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10/1/2004

Discharge Medication Program Tied to Better CVD Outcomes

Kate Traynor

A simple discharge medication program implemented by Salt Lake City-based Intermountain Health Care is associated with improved outcomes for patients hospitalized with cardiovascular disease, according to a recent report in the Annals of Internal Medicine.

Before the discharge medication program began, about 40–70 percent of patients without documented contraindications to the targeted cardiovascular drugs had received discharge prescriptions for the appropriate medications. A year after the discharge medication program began, adherence to the recommendations for discharge prescribing had increased to at least 90 percent for each medication and stayed at that level through the study's end three years later.

The study focused on five discharge medications—aspirin and a hydroxymethylglutaryl-coenzyme A reductase inhibitor, or statin, for patients with a diagnosis of coronary artery disease (CAD); aspirin, a statin, and a beta-blocker for patients with CAD and an acute myocardial infarction; an angiotensin-converting-enzyme inhibitor for patients with congestive heart failure; and warfarin for patients with structural heart disease and patients over age 65 years with atrial fibrillation.

For patients with cardiovascular disease, the death rate was 96 per 1,000 person-years before the discharge program began and fell to 70 per 1,000 person-years a year later, a 21-percent reduction in risk. The readmission rate for these patients after the program started also fell at the one-year point, from 210 to 191 person-years, which corresponded to a 6-percent reduction in risk.

In all, the study examined prescribing for 26,000 patients who were admitted before the discharge medication program began and 31,465 patients admitted after the project began.

The study took place at Intermountain's 10 largest hospitals, but the discharge medication program has since been expanded to include all 21 hospitals in the health system. The report described the discharge medication project as "a solidly integrated program that continues to provide high rates of adherence to cardiovascular medication guidelines."

Dal C. Coleman is director of pharmacy at Logan Regional Hospital, in Logan, Utah, one of the study sites. Participation in the ongoing discharge medication program is voluntary, Coleman said, and although the project has the support of many physicians, not all are enthused about the program.

"I think with any physician, there's probably some resistance or a feeling that I try to do the best I can, and the system sometimes breaks down," preventing patients from receiving the recommended discharge medications, Coleman explained. "But I think for the most part, people are pretty conscientious in trying to do the right thing."

Data-collection forms for the program were designed to encourage physicians' use, with check boxes for recording the patient's diagnosis and discharge instructions. The section on medications also uses check boxes and fill-in-the-blank areas to specify the patient's recommended medication regimen.

When signed by the physician, the medication section of the discharge form is a valid prescription that the patient can have filled at a community pharmacy. Coleman said he sent a letter to local pharmacies to explain the discharge medication program and ask that the signed medication form be honored as a prescription.

He described the medication form as "a win for everybody."

"It serves multiple purposes," Coleman explained. "Physicians don't have to write out all their scripts again. It aids us in collecting the data, and it covers [physicians] in their chart for contraindications" or other reasons the patient was not prescribed the usual discharge medications.

Coleman said he currently has three pharmacists covering the shifts each day at Logan, a 148-bed nonprofit hospital. He said the pharmacists currently have no routine involvement with patients during the discharge process but are responsible for collecting discharge medication data and submitting it to a centralized group for analysis.

But Coleman noted that the pharmacy staff screens admissions data to identify patients with cardiovascular disease who would benefit from the recommended drug therapy.

"We're trying to proactively intervene before they're discharged to get them on the right medications while they're in the hospital," he said. "I think it's the nature of pharmacists to want to have people on the right medications, especially where it's clinically proven that these medications decrease mortality and morbidity."

Except for statin use, the drug interventions that were examined in the study were based on American Heart Association and American College of Cardiology guidelines that were in effect when the study began in 1998. Several of the interventions—including aspirin and an ACE-inhibitor at discharge after an acute myocardial infarction—were subsequently adopted as quality measures by the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services.

Coleman said that incorporating discharge medication recommendations into quality improvement initiatives can increase acceptance of the measures and provide resources for pharmacists to reinforce appropriate prescribing.

For instance, he said, HealthInsight, Utah's Medicare quality improvement organization, provides educational materials to encourage adherence to accepted standards of care for patients with acute myocardial infarction or heart failure. Coleman said he obtained preprinted adhesive reminder notes from HealthInsight that describe discharge medications for patients with acute myocardial infarction that the pharmacy can place on a patient's chart for the physician to see.

"We've started using them recently," Coleman said. He added that the notes "give a lot of information" but are not part of the medical record and may seem less confrontational to physicians than more direct reminders.

Coleman noted that some physicians who had initially resisted the discharge medication program eventually came around.

One hospital that was involved in the study, he said, "had a lot of resistance" to the program from physicians.

"Then after a period of time, they ran out of the forms," Coleman said. "And they said they had doctors calling upset" that the forms weren't available.