Published in the September 2005 issue of Today’s Hospitalist
When it comes to treating patients with acute coronary syndrome (ACS), hospitalists have an opportunity to improve the long-term mortality rates of a large group of patients.
That’s the message of some cardiologists who are frustrated with the discharge drug regimen that ACS patients receive in U.S. hospitals. Their complaint? Too many of these patients are leaving the hospital without a prescription for four widely accepted “and relatively inexpensive “medications that can drastically reduce mortality.
The number of ACS patients receiving antiplatelets, beta-blockers, ACE inhibitors and statins at discharge is rising, but that growth has been sluggish. Even worse, the number of patients who leave the hospital with a prescription and are still taking the drugs six months later is awful.
As one researcher bluntly puts it, “We spend billions of dollars on coming up with these innovations, but at the end of the day the practical application turns out to be pathetic.”
How do hospitalists fit into the picture? Cardiologists say that because hospitalists exert considerable influence in the inpatient setting, they can help lead the charge to make sure that these drugs are a regular part of discharge drug regimens. That includes not only taking the lead in systems improvement projects, but helping change patient education to reflect the challenges of keeping patients on ACS drugs.
A look at the numbers
One of the most recent studies to demonstrate the mortality improvements these drugs can produce was published in the Feb. 17, 2004, issue of Circulation. Researchers found that when combined, the four therapies reduced six-month mortality in ACS patients by 70 percent to 80 percent.
Debabrata Mukherjee, MD, lead author of the study and professor of interventional cardiology at the University of Kentucky, says that the research makes an important point about the relationship between drug therapy and percutaneous coronary intervention.
“One area of plaque may cause an initial problem,” explains Dr. Mukherjee, “but treating that plaque alone doesn’t take care of the whole arterial tree. Long-term prognosis depends on not only what we do with the balloon and stent in the hospital, but what we do for several months after the acute presentation.”
While no one would argue with that message, changing the prescribing patterns of inpatient physicians has proven to be a challenge. While the number of ACS patients taking drugs like aspirin at discharge has improved significantly, the use of medications like ACE inhibitors continues to lag.
A new study published in the July 25, 2005, Archives of Internal Medicine, for example, found that while about 85 percent of post-MI patients received aspirin at discharge and about 80 percent received beta-blockers, only about half of patients received ACE inhibitors. The fact that so many post-MI patients received aspirin and beta-blockers may seem like good news “until you consider this study examined only those patients who had no contraindications for the therapies.
“You’d like to think that if you took out the people with contraindications that these drugs would be used in 90 percent to 95 percent of patients,” explains the study’s lead author Matthew T. Roe, MD, who is assistant professor of medicine at Duke University Medical Center and Duke Clinical Research Institute in Durham, N.C. “These therapies are still being underutilized.”
The causes of undercare
While the Archives study provides a broad overview of how well physicians are prescribing commonly accepted ACS therapies, it also hones in on some of the reasons that these drugs are not being used in more patients.
When researchers compared discharge drug regimens for patients with ST-segment elevation MI (STEMI) and patients with non-STEMI, they found that non-STEMI patients received fewer antiplatelets, beta-blockers and ACE inhibitors both during hospitalization and at discharge.
This discrepancy doesn’t come as a surprise to Dr. Roe. He explains that several studies have shown that ACS patients who go to the cath lab tend to more frequently receive a full range of appropriate medications. Patients who don’t receive acute care, on the other hand, are less likely to receive the appropriate drugs at discharge.
“Our care processes in the hospital are dominated by the STEMI patients,” he explains. “Everyone is focused on these patients. They get rushed to the cath lab or they get thrombolytic therapy.”
“If someone is healthy enough to be indicated for an invasive procedure, everything else falls in line,” Dr. Roe adds. “If they don’t receive that procedure, however, they don’t always receive the other treatments.”
Dr. Roe hypothesizes that non-STEMI patients may be missing out on antiplatelets, beta-blockers and ACE inhibitors because they suffer from other diseases like renal insufficiency and heart failure. Cardiologists, however, are quick to point out that these medically complex patients often need those therapies the most.
“Beta-blockers reduce mortality more than any other drug,” says Wilbert S. Aronow, MD, clinical professor of medicine at New York Medical College in Valhalla, N.Y., and a frequent contributor to the medical literature on issues related to ACS and post-MI care.
Dr. Aronow acknowledges that when giving beta-blockers to heart failure patients, physicians need to make sure the patient is stable and doesn’t have any marked signs of fluid retention. But he is frustrated by the notion that physicians may be holding back drugs in medically complex patients.
“Beta-blockers are indicated if you have heart failure, they’re indicated if you have COPD without bronchospasm, and they’re especially indicated if you have diabetes,” Dr. Aronow says. “There are very few patients who should not be on drugs like beta-blockers.”
Keeping it simple
The physicians interviewed for this story agreed that for the most part, resistance to prescribing drugs like beta-blockers and ACE inhibitors to patients with multiple diseases is fading. Making sure that physicians act on that confidence and consistently give these drugs to ACS patients, however, presents hospitals with another challenge.
To improve the number of ACS patients who are receiving these medications, hospitals are employing classic quality improvement techniques. But one researcher who has studied these efforts says that when it comes to improving discharge drug patterns, simpler seems to be more effective.
Elizabeth H. Bradley, PhD, associate professor and director of the health management program at Yale School of Medicine, says she has found that the single most important tool to improve the use of drugs like beta-blockers at discharge is the standing order. While a number of hospitals have tried sophisticated strategies like clinical pathways, multidisciplinary teams and flow charting, they typically do no better than facilities that stick with standing orders.
“We were surprised by just how much empirically the TQM systems theories did not turn out to be that critical in discharge medications, with the exception of standing orders,” Dr. Bradley explains. “Sometimes we want to use TQM principles on easier projects, but it only ends up upsetting people. Physicians sometimes just need a reminder in the form of a standing order.”
While simple may be better, at least when it comes to improving discharge drug rates for ACS, Dr. Bradley notes that one element is critical: support for the project from a physician leader. Problems can develop, Dr. Bradley explains, when hospitals start feeding back data to physicians without first engendering trust in the initiative and the system. When they receive data on their performance, doctors feel like they’re being singled out.
“In some of our studies,” Dr. Bradley explains, “when the feedback was very physician-specific, it was sometimes seen as a punishing thing. If you don’t already have the culture that says we’re all trying to improve, physician-specific data feedback can backfire.”
She is also quick to add that if she were looking for a group of physicians to fill this role, she would look no further than hospitalists.
“Hospitalists have a golden opportunity to be that champion, to be the nudger and the physician who establishes that this is normal,” Dr. Bradley explains. “In all of our studies, having someone the physicians all respect is the dominant factor. You need someone who has the pulse of what’s going on to say this is standard and anything else is weird.”
Looking beyond discharge
While some cardiologists are urging hospitalists to take the lead in boosting the number of ACS patients taking antiplatelets, beta-blockers, ACE inhibitors and statins at discharge, others say that getting more scripts in the hands of patients is only the beginning. The reality is that even if you give these drugs to all of your patients at discharge, many will simply stop using them.
Javed Butler, MD, assistant professor of medicine at Vanderbilt University in Nashville, has conducted several studies that make exactly this point. One of his studies published in the 2002 Journal of the American College of Cardiology, for example, found that only about half of all MI patients left the hospital taking a beta-blocker. Even worse, one-third of these patients stopped taking the medicines within six months.
This is not an isolated finding. As Dr. Butler explains, other studies looking at patient compliance with ACE inhibitors and statins have found similar results.
Dr. Butler says that in his experience, patients and primary care physicians are too quick to chalk up symptoms like shortness of breath, fatigue and dizziness as side effects of beta-blockers instead of symptoms of heart failure. All too often, he says, the drug is pulled and patients lose any mortality benefits they were getting from the drug.
When talking about potential side effects, Dr. Butler urges patients to put the side effects of these drugs into perspective. If they complain that they feel dizzy when they stand up too quickly, he gives them a simple suggestion: “Don’t stand up so fast.”
His goal is to help patients balance the side effects of these drugs with the benefit. “I say that if you stop this medication because of a little dizziness,” Dr. Butler explains, “you’re stopping a 35 percent mortality benefit. Patients need to understand that by stopping these medicines they may avoid side effects, but there is a price to pay.”
An eye on prevention
Some in hospital medicine say the condition warrants an even more significant change in attitude among hospitalists.
Take the patient who comes to the hospital with community-acquired pneumonia, but who also has hypertension that’s not well-controlled. Alpesh Amin, MD, executive director of the hospitalist program at the University of California, Irvine, says the case offers an excellent example of how hospitalists need to think preventively.
Controlling the patient’s hypertension might help prevent a future myocardial infarction, he says, which in turn will help prevent heart failure.
“Hospitalists should be on the forefront of determining not only if patients came in with pneumonia,” Dr. Amin says, “but whether they also have risk factors for heart disease. This patient could have a problem 10 years from now, so the question is how we can ensure that we start the right therapy before sending them out. It’s the proactive piece of hospital medicine.”
Dr. Amin acknowledges that preventive care may not always be a top priority for hospitalists, but he says that the specialty has a much better opportunity to get involved in prevention than most other inpatient physicians. While hospitalists don’t have the same doctor-patient relationship as primary care physicians, they have an infinite amount of time compared to other inpatient physicians.
“Prevention is something we should push ourselves to do because we have a unique opportunity,” Dr. Amin says. “We have these patients with us for several days at a time. We have an opportunity to go back to the patient and say you came in with this, but let’s think about 10 years from now.”
“Emergency room physicians don’t have that opportunity because they’re seeing the patients for four hours,” he continues. “We’re seeing the patient for four days, which means that we have an opportunity to develop that relationship and start providing some preventive care.”
Edward Doyle is Editor of Today’s Hospitalist.