By Annette M. Boyle
LOS ANGELES—Appropriate and consistent use of medications markedly slows the progression of heart failure and reduces its mortality. Despite the clear benefits of medication, the number of heart failure patients who are nonadherent remains stubbornly high, however.
The VA Greater Los Angeles Healthcare System (VAGLAHS) has developed a program that shows promise for motivating HF patients to continue to take their medications as prescribed.
The VA cares for more than 210,000 veterans with heart failure, making development of programs that maximize treatment effectiveness a high priority. Multiple agents, including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs) and aldosterone antagonists (AAs), reduce heart failure-associated hospitalizations, morbidity and mortality. No matter how efficacious a medication, though, it will not work for a patient who does not take it—which would include 40% to 60% of heart failure patients.
The VAGLAHS established the Heart Failure Post-Discharge Management Clinic in 2010 to supplement the efforts of the system’s cardiomyopathy clinic. The post-discharge clinic works with all patients with heart failure who are discharged from inpatient care to help them transition to outpatient care.
“We started the clinic in 2010 with the goal of reducing HF readmission for patients admitted with HF as their primary diagnosis,” recounted Freny Mody, MD, director of the Advanced Heart Failure Program and the Preventive Cardiology Program at VAGLAHS.
Patients attend six scheduled visits at the multidisciplinary clinic over a two- to three-month period before they are referred to other clinics for ongoing care. During the visits, patients see a clinical pharmacist specialist, a case manager and physician assistant. A cardiologist oversees all care.
At the first visit, clinicians identify the etiology of the patient’s heart failure and the factors that prompted the hospitalization, including medication nonadherence or inappropriate diet.
The visits aim to rapidly titrate medications to reach guideline-directed therapeutic levels associated with improved survival and reduced heart failure admissions and improve overall function.
Patients also benefit from “education on dietary salt and fluid restriction, medical reconciliation and rapid diuretic adjustment for outpatient lifestyle,” said Mody. They are referred for long-term follow-up in the continuous cardiomyopathy clinic and defibrillator therapy, if appropriate.
A pair of studies of the program’s effectiveness found it both significantly reduced 90-day readmissions and increased medication adherence. In a study published in the April issue of the Annals of Pharmacotherapy, the researchers demonstrated found that the clinic reduced hospital readmissions within 90-days of discharge by more than two-thirds.1
The study compared 144 HF patients referred to the clinic between 2010 and 2012 to 133 HF patients who were discharged to usual care in 2009 following inpatient hospitalization. Patients hospitalized in 2009 and again in the 2010-2012 time period were excluded to avoid duplication.
While 23.3% of controls were readmitted for HF within three months of discharge, only 7.6% of those referred to the clinic required readmission. After adjustment, the total risk reduction attributed to the clinic was 83%. Similar results were seen when comparing time-to-first HF readmission or all-cause mortality, with an adjusted risk reduction of 72%.
A study published in Clinical Therapeutics this spring provides some additional insight into the results of the clinic. Analyzing the same 277 patients as the Annals of Pharmacotherapy study, it showed that the clinic increased overall medication adherence rates from 69% to 87%. Adherence for digoxin and beta-blockers among clinic attendees was about 10 points higher than among controls, while adherence for AAs rose from 46% to 85% and ACEI adherence increased from 68% to 87%. ARB adherence was lower in the clinic group at 77% compared to controls at 100%, but the number of patients prescribed ARBs made the analysis less reliable, according to the authors.2
“Close contact with patients and education on the indication and benefit of medication” contributed to the increased adherence, according to Mody.
- Jackevicius CA, de Leon NK, Lu L, Chang DS, Warner AL, Mody FV. Impact of a Multidisciplinary Heart Failure Post-hospitalization Program on Heart Failure Readmission Rates. Ann Pharmacother. 2015 Nov;49(11):1189-96. doi:10.1177/1060028015599637. Epub 2015 Aug 10.
- Lu L, Jackevicius CA, de Leon NK, Warner AL, Chang DS, Mody FV. Impact of a Multidisciplinary Heart Failure Postdischarge Management Clinic on Medication Adherence. Clin Ther. 2017 Jun;39(6):1200-1209. doi:10.1016/j.clinthera.2017.04.012. Epub 2017 May 22.
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