Published in the November 2004 issue of Today’s Hospitalist
Who should be responsible for making sure that patients with coronary artery disease are taking medicines like aspirin, statins, beta-blockers, ACE inhibitors and warfarin: inpatient physicians who see these patients only during acute episodes, or outpatient physicians who see these patients on an ongoing basis?
When physicians at LDS Hospital and Intermountain Health Care in Salt Lake City took a hard look at that question several years ago, they decided that it was time for a change. They were growing frustrated with the relatively lackluster rates of patients who could benefit from–but simply weren’t taking–tried and true medicines to treat their heart disease.
Physicians at the health system knew from their own research that when certain drugs were prescribed at discharge, patients were much more likely to continue taking them. One study in the 1990s conducted at the health system, for example, showed that patients who were discharged on statins were three times more likely to still be taking them three years later.
As a result, the health system decided to make inpatient physicians responsible for prescribing cardiovascular drugs to patients with conditions like coronary artery disease, congestive heart failure and atrial fibrillation. The health system found that by incorporating those duties into the hospital’s discharge process, it was able to save lives and dramatically reduce costs.
Revamping the discharge process
In the late 1990s, Intermountain began to look at ways to revamp its discharge process to make sure that more patients were taking the medicines they needed to stay out of the hospital.
Researchers started by scouring the literature for evidence of which drugs could help prevent secondary events, from heart attacks to strokes. They then started to build a list of drugs that physicians would be asked to consider prescribing to patients with coronary artery disease.
To make sure physicians remembered to prescribe these medicines to the appropriate patients, the health system created a discharge form that listed the appropriate indication for each medication. Physicians would be expected to either order a drug by simply checking off a box, or to record a contraindication explaining why the drug was not appropriate.
If a physician did not prescribe an appropriate medication or list a contraindication, the discharge planning nurse would contact the attending physician or resident.
Within a year, the number of patients receiving prescriptions skyrocketed from between 30 percent and 60 percent for the drugs on the list to at least 90 percent for all drugs.
The shift in prescribing patterns produced impressive results. One year after the discharge process was revamped, the unadjusted readmission rate dropped from 210 per 1,000 person years to 191 for patients in the study, and the unadjusted mortality rate dropped from 96 to 70.
Researchers saw the greatest benefits in terms of both death and rehospitalization in patients with congestive heart failure. Researchers found a 23 percent reduction in mortality in this group, an effect that lasted a full year. Readmission rates in this population also dropped 9 percent.
In the larger group of cardiac patients without congestive heart failure, mortality rates still dropped by 19 to 21 percent. Readmission rates for this population were also 8 percent lower after a year. (For the study’s full results, see the Sept. 21 Annals of Internal Medicine.)
Shift in thinking
Donald L. Lappe, MD, chief of cardiology at LDS Hospital in Salt Lake City and medical director of cardiovascular services for Intermountain Health Care, says that from patients’ point of view, it makes perfect sense for inpatient physicians, not physicians in the community, to prescribe these medicines.
“If a surgeon doesn’t send you home on a certain drug,” he explains, “it must not be important. If your surgeon or hospitalist doesn’t send you home on a medicine, why would you start it as an outpatient?”
Physicians and clinical staff at the health system needed a little more convincing. Dr. Lappe says that asking inpatient physicians to prescribe drugs that will be taken on an outpatient basis represented a change in philosophy on several fronts.
For one, he says, it meant that clinical staff had to explicitly acknowledge that it was important to practice evidence-based medicine. Second, and perhaps even more significantly, he says, physicians needed to be convinced that the point of accountability was at the time of discharge, not after the patient has left the hospital.
“There’s been a lot of confusion in the past,” Dr. Lappe explains, “because surgeons would say it’s up to the internist to do that. Others would say, “If I’m not seeing them in a week, I shouldn’t put them on a statin.’ ”
To help make sure that everyone understood how the new initiative would shift responsibility, Dr. Lappe spent a fair amount of time educating not only inpatient doctors about the new initiative, but outpatient doctors whose patients would receive prescriptions upon discharge from the hospital.
In addition to regularly making presentations to all staff, a process that continues to this day, he also gives feedback on how well hospitals as a whole are doing meeting the guidelines. When there are problems, the health system can break the data down to the level of individual doctors.
The discharge form
The crux of Intermountain’s effort to change the discharge process is its discharge form. In addition to reminding physicians to prescribe certain medications or list contraindications when a drug is not appropriate, it also allows the health system to easily track the drugs that patients have received and link that to their diagnoses.
One of the nice things about the system, Dr. Lappe says, is that you don’t need a sophisticated electronic medical records system to get started (although he acknowledged that computer technology makes life easier). It’s relatively easy to create the form and track the results using fairly basic spreadsheet software.
And detailed data, he adds, are a key to convincing physicians to change their ways. Dr. Lappe recalls one physician who said that because so many of his patients are over 80, there was little reason to give them statins. After all, the argument went, these patients were too old to see any benefit from the drug.
Because the health system has kept data on more than 12,000 patients who have gone through the health system’s catheterization lab in the last 10 years or so, Dr. Lappe says, researchers were able to look at the impact of statins at discharge by age.
“It turned out that patients in their 80s and 90s had the greatest reduction in three-year mortality from statins,” he explains. “The older you are, the more incremental benefit you get from going home on statins.”
When presented with the data, Dr. Lappe recalls, the physician agreed that statins would be helpful for his patients.
While reductions in mortality and readmission rates have been an exciting result of the health system’s initiative, researchers have found that it has produced another derivative benefit.
“If you get people to change their practice in one domain of the health care system,” Dr. Lappe explains, “it will umbrella or halo into other areas.”
When researchers examined a much larger group that included patients who had not been hospitalized, for example, they found that about 90 percent of outpatients were taking the drugs. While many of these patients never went through the hospital, their outpatient physicians knew about the discharge process and were acting on their own to follow the same evidence as their inpatient colleagues.
“It took me a year or two to realize the concept that you don’t have to manage a process in every place that it occurs,” Dr. Lappe says. “If you pick a common domain that represents a significant point of care that will engage everybody, caregivers will adopt the initiative being introduced in all domains. You don’t have to manage it on the inpatient and outpatient side, and in private health plans and Medicare populations.”
Dr. Lappe notes that the discharge program has helped pave the way for evidence-based medicine in other more subtle ways, including physicians’ overall embrace of evidence. He says that fewer physicians now argue that because one patient experienced muscle pains after taking a statin that none of that physician’s patients will receive the drug.
“Many of our doctors are now realizing that their individual experience is very anecdotal and that they don’t necessarily have broad validity for treatment strategies,” Dr. Lappe explains. “When we discuss issues in treating acute coronary syndrome or heart failure, people are arguing based not so much on their own experience, but what the literature says.”
Finally, Dr. Lappe says that the health system’s success in changing the mandate of inpatient physicians has potentially valuable lessons for hospitalists.
“They have to think of themselves beyond being episodic inpatient managers,” he says. “They are really accountable for patients coming in and getting through the hospital, and they need to make sure they are sent out with the appropriate medication and communication and care.”
Besides, he adds, there are relatively few areas in health care where by prescribing a few medications, you can achieve a 25 percent reduction in morbidity and mortality. “We’re often arguing over a few percentage points, where we need tens of thousands of patients to gain significance in terms of outcomes,” he says.
With congestive heart failure patients alone, by comparison, the discharge initiative helped save the health system about $5 million a year. “With the numbers we’re talking about,” Dr. Lappe says, “you only need a few percentage points to make a big difference.”