Emergency Update

An exclusive collection of interview-based emergency articles by leading experts

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Table of Contents 14

ew Performance Measures N for Atrial Fibrillation — N.A. Mark Estes, III, MD, FACC, FAHA, FHRS

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Recipe to Improve A Transitional Care — Jane Brock, MD, MSPH

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Focused Update for Managing A STEMI Patients — Elliott M. Antman, MD, FACC, FAHA

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nhancing Post-Discharge E Contact After AMI — Edward P. Havranek, MD

A message from the editor We at Physician’s Weekly are excited to present you with an eBook dedicated to news in emergency medicine. In recent months, our publication has featured a variety of news items in this field, focusing on clinical and evidence-based research as well as guidelines. The content in these articles relies on the expertise of our contributing physician authors. We anticipate that Physician’s Weekly will continue to feature news in this field of medicine in the coming months. We hope that you find this information useful in your practice. Please let us know your thoughts by contacting us at editor@physweekly.com.

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New Performance Measures for

Atrial Fibrillation New performance measures for the treatment of non-valvular atrial fibrillation and atrial flutter have been released, stressing the need for assessing thromboembolic risk factors and for appropriate anticoagulant therapy.

N.A. Mark Estes, III, MD, FACC, FAHA, FHRS Professor of Medicine Director, Cardiac Arrhythmia Service Tufts University School of Medicine

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October 20, 2008 • Issue No. 39 Click here to view this article online.

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n February 2008, the American College of Cardiology (ACC) and the American Heart Association (AHA) developed new performance measures for non-valvular atrial fibrillation (AF) to facilitate the translation of scientific evidence into clinical practice. “We extracted what we consider to be three measures best supported by evidence from the new guidelines for the treatment of AF,” says N.A. Mark Estes, III, MD, FACC, FAHA, FHRS, who chaired the writing committee. “These measures include the stratification of patients according to risk, the employment of warfarin therapy, and the strict monitoring of the international normalized ratio [INR]. Physicians should view these performance measures as an earnest attempt

by professional societies to help physicians assess their performance as related to what are considered the best recommendations for AF, not as bureaucratic burden.”

Assessing Three Key Measures In addition to prior stroke or transient ischemic attack—two of the most powerful independent predictors of stroke—heart failure, impaired left ventricular systolic function, hypertension, advanced

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age, and diabetes have consistently emerged as risk factors for AF. “Overwhelming evidence shows that anticoagulation therapy, particularly warfarin, appears to reduce the risk of stroke in selected groups of patients,” says Dr. Estes. “As a result, the first perfor­ mance measure we focused on was the assessment of thromboembolic risk. Risk stratification is an important part of good quality clinical care. When patients present, clinicians should stratify AF risk based on CHADS2 scores [Table 1], a clinical prediction rule for estimating the risk of stroke in AF patients. The CHADS2 index stands for cardiac failure, hypertension, age, diabetes, and stroke; the stroke risk has a subscripted two to represent that it is weighed twice as high as the other factors. Based on the available evidence, anticoagulation therapy should be con­sidered for patients if they have a CHADS2 score of 2.0 or greater. However, there are important exclusion criteria to consider [Table 2].”

The second performance measure relates to the assessment of an individual patient for anticoagulation therapy. “Anticoagulation therapy with warfarin—a vitamin K antagonist—is recommended for patients with more than one moderate risk factor unless otherwise contraindicated,” says Dr. Estes (Table 3).

“However, the decision to initiate warfarin should be determined by physicians based on the benefits and risks of anticoagulation therapy for each individual patient. If the benefits for antico­agulation therapy

Excluded Populations for Using Chronic Anticoagulation Therapy

Table 2

The following types of patients should be excluded from using chronic anticoagulation therapy: • Patients at low risk for thromboembolism.

• Patients with only one moderate risk factor.

• Postoperative patients.

• Patients with transient or reversible causes of AF (eg, pneumonia or hyperthyroidism).

• Women who are pregnant.

•M edical reasons documented by physicians, nurse practitioners, or physician assistants (eg, allergy or risk of bleeding).

• Documentation of patient reason(s) for prescribing warfarin (eg, economic, social, and/or religious impediments, or non-compliance).

Source: Adapted from: Estes NA III, et al. J Am Coll Cardiol. 2008;51:865-884.

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The CHADS2 Stroke Risk Stratification Scheme Table 1

CHADS2 Criteria

Risk Score*

Prior stroke or transient ischemic attack

2 points

Age 75 years or older

1 point

Hypertension

1 point

Diabetes mellitus

1 point

Heart failure or impaired left ventricular systolic function

1 point

* According to the Performance Measures for Adults with Non-valvular Atrial Fibrillation or Atrial Flutter, patients with CHADS2 scores ≥2.0 should be considered for anti­coagulation therapy.

Source: Adapted from: Estes NA III, et al. J Am Coll Cardiol. 2008;51:865-884.

outweigh the risks, physicians should elect to start patients on warfarin.”

The third performance measure is to monitor AF patients on warfarin with a monthly assessment of INR once anticoagulation is stable. The 2008 ACC/AHA performance measures note that frequent monitoring of INR levels is essential to directing warfarin dose adjustments to maintain anticoagulation intensity in the target range. “Physicians should aim to maintain INR scores between 2.0 and 3.0,”says Dr. Estes, “and more frequent monitoring may be required during the initiation of warfarin therapy.”

Tracking Physician Performance Dr. Estes emphasizes that while the performance measures focus on AF, they should also be applied to atrial flutter because this condition has been asso­ ciated with the same risk factors as AF. In addition, the ACC/AHA performance measures contain paperbased specifications and assessment tools (also available online at www.acc.org) that may aid doctors as they manage patients with AF. “These performance measures are meant to be a practical and useful tool to help physicians assess their performance on a patientby-patient basis,” Dr. Estes notes. “They can easily be incorporated into routine evaluations by ancillary staff, the patients themselves, and ultimately by electronic medical records that prompt medical personnel to determine AF and atrial flutter risk factors.”

According to Dr. Estes, the writing committee and task force associated with the performance measures

Table 3

Antithrombotic Therapy for Patients With Non-Valvular AF

Less Validated/Weaker Risk Factors

Moderate-Risk Factors

High-Risk Factors

• Female gender

• Age more than or equal to 75 years

• Age 65 to 74 years

• Hypertension

• Coronary artery disease

• Heart failure

• Thyrotoxicosis

• L eft ventricular ejection fraction ≤35%

• Prior stroke, transient ischemic attack, or systemic embolism

• Diabetes mellitus Risk Category

Recommended Therapy

No risk factors

Aspirin 81 mg to 325 mg daily

One moderate-risk factor

Aspirin 81 mg to 325 mg daily or warfarin (INR 2.0 to 3.0, target 2.5)

Any high-risk factor or more than one moderate-risk factor

Warfarin (INR 2.0 to 3.0, target 2.5) Abbreviation: INR=international normalized ratio.

anticipate that their document will be used to direct reimbursement for pay-for-performance initiatives in the future. “Like all performance measures,” he says, “the question is whether or not the document will help clinicians reduce the risk of stroke from AF or atrial flutter. Our next step is to demonstrate that these measures can improve patient outcomes as well

Source: Adapted from: Estes NA III, et al. J Am Coll Cardiol. 2008;51:865-884.

as make the practice of medicine easier for physicians who treat these patients.”

N.A. Mark Estes, III, MD, FACC, FAHA, FHRS, has indicated to Physician’s Weekly that he has or has had the following financial interest: Boston Scientific, Medtronic, and St. Jude Medical. For more information on this article, including references, please visit: www.physweekly.com.

References Estes NA 3rd, Halperin JL, Calkins H, et al. ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults with Nonvalvular Atrial Fibrillation or Atrial Flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation) Developed in Collaboration with the Heart Rhythm Society. J Am Coll Cardiol. 2008;51:865-884. Available at: http://content.onlinejacc.org Spertus JA, Eagle KA, Krumholz HM, et al. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. Circulation. 2005;111:1703-1712.

Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119-125.

Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace. 2006;8:651-745.

McNamara RL, Brass LM, Drozda JP Jr, et al. ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Commitee to Develop Data Standards on Atrial Fibrillation). J Am Coll Cardiol. 2004;44:475-495.

Snow V, Weiss KB, LeFevre M, et al. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2003;139:1009-1017.

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Jane Brock, MD, MSPH Clinical Coordinator Colorado Foundation for Medical Care

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December 24, 2007 • Issue No. 49 Click here to view this article online.

A Recipe to Improve

Transitional Care New tools are being created to help healthcare facilities integrate a framework for transitioning patients across different settings in an effort to reduce readmission rates after hospital discharge.

O

lder patients with chronic illness frequently require care from a variety of practitioners in multiple settings, including hospitals, nursing homes, homecare services, and physician offices. Despite recent efforts focusing on processes of quality and measurable improvements, each setting remains relatively isolated from each other, creating a unique quality gap. A tremendous cost to patients and society results from this gap as it frequently leads to poor health outcomes and significant monetary expenses.

Elimination of the gap in quality care is likely to require standardized approaches to coordinate services, according to Jane Brock, MD, MSPH. “Effective recruitment of patients in their own care, and ensuring reliable and traceable information transfer across settings are critical. The current state of transitional care is one of the biggest money wasters in medicine today.”

Defining the Problem Professional and academic organizations have defined transitional care as a set of actions de­signed to ensure the coordination and continuity of healthcare as pa-

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tients transfer between locations or different levels of care in the same location. Dr. Brock says that transitions of care are associated with adverse events, medication errors, poor pa­tient compliance, and patients returning to a higher-intensity care setting. “Despite most practitioners acknowledging that poorly executed care transitions are dangerous to patients and contribute to increased healthcare costs, few models of successful quality improvement interventions for transitional care currently exist.”

Continuity and coordination of care are important components in transitions of care, according to Dr. Brock. “Continuity of care refers to ensuring that patients see the same physician or healthcare team throughout their course of treatment, while coordination of care means that patients have a care plan that aggregates the available information and is reliably shared and followed by all involved providers at the time the patient transitions among silos.”

The Care Transitions Intervention The Colorado Foundation for Medical Care (CFMC), as a special study funded by CMS, has created a framework for improving transitional care processes. The Transitions of Care Pilot Program includes implementation of the Care Transitions Intervention (developed

by Eric Coleman, MD, MPH at the University of Colorado) and standardization of handoff management activities to ensure reliable coordination of care. The CFMC collaboration has resulted in an evidence-based interdisciplinary team approach to enhance transitional care. Data on the Care Transitions Intervention (CTI) is available at www.caretransitions.org “The CTI prepares patients and caregivers for successful incorporation of key self-management skills at the time of a care transition as opposed to assuming that patients can execute their care plan flawlessly on arrival to the next care setting through the receipt of written discharge instructions,” says Dr. Brock. Research has demonstrated that the CTI has reduced the risk of patients returning to hospitals for care.

Identifying Key Interventional Strategies The CTI outlines several important inter­ ventions that can have a profound impact on transitional care improvement efforts (Table 1). “Basically, the CTI consists of four key components: medication selfmanagement, a patient-centered record (eg, personal health record), primary care and specialist follow-up, 10

A “Recipe” for Successful Transitional Care Projects

Table 1

1. Recruit a multi-setting community • Recruit the hospital first and gain their input about other specific providers to recruit.

2. Foster collaboration and cooperation • Involve the participants in the program and help them to see the broader picture of transitional care.

• Engage the front-line providers in process map development through interviews and documentation of their processes.

3. Prepare participants for training and implementation • Meet with each participant to fully discuss their reasons for participating, their goals for improvement, the barriers they expect to encounter, and their plan for implementation.

4. Coaching training • Attendees should include personnel who provide direct care, as well as higher-level decision makers.

• It may be difficult to determine the best potential attendees from the hospital, as many different provider types are in­volved in discharge processes.

• At a minimum, involve case managers and staff nurses.

5. Facilitate the plan for implementation • This process should begin well before the training.

• Final planning can begin at the training.

6. Develop standardized transition protocols • Agree on information exchange. Consider the following components: - The Personal Health Record.

- A continuity of care record.

- A handoff management dataset.

7. Implement a test model

and knowledge of ‘red flag’ warning symptoms or signs indicative of a worsening condition,” Dr. Brock explains. “Using patient-centered records and transition coaching, the CTI requires five coach-patient encounters. These occur during a visit in the hospital, a visit in the home within 72 hours of discharge, and three follow-up phone calls.”

The mission of CFMC’s pilot program is to facilitate organizations coming together to improve transitions

of care through collaborative development of new processes for cooperation that include delivering the CTI. “There is much variation in how providers are and are not coordinating care,” says Dr. Brock. “The idea behind our program is to establish several variations of ‘recipes’ across different healthcare settings so that all stakeholders can benefit.” Dr. Brock notes that the added responsibilities of each provider in the CTI can be a challenging hurdle to overcome. “However,” she adds, “studies estimate that 30% to 60% of healthcare activity is wasteful. Developing and standardizing a new approach can enable each care team to waste less time and effort through knowledge of and reliance on its partners’ processes. In turn, these potential barriers can be broken.”

Strive for Long-Term Improvements The history of quality improvement efforts is filled with projects that enhance results for the short term, but fail to last for the long haul. “Building a test model within the community that hinges on workflow efficiencies can help sustain results,” Dr. Brock says (Table 2). “A test model can help detect where efficiencies might lie and aid pro­viders in finding the appropriate ‘recipe’ for their unique setting. Our hope is that multi-setting communities of healthcare providers can work together to incorporate the CTI and provide quality transitional care without adding resources by establishing predictable and reliable ‘standard operating procedures’ for transferring patients among themselves.”

Jane Brock, MD, MSPH has indicated to Physician’s Weekly that she has or has had no financial interests to report.

Table 2

Implementing A Test Model

Several factors are crucial to successful implementation of a transitional care model. These factors include: • Accurate capture of the patient’s PCP upon admission to the hospital (and every setting). This capture point often begins in the emergency department in hospitals, or intake processes in other settings.

• Milestone markers within the PHR provide patients and providers a visual indicator for assessing the patient’s own mastery of the four pillars. The pillars should be reviewed during every patient encounter, until the patient indicates mastery.

• Provide a visual indicator for the patient to wear to assist providers with identifi­cation of patients receiving the CTI (eg, visual indicator could be a silicon band that is a specific color with a PCP’s phone number imprinted on it).

• Knowledge of readmission rate data may assist participants in all healthcare settings to recognize the importance of care coordination and to understand how s/he may contribute to reducing these rates. Share data with the participants. This helps them to understand where they fit in the continuum of care.

• Hold weekly transitions rounds with providers from each participating site. These allow providers the opportunity to be held accountable for their contri­bution to patient transitions, to resolve any problems with information exchange, and to acknowledge which processes are working smoothly.

Abbreviations: PCP=primary care physician; PHR=Personal Health Record; CTI=Care Transitions Intervention Source: Adapted from: Patient-Centered Care: Supporting Providers in Improving Transitional Care. Draft Framework for Multi-Setting Coordination of Care Improvement.

References The Care Transitions Intervention (CTI) imparts to beneficiaries the key self-management skills that pertain to care transitions. It is comprised of a set of skills and tools that are operationalized through coaching sessions designed to encourage and empower the patient and/or family/ caregiver to take an active role in their health care and to communicate effectively with care providers during a transition. The intervention has been demonstrated to reduce the risk of returning to the hospital. For tools and more information, go to www.caretransitions.org The Case Management Society of America is making efforts to improve transitioning care, including the initiation of the National Transitions of Care Coalition. For more information on this initiative, go to www.ntocc.org For a copy of the April 2007 version of “Patient-Centered Care: Supporting Providers in Improving Transitional Care. Draft Framework for Multi-Setting Coordination of Care Improvement,” go to www.cfmc.org/files/pcc Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51:556-557.

Coleman EA, Min S, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification.

Health Serv Res. 2004;29:1449-1466.

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A Focused Update for

Managing STEMI Patients New data from clinical trials assessing various aspects of ST-elevation myocardial infarction, or STEMI, have led to an updated set of joint guidelines to improve outcomes in these patients.

Elliott M. Antman, MD, FACC, FAHA Director, Samuel A. Levine Cardiac Unit Cardiovascular Division Brigham & Women’s Hospital Professor of Medicine Harvard Medical School

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May 26, 2008 • Issue No. 20 Click here to view this article online.

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lmost 500,000 Americans each year have an ST-elevation myocardial infarction (STEMI), but these events can be quickly recognized and treated to reduce further heart damage. In 2004, the American College of Cardiology (ACC) and American Heart Association (AHA) released joint guidelines for treating STEMI. Since then, new clinical trial data on a variety of aspects of STEMI care have emerged, prompting ACC/AHA to update portions of the 2004 joint guidelines in late 2007. In addition to other data, late-breaking clinical trials presented at the 2005 and 2006 annual scientific meetings of the ACC, AHA, and European Society of Cardiology were reviewed to identify key information that has since impacted the guideline recommendations.

Published in the January 15, 2008 issues of Circulation and the Journal of the American College of Cardiology (www.cardiosource.com/guidelines), the new ACC/AHA guidelines reinforce the goal of restoring blood flow to the heart as quickly as possible during the initial treatment of STEMI. “We have evidence showing that improved systems of care can lead to faster times to reperfusion, resulting in better outcomes for patients with STEMI,” says Elliott M. Antman, MD, FACC, FAHA, who chaired the guideline writing group.

Facilitated & Rescue PCI The 2007 ACC/AHA guidelines for STEMI clarify data on administering a strategy of planned immedi-

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Table 1

Reperfusion Recommendations

• STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal.

• STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrino­lytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated.

Abbreviations: PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.

Source: Adapted from: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. American College of Cardiology/American Heart Association.

ate PCI after an initial pharmacologic regimen has been given, also known as facilitated PCI. “Several regimens have been used to evaluate facilitated PCI,” Dr. Antman explains. “These include full-dose fibrinolytic therapy, a combination of a fibrinolytic therapy plus a glycoprotein (GP) IIb/IIIa, or a GP IIb/IIIa inhibitor alone. Despite promising initial results of small trials, there’s no evidence of their impact on improving mortality or reinfarction rates. In fact, these regimens increase the risk of bleeding, so the new guidelines recommend against a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI.” However, facilitated PCI using regimens other than full-dose fibrinolytic therapy should be considered only when patients are at high risk, when PCI is not available within 90 minutes, and when the bleeding risk is low. “This recommendation opens the door for some future research,” notes Dr. Antman.

According to the guidelines, patients with STEMI presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact (Table 1). This systems goal also stands for hospitals without PCI capability, but only if patients can be transferred and receive treatment within the 90-minute window. On the other hand, patients who cannot be transferred to a PCI center and undergo PCI within 90 minutes should be treated with fibrinolytic therapy within 30 minutes of presenting to the hospital unless such therapy is contraindicated.

The update also includes new information on rescue PCI, which refers to the need for PCI after fibrin14

olytic treatment has failed to restore blood flow to the heart. “The guidelines now recommend that proceeding with rescue PCI is reasonable in patients with hemodynamic or electrical instability and/or persistent ischemic symptoms,” Dr. Antman says. “In addition, PCI of a hemo­dynamically significant stenosis in infarct arteries more than 24 hours after STEMI may still be considered as part of an invasive strategy when fibrinolysis is successful or patients do not undergo primary reperfusion. However, the guidelines now recommend that PCI of a totally occluded infarct artery more than 24 hours after STEMI is not advisable in asymptomatic patients with one- or two-vessel disease if they are hemo­dynamically and electrically stable and do not have evidence of severe ischemia.”

Clarifying b-Blocker Use The 2007 ACC/AHA update also helps clarify which patients with STEMI are candidates for early intravenous (IV) β-blocker therapy. STEMI patients with several characteristics should not be administered IV b-blockers (Table 2). “The 2004 guidelines were based on studies that showed a reduced incidence of subsequent reinfarction and recurrent ischemia in patients receiving both fibrinolytic therapy and IV bblockers,” notes Dr. Antman. “However, more recent studies have uncovered uncertainty about the use of IV b-blockers in the setting of fibrinolytic therapy.”

Two randomized trials of IV b-blockade found that early b-blocker therapy in myocardial infarction did not significantly reduce mortality.

Table 2

b-Blocker Recommendations

• Oral b-blocker therapy should be initi­ated in the first 24 hours for patients who do not have any of the following: 1) Signs of heart failure.

2) Evidence of a low output state.

3) Increased risk for cardiogenic shock.

4) Other relative contraindications to b-blockade.

• Patients with early contraindications within the first 24 hours of STEMI should be reevaluated for candidacy for b-blocker therapy as secondary prevention.

• Patients with moderate or severe left ventricular failure should receive b-blocker therapy as secondary prevention with a gradual titration scheme.

Abbreviation: STEMI, ST-elevation myocardial infarction.

Source: Adapted from: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. American College of Cardiology/American Heart Association.

Using Ancillary Therapies A series of new recommendations are available in the updated guidelines for ancillary therapies in STEMI patients. For example, selective cyclo-oxygenase-2 (COX-2) inhibitors and other non­ selective nonsteroidal antiinflammatory drugs (NSAIDs) have been associated with increased heart risks; this risk appears to be amplified in patients with established heart disease (Table 3).

An AHA scientific statement on the use of NSAIDs concluded that the risk of cardio­vascular events is proportional to COX-2 selectivity and the underlying risk in STEMI patients. “Non-pharmacological approaches are recommended as the first line of treatment,” explains Dr. Antman, “followed by a stepped-care approach to pharmacological therapy.

The updated guidelines now recommend discontinuing NSAIDs when patients present to the cardiac care unit with STEMI. When preparing STEMI patients for discharge, it’s recommended that physicians review the need for long-term musculoskeletal pain therapy. Essentially, the lowest effective doses should be used for the shortest possible time. COX-2 selective NSAIDs should be considered only as a last resort in all STEMI cases.”

Elliott M. Antman, MD, FACC has indicated to Physician’s Weekly that he is a senior investigator in the TIMI Study Group. That study group has received grants from Accumetrics,

Table 3

Analgesia Recommendations

• Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain asso­ciated with STEMI. • Patients routinely taking the following medications before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use: - NSAIDs (except for aspirin).

- Nonselective COX-2 agents.

- Selective COX-2 agents.

Abbreviations: COX-2, cyclo-oxygenase-2; IV, intravenous; NSAIDs, non­steroidal anti-inflammatory drugs; STEMI, ST-elevation myocardial infarction.

Source: Adapted from: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.

American College of Cardiology/American Heart Association.

Amgen, AstraZeneca, Bayer Healthcare, Beckman Coulter, Biosite, Bristol-Myers Squibb, CV Therapeutics, Eli Lilly, GlaxoSmithKline, Inotek Pharmaceuticals, Integrated Therapeutics, Merck, Millennium, the NIH, Novartis, Nuvelo, Ortho-Clinical Diagnostics, Pfizer, Roche Diagnostics, Roche Diagnostics GmbH, Sanofi-Aventis, Sanofi-Synthelabo Recherche, and Schering-Plough. Dr. Antman has also received honoraria from or been on the speaker’s bureau for Eli Lilly and SanofiAventis. He has also worked as a consultant/advisory member for Sanofi-Aventis.

References For information from the American College of Cardiology on the 2007 focused update of the 2004 guidelines for the management of patients with ST-elevation myocardial infarction—including the complete guidelines, slide decks, and audiocasts—go to www.cardiosource.com/guidelinefocus Antman EM, Hand M, Armstrong PW, et al. 2007 Focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With STElevation Myocardial Infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

Circulation. 2007 December 10. E-pub ahead of print. Available at www.cardiosource.com/guidelines Gibbons RJ, Smith S, Antman E. American College of Cardiology/American Heart Association clinical practice guidelines: Part I: where do they come from? Circulation. 2003;107:2979-2986.

Antman EM. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines.

2004. Available at www.acc.org/qualityandscience Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomized placebocontrolled trial. Lancet. 2005;366:1607-1621.

Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomized placebo-controlled trial. Lancet. 2005;366:1622-1632.

Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet. 2006;367:569-578.

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Enhancing

Post-Discharge Conta After

Published studies have demonstrated that patients who suffer an acute myocardial infarction have poor adherence to medications after discharge, but efforts to improve post-discharge communication may enhance outcomes.

Edward P. Havranek, MD Director, Cardiac Catheterization Laboratory Denver Health Medical Center Professor University of Colorado Health Sciences Center

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October 6, 2008 • Issue No. 37 Click here to view this article online.

act

AMI

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T

here has been increasing recognition that broad adoption of established strategies may further reduce mortality rates in acute myocardial infarction (AMI). Many large-scale studies have been designed to improve rates of prescriptions for proven medications, and some of these efforts have achieved success. “Quality-of-care efforts are continuing to evolve,” explains Edward P. Havranek, MD. “These efforts are starting to focus more heavily on ensuring that AMI patients actually take medications that have been proven to reduce mortality once they have been prescribed.”

Early outpatient follow-up of AMI patients after hospital discharge is recommended in published guidelines, and several evidence-based therapies— most notably β-blockers and statins—are critical to improving long-term mortality rates. However, many AMI patients fail to adhere to these therapies, says Dr. Havranek. “Several years ago, only about two-

Table 1

The Importance of Early Follow-Up

A study of 1,516 patients hospitalized with an AMI was conducted to assess rates of early follow-up (defined as patient-reported visits with primary care physicians or cardiologists within 1 month after discharge). Findings suggested that early outpatient and collaborative followup after discharge can increase rates of evidence-based medi­cation use. Among the findings: • 34% of participants reported no outpatient followup during the month following discharge.

• When compared with those not receiving early followup, those receiving early follow-up were more likely to be prescribed b-blockers (80.1% vs 71.3%), aspirin (82.9% vs 77.1%), or statins (75.9% vs 68.6%) at 6 months.

• A persistent relationship remained between early followup and b-blocker use (risk ratio, 1.08).

• In secondary analyses, statin use was higher in patients receiving collaborative follow-up (risk ratio, 1.11).

Source: Adapted from: Daugherty SL, et al. Arch Intern Med. 2008;168:485-491.

Efforts are needed to ensure that patients continue medication use and increase their chances for survival.

thirds of patients who should have been receiving β-blockers and/or statins to reduce their mortality risk were actually prescribed them. Since then, prescription rates for these medications are up considerably. That said, it’s estimated that between one-half and two-thirds of patients with this asymptomatic, chronic illness will stop taking these medications shortly after discharge. This is why efforts are needed to ensure that patients continue medication use and increase their chances for survival.”

New Studies Assess Adherence to AMI Therapies The March 10, 2008 Archives of Internal Medicine featured two studies that assessed the care of AMI patients after discharge. The first, conducted by Stacie L. Daugherty, MD, MSPH, and colleagues, demonstrated that many AMI patients who were discharged from the hospital struggled to adhere to post-treatment drug regimens. “Patients who didn’t visit their primary care physician (PCP) within a month of their event were less likely to adhere to their prescribed AMI drug regimens when evaluated 6 months later than those who did meet their PCP within 30 days of 18

— Edward P. Havranek, MD the event,” Dr. Havranek says (Table 1). “This study demonstrates that proper transitions from hospitals to outpatient settings are crucial to sustaining longterm management. If the handoff from the hospital specialist to the PCP isn’t accomplished, there are long-term consequences to consider.”

A second study from the March 10, 2008 Archives of Internal Medicine by David H. Smith, RPh, PhD, and colleagues assessed the impact of using a simple direct-to-patient intervention for AMI patients postdischarge. The intervention consisted of two mailings that were done 2 months apart from each other in which letters to patients described the importance of β-blocker use. “In this study, the authors addressed the problem of poor adherence head on,” says Dr. Havranek. “They asked their patients how they could best craft messages that will help them adhere to their medications. It seems simple to ask patients what works best for them, but these efforts are important and sometimes forgotten. Addressing patients’ needs and concerns are critical aspects to decreasing AMIrelated mortality.”

An Intervention to Enhance Drug Adherence

Table 2

In an analysis of 836 post-AMI patients who were dispensed a b-blocker prescription after discharge, researchers tested an intervention consisting of two mailings 2 months apart that described the importance of b-blocker use.

Among the findings: • Patients in the intervention arm had a mean absolute increase of 4.3% of days covered with b-blocker therapy per month compared with patients in the control arm.

This represented 1.3 extra days of b-blocker therapy.

• Patients in the intervention arm were 17% more likely (relative risk, 1.17) to have 80% of days covered in the 9 months after the first mailing.

• F or every 16 patients receiving the intervention, one additional patient would become adherent to b-blocker therapy (coverage with b-blockers for 80% or more days per month).

Source: Adapted from: Smith DH, et al. Arch Intern Med. 2008;168:477-483.

Findings from Smith et al showed that AMI patients receiving the intervention of two mailed letters after hospital discharge had an average absolute increase of 4.3% of days covered with prescription drug therapy (in this case, β-blockers) per month when compared with the control group (Table 2). “Although this was a modest effect,” Dr. Havranek notes, “these findings are important because medications like β-blockers have been shown to reduce mortality by 20% to 30% after an AMI.”

Continued Efforts Are Warranted Dr. Havranek notes that the intervention used in the

study by Smith et al was simple and reproducible.

“Other institutions—hospitals and primary care settings alike—throughout the country can adopt this intervention with little resistance. In fact, hospitals can go even further by developing programs in which patients are called 1 to 2 weeks after discharge. They can be asked if there are any questions or problems concerning their medications. Such programs could go miles toward reducing the problem of adherence drop offs shortly after hospital discharge.”

The healthcare system continues to place a huge burden on primary care to treat AMI patients after discharge. Dr. Havranek says it is important to share adherence enhancement tools broadly so they can be more widely adopted. “Hospitals should try to partner with PCPs and pool their resources to develop programs aimed at increasing post-discharge adherence rates. When messages to patients come from their PCPs, they may be more likely to listen to them.

Hospitals may need to get ‘buy in’ from PCPs to have their names on letters to patients and to get PCPs involved with such programs. The hope is this will lead to a more seamless transition of care that will ultimately improve long-term AMI mortality rates.”

Edward P. Havranek, MD has indicated to Physician’s Weekly that within the past 10 years (but not the last 2 years) he has worked as a consultant for Bristol-Myers Squibb and CV Therapeutics, as a paid speaker for Bristol-Myers Squibb, Merck, and Takeda, and has received grants/research aid from Bristol-Myers Squibb, Merck, and AstraZeneca. For more information on this article, including references, please visit: www.physweekly.com.

References Daugherty SL, Ho PM, Spertus JA, et al. Association of early follow-up after acute myocardial infarction with higher rates of medication use.

Arch Intern Med. 2008;168:485-491. Available at: http://archinte.ama-assn.org Smith DH, Kramer JM, Perrin N, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168:477-483. Available at: http://archinte.ama-assn.org Havranek EP. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction--invited commentary. Arch Intern Med. 2008;168:483. Available at: http://archinte.ama-assn.org Peterson ED, Roe MT, Mulgund J; et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295:1912-1920.

Kramer JM, Hammill B, Anstrom KJ; et al. National evaluation of adherence to beta-blocker therapy for 1 year after acute myocardial infarction in patients with commercial health insurance. Am Heart J. 2006;152:454.e1-454.e8.

Zuckerman IH, Weiss SR, McNally D, Layne B, Mullins CD, Wang J. Impact of an educational intervention for secondary prevention of myocardial infarction on Medicaid drug use and cost. Am J Manag Care. 2004;10:493-500.

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