Prescribing for a heart failure patient at hospital discharge can be tricky, despite detailed guidelines on the subject.
“There's a balance to be struck. You can use the hospital event to adjust medications, but if you do that some patients may be prescribed many new medications at the same time, and the reality is that it may be too much for some of them,” said Larry A. Allen, MD, MHS, medical director of advanced heart failure at the University of Colorado in Aurora.
“The problem is that if we don't prescribe the therapies at that important time of hospital discharge, some patients may never be prescribed them at all,” Dr. Allen said.
He led a study of nearly 159,000 heart failure patients finding that 47% needed to start at least 1 new heart failure medication by discharge to meet quality measures, 24% needed to start more than 1, and 14% needed to start 3 or more. The study included 271 hospitals between 2008 and 2013 and was published in the Oct. 6, 2015, Circulation.
When hospitalists encounter such patients, many of them are not taking the opportunity to get their medication regimens up to guidelines, according to study co-author Gregg C. Fonarow, MD, professor of medicine and associate chief of the division of cardiology at the University of California Los Angeles.
“Unfortunately, unless these patients are in a hospital where there are strictly implemented systems for care or medication management, they are discharged with the same medications they came in with. There is a very short-term, nihilistic view of managing whatever the acute complaint was and not taking the opportunity to ensure these patients are on the guideline-established medications,” he said.
However, there's also a real concern that the risk of drug-drug interactions and patient nonadherence increases with each additional medication in polypharmacy, noted Dr. Allen. He and other experts offered their advice on balancing these priorities.
Thinking long term
While hospitalists' focus is naturally on stabilizing a patient, they shouldn't do that at the expense of long-term care needs, experts said.
“There is a tendency to downplay heart failure risk for rehospitalization, where it's regarded as a chronic illness and the goal is to get the patient stabilized and send them home, but that's not patient-centered care and it's not taking full advantage of the measures that are there to guide us,” Dr. Fonarow said.
On the other hand, the ever-shortening duration of heart failure hospitalizations poses prescribing challenges, as an editorial accompanying the study in Circulation noted. With stays of only 4 or 5 days, it is “increasingly impractical and potentially dangerous to require inpatient initiation of several new medications that can have synergistic effects on heart rate, blood pressure, renal function, and serum potassium,” the editorialists wrote.
It's a tightrope for hospitalists to walk, said Jeffrey L. Schnipper, MD, MPH, ACP Member, a physician at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School in Boston.
“Hospitalization is a perfect time to reevaluate a patient's medication regimen, but you can also argue it's the wrong time because of the patient's medical instability,” he said. “Some hospitalists feel uncomfortable prescribing long-term outpatient medications and feel it should be done by outpatient providers. It can seem like passing the buck, but these medications need to be followed up and these patients need to be monitored. Yet the literature is long on this, that if patients start these therapies in the hospital, they are more likely to still be on those therapies a year later.”
Other research shows that only 10% to 15% of heart failure patients are prescribed guideline-recommended therapies at outpatient visits, noted Dr. Fonarow. “They have a markedly higher risk of rehospitalization and death in contrast to those who start [these therapies] in the hospital. Leaving it to an outpatient basis is leaving patients to fend for themselves,” he said.
Of course, they don't have to be left entirely on their own. Dr. Schnipper encourages hospitalists to open up the lines of communication with outpatient clinicians. “The right thing to do is have a conversation with the patients' primary care provider or cardiologist and agree on who will follow up. It takes time, and it's sometimes difficult for inpatient and outpatient physicians to have these conversations, but that's not an excuse,” he said.
That step is particularly important for patients who really can't start all the drugs they need during or immediately after hospitalization. “It's just as important to identify patients who are not current candidates for a particular therapy [while hospitalized] and to help effectuate a plan where it can be reliably initiated on an outpatient basis,” Dr. Fonarow said.
For patients who are going to be started on multiple medications during hospitalization, Dr. Fonarow offered a reassuring metaphor. “No one would think to send a heart attack patient home without antiplatelet therapy, a statin, an ACE inhibitor, and a beta-blocker. Yet in many cases all of those medications would be new to that patient,” he said.
To find the right balance, hospitalists should start by carefully evaluating the patient's current medication list and seeing where the guideline-directed medications fit in. “All guideline therapies should be considered and then an integrated, thoughtful, tailored plan should be implemented. That may not include prescriptions for all guideline medications [then and there], but it should include plans for them [at some point], with accepted rationales,” said Dr. Allen.
Of course, some patients will not be able to take all recommended therapies for various reasons, he noted. “The guidelines have defined reasons why medications would be contraindicated, specific to each medication,” Dr. Allen said.
The process should also tap into the power of multidisciplinary teams, said Dr. Fonarow. “It's ultimately the physician's responsibility to ensure that appropriate therapies are prescribed to each patient who is eligible, at the right dose at the right time, but effective systems use the team approach. Pharmacists, advanced practice nurses, heart failure nurse educators, bedside nurses, and social workers are all potentially critical for evidence-based prescribing, medication management, counseling of patients and caregivers, and follow-up.”
The bottom line is that hospitalists can't do it alone. “We've seen how challenging reducing early readmission is for heart failure patients. One in 4 will be readmitted in 30 days. This highlights how critically important getting them on the right therapy is, and how it should not fall exclusively on physicians but on health care delivery systems to form teams that can assist in managing these patients,” Dr. Fonarow said.
Systemic solutions include improving electronic medical records to assist with both guideline-accordant prescribing and documentation when guidelines weren't followed.
“We should have health information exchanged around the guidelines. As we accumulate patients and as patients rack up years in their records, virtual charts will become very large. No one will be able to biopsy a chart that is 20 years long to see why a patient wasn't put on an ACE inhibitor,” Dr. Schnipper said. “We'll need to improve our systems so that when we are not providing guideline care for good reasons, it's documented and easy for others to see and we don't get dinged from quality measures on it.”
The heart failure guidelines may also need to be adapted to improve compliance, suggested Dr. Allen. One issue is that the guidelines are typically based on research in healthier, younger patients. “The problem is that we apply that to patients who are not as clearly followed as in randomized trials, patients who have comorbidities and do not particularly do well with polypharmacy,” Dr. Allen said.
Dr. Schnipper agreed, “The guidelines are written one condition at a time. None of my heart failure patients have just one condition. We need more research in patients with multiple comorbidities.”
Guidelines could also address the need for shared responsibility among clinicians. “The goal is to get patients with heart failure on guideline-directed medical therapies, but the way to do that probably needs to evolve over time so all the pressure isn't on the discharging hospitalist to do it,” said Dr. Allen.