Evaluation of Heart Failure in the Internal Medicine Clinic

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Evaluation of Heart Failure in the Internal
Medicine Clinic

• Natohya Henry, Pharm.D.
• Kristin Campbell, Pharm.D., Jennifer Campbell,
  Pharm.D., CDE Christa George Pharm.D., BCPS,
  CDE Kristie Ramser, Pharm.D., CDE, Laura
  Sprabery, MD, FACP,
• Craig Dorko, MD, FACP
• The Regional Center at Memphis

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Heart Failure

• Approximately 5 million patients diagnosed with
  HF
• Primary reason for 12-15 million office visits
  yearly
• Death due to heart failure has steadily increased
  
• Most common Medicare diagnosis-related group
• Approximately 2.9 billion spent on heart failure
  medications annually
• Estimated 34.8 billion spent on direct and
  indirect costs in 2008

Hunt, S A, et al. Circulation. 2005
112e154-e235 Rosamond W, et al. Circulation.
2008 117e25-e146
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Heart Failure

• complex clinical syndrome that can result from
  any structural or functional cardiac disorder
  that impairs the ability of the ventricle to fill
  with or eject blood
• Ranges from normal LV size and preserved EF to
  severe dilatation and/or markedly reduced EF
• Cardinal symptoms dyspnea, fatigue, and fluid
  retention
• Treatment goals vary based on EF/ stage

Hunt, S A, et al. Circulation. 2005 112e154-e235
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NYHA ClassificationStages of Heart Failure
www.hfsa.org
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ACC/AHA 2005 Guidelines
Stages in the development of HF/recommended
therapy by stage
Hunt, S A, et al. Circulation. 2005 112e154-e235
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Preserved EF

• Definition varies with criteria and threshold
• Studies have used EF gt 40, 45, and 50
• Abnormal diastolic function which can lead to
  systolic dysfunction
• No evidence-based morbidity and mortality
  reducing medications
• Treatment modalities include addressing the
  underlying cause
• HTN, A. fib, CAD, Aortic stenosis

Hunt, S A, et al. Circulation. 2005 112e154-e235
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Reduced EF

• Systolic dysfunction with or without diastolic
  dysfunction
• Evidence-based medications titrated to target
  doses proven to decrease morbidity, mortality,
  and hospitalizations
• Studies performed in patients with EF 40
• CMS Core Measures

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CMS Core Measures

• Evaluation of left ventricular systolic (LVS)
  function
• ACE-I or ARB for LVS dysfunction
• Comprehensive discharge instructions
• Smoking cessation counseling

www.hospitalcompare.hhs.gov
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Routine Assessment

• Ability to perform routine/ desired activities
• Volume status and weight
• Use of ETOH, tobacco, and illicit drugs
• Evaluate sodium intake and diet
• Repeat measurement of EF if change in clinical
  status
• Labs (serum electrolytes, renal function)

Hunt, S A, et al. Circulation. 2005 112e154-e235
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Evidence-Based Therapies
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Hunt, S A, et al. Circulation. 2005 112e154-e235
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Evaluation of HF in the Internal Medicine Clinic

• Objectives
• Assess adherence to ACC/ AHA guidelines
• Assess compliance with CMS core measures

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Methods

• Active diagnosis of HF
• Clinic patient for one
• consecutive year

Pre-Intervention Medical Record Review

• Symptoms/ ER visits
• Smoking and smoking cessation
• Diet and daily weights

Phone Interview
Intervention with Internal Medicine Physicians

• Review of results
• Review of ACC/ AHA guidelines
• Review of CMS core measures

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Medical Record Review

• Patient characteristics
• Documentation of EF, NYHA classification, smoking
  and smoking cessation
• CHF medications and doses
• Followed by cardiology
• Comorbidities
• Hospitalizations/ ED visits due to HF

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Baseline Characteristics
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Baseline Characteristics
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Results
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Use of Heart Failure Medications in All Patients
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Use of Evidence-Based Medicationswith EF 40
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Phone Interview
Patients interviewed regarding whether they
received counseling on symptoms of HF and when to
report to the ER
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Phone Interview
Patients interviewed regarding lifestyle
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Conclusions

• Majority of patients with EF 40 were on an
  ACE-I and evidence-based beta blockers
• Most patients on ACE-I at target doses
• 6 of patients on beta blockers at target doses
• Of patients not at target ACE-I doses, one-third
  actively titrated
• Of patients not at target beta blocker doses,
  none actively titrated
• More than one-third of patients reported
  receiving counseling on symptoms of worsening HF
  and when to go to the ER
• Two-thirds of charts with documented EF
• 80 of smokers received smoking cessation
  counseling

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References

• ACC/AHA 2005 Chronic Heart Failure Guidelines
  Update. Circulation. 2005 112e154-e235
• Heart Disease and Stroke Statistics-2008 Update.
  Circulation. 2008 117e25-e146
• Stages of heart failure-NYHA Classification.
  www.hfsa.org
• Treatment Guidelines from The Medical Letter. The
  Medical Letter, Inc. 2006 41-4
• Heart Failure Core Measures Set Joint
  Commission. www.jointcomission.org

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