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Ask anyone who keeps data about ACE inhibitor use and they will tell you the numbers should be better. National benchmarking data shows that between 1995 and 1998, use of ACE inhibitors among heart patients was between 30% and 50%, when perhaps as many as 90% of patients should have been on the drug, says James B. Young, MD, section head of Heart Failure and Cardiac Transplant Medicine and medical director of the Cleveland Clinic Health System’s Kaufman Center for Heart Failure.
At the clinic’s own facilities, 1998 data showed that only 61% of patients who might have benefited from ACE inhibitor use were given the drugs and, according to Deborah M. Nadzam, PhD, FAAN, director of the Cleveland Clinic Health System Quality Institute, the range was between 29% and 70% depending which of the eight system hospitals one is talking about.
"We knew it was a problem for us just as it was a problem for others," says Young. "Those of us who have worked in the heart failure arena have tried to improve ACE inhibitor use as a way to impact morbidity and mortality. We had data from our own system and from [the Centers for Medicaid and Medicare Services] that indicated there was underutilization."
Tackling the issue was about more than just impacting patient care though, Young admits. "There were other drug classes that would likely demonstrate benefit, too, and would have a similar lack of utilization. We thought we could create a new paradigm that would work for this drug and others."
Before starting, however, Young and a team of physicians, nurses, and pharmacists looked at what a good target for the health system’s patient base would be. "There are a number of national benchmark targets out there that show in a high risk, unstable, hospitalized patient population, the target should be 70 [percent] to 80% of patients on ACE inhibitors," Young explains. "For stable outpatients, it should be 80% to 90%, and for stable patients who can tolerate the drugs without side effects like a rash or cough, you can argue that 100% should be on them."
But in 1998, when they started to look at the numbers, the group wanted to make sure that the target they set was right for its own patient base. "We looked at patients in our hospitals with decompensated congestive heart failure," Young continues. "We looked at comorbidities that might have precluded use. We looked at the actual number of patients we could titrate doses for. And we determined that 80% was a reasonable target."
The team put together a protocol derived from clinical evidence and created teaching tools that clinicians could use, says Young. Among them was a pocket card that would enable physicians to quickly determine the proper dosages for patients. In addition, they created preprinted orders for the physicians and new educational materials for patients. (To see a preprinted order sample click here, and a sample card, click here.) A new chart review document was created for physicians to document improvement or worsening over time. The program was rolled out via lectures and grand rounds at each individual facility. There was also a continuing medical education dinner meeting for physicians with large numbers of heart failure patients.
"It’s not that the docs don’t know that ACE inhibitors are good," Young says. "These are hard drugs to use. They can cause rashes, hypotension, odd tastes in patients’ mouths, and coughs. It requires time and care to juggle all the other medications a patient might be on and get them titrated on this. So it’s not an issue of knowing or not knowing, but of motivating them that the impact they could make is significant enough to offset the hassle factor for the patient. You have to have that buy in." In addition to the main team, says Nadzam, each hospital also formed its own individual team to make sure that the program worked for its individual patient base. "We knew we had to be flexible."
Over the course of 10 months, the system was able to increase the use of ACE inhibitors by 10%. "We didn’t reach our target," says Young. "But we were consistent across the system."
The increase was based on data from 3,406 patients discharged with a heart-failure diagnosis. "That’s by far our highest-volume DRG," Nazdam adds. Young continues: "In the 10 months of data we used in 1998, there were 17,961 hospital days devoted to caring for heart failure patients. That’s why we focus on this."
The system doesn’t view the ACE program as finished, he adds. "We aren’t there yet, but there are things we have learned over the last two years that make me view the project as a success." For instance, after two years of promoting this program, Young wonders whether 80% is a realistic target for this particular patient population. "When you look at the benchmarks, they are all speculative in nature," he notes. "We are still having a lot of discussions about what would be a realistic target."
Another benefit of the project is its ability to translate to other drug classes. "In the last two years, beta blockers have become perhaps even more important than ACE inhibitors," Young says. "Now we have to work with a drug class that is even more difficult to up-titrate than ACE inhibitors. So we can take this program, look at the beta blockers, and come up with a plan to increase their use using this as a template."
The health system conducted a study that showed one-third of patients who could use beta blockers were on them between 1998 and 2000. Currently, that number stands at about 50%. "We think a good target for that might be around 60%, but we haven’t finished figuring it all out yet," he says. In addition, says Nazdam, the team model used for the ACE inhibitor project has been expanded to other process and quality improvement initiatives. There are now multidisciplinary teams working on stroke care, colorectal and breast cancer care, chronic obstructive pulmonary disease, diabetes, and end care. "It has completely changed the way we do PI and QI."
Another lesson learned, says Young, is the realization that not every hospital is the same. "When you have a system that has smaller community hospitals, teaching hospitals, and referral hospitals, the patients in these disease categories are all different," he notes. "The peripheral community hospitals are plagued with elderly patients, often those who are coming from or going to nursing homes. Those aren’t the type of patients who are undergoing heart transplant evaluation at the central referral hospital. Patients are different and diverse. You have to find out how to best manage patients in each institution, and find out what the physicians need to manage that particular population. You have to have a team that understands the differences in patient populations and are flexible enough to make sure protocols differ in ways that make sense to those different populations."
[For more information, contact:
• Deborah M. Nadzam, PhD, FAAN, Director, Quality Institute, and James B. Young, M.D., Section Head of Heart Failure and Cardiac Transplant Medicine, Medical Director of the Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 444-2270.]