent one more event.

Maximizing patient education across the continuum is also crucial, the authors argued, in reducing hospital admissions and making patients more compliant with treatment. Education should include health professionals from numerous specialties. In addition, there should be follow-up calls and office visits in the early post-discharge period. Home health services can also prevent readmissions.

Also critical to HF management are efforts to improve adherence to prescribed treatments, strong and effective communication, affordable medications that are easily available and determining what will improve an individual patient’s quality of life.

With healthcare changing so rapidly, implementing these changes efficiently and effectively is crucial, the authors argued.

“[W]e are long overdue for the organizational transformation discussed in this paper, and are in fact the last major complex industry to adopt integrated logistics to improve the tangible value of our services to society.”