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HF is a 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.
Chronic Heart Failure through REDUCED EJECTION FRACTION PRESERVED EJECTION FRACTION
(HFpEF)
Transitions of Care
(HFrEF)
EF typically defined as EF >50%
Shawn D. Anderson, Pharm.D., BCACP 40% diastolic dysfunction
Department of Veterans Affairs Inadequate cardiac
Gainesville, Florida output
Symptoms
Elevated BNP (NT-proBNP)
Navigating the Oceans of Opportunity 2013 ACCF/AHA Guideline for the Management of Heart Failure
4
American Heart Association Heart Disease and Stroke Statistics 2014 Update
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Emergency
Department
Hospital
Heidenreich P, et al. Circ Heart Fail 2013
1.0 HF
Admission Initial diagnosis 1st admission (n = 14,374) P<0.0001
2nd admission (n = 3,358)
0.8
3rd admission (n = 1,123)
Cumulative mortality
Ambulatory Acute HF
HF care care 0.4
0.2
1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%
Transition 0.0
from 0.0 0.5 1.0 1.5 2.0
hospital to
home Time since admission
Desai AS, et al. Circulation 2012;126:501-506 2013 ACCF/AHA Guideline for the Management of Heart Failure
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2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure
2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure
2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure
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ACC/AHA/AMA-PCI Performance
Quality Improvement Initiatives
Measures (IP)
Inpatient HF Measure Description
Percentage of patients aged 18 y with a principal discharge diagnosis of HF
Core measures with documentation in the hospital record of the results of an LVEF assessment
2. LVEF assessment performed either before arrival or during hospitalization, OR documentation in the
Transition hospital record that LVEF assessment is planned after discharge
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Quality improvement
Why? ReadmissionsPenalties
HospitalReadmissionsReductionProgram
CMS core measure are high on discharge
Before admission, there is low utilization of HF-specific
medications and at sub-optimal doses
Opportunities
Involvement in interdisciplinary teams Policy inBrief: Medicares Hospital Readmissions Reduction Program
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html 29
Mildred-LaForest SK, et al. Pharmacotherapy 2013;33:529-548
Warden BA, et al. Am J Health-Syst Pharm 2014;71: 134-39 Gorodeski EZ, Starling RC, Blackstone EH. NEJM 2010;363(3):297-298.
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ACC/AHA/AMA-PCI Performance
Are Readmissions Avoidable?
Measures (OP)
Measure Description
Percentage of patients aged 18 y with a diagnosis of HF for whom the
quantitative or qualitative results of a recent or prior (any time in the past)
1. LVEF assessment
LVEF assessment is documented within a 12-mo period
Van Walraven, et al. Journal of Evaluation in Clinical Practice 2012;18:12111218 Bonow RO, et al. Circulation 2012;125:2382-2401
ACC/AHA/AMA-PCI Performance
Factors that Precipitate AHF
Measures (OP)
Nonadherence with medication regimen, sodium and/or fluid restriction
Acute myocardial ischemia Measure Description
Uncorrected high blood pressure
Percentage of patients aged 18 y with a diagnosis of HF with a current or
AF and other arrhythmias 6. Beta-blocker therapy for LVSD prior LVEF of <40% who were prescribed beta-blocker therapy with
Recent addition of negative inotropic drugs (eg, verapamil, nifedipine, (outpatient and inpatient bisoprolol, carvedilol, or sustained-release metoprolol succinate either within a
diltiazem, beta blockers) setting) 12-mo period when seen in the outpatient setting or at hospital discharge
Pulmonary embolus
Percentage of patients aged 18 y with a diagnosis of HF with a current or
Initiation of drugs that increase salt retention (eg, steroids, 7. ACE inhibitor or ARB therapy prior LVEF of <40% who were prescribed ACE inhibitor or ARB therapy either
thiazolidinediones, NSAIDs) for LVSD (outpatient and within a 12-mo period when seen in the outpatient setting or at hospital
Excessive alcohol or illicit drug use inpatient setting) discharge
2013 ACCF/AHA Guideline for the Management of Heart Failure Bonow RO, et al. Circulation 2012;125:2382-2401
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26.9%
P=NS
73.1%
Koshman, et al. Arch Intern Med. 2008;168:687-94 Schrager J, et al. Acad Emerg Med 2013; 20:554-561.
Home-Based
HF Clinic
Clinic Based
AMBULATORYHFTREATMENTCENTER
ED-Based (OU)
ORALMEDICATION
TITRATION
HOMECARELOOP ACUTETHERAPY
NURSE/PHARMACIST
DIRECTEDEDUCATION
EVALUATION,ACTIVE
Home REMOTE
MONITORING MULTIDISCIPLINARY
INTERVENTION,
ED HOSPITAL
HOME REASSESSMENT
Enhanced HFCLINIC
SELFTREATMENT
Ambulatory
SOCIALWORKSUPPORT
HF Treatment
ADVANCEDCARE
PLANNING
GENERAL
Emergency MEDICALHOME
Hospital
Department Desai AS, et al. Circulation 2012;126:501-506
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Our Program
Return to HF outpatient clinic within 3-14 days HF Care Coordination and Home
6 months of HF clinic for stable patients Telehealth management for
Long term HF clinic for complex patients appropriate patients
43
In Summary
Heart failure prevalence and costs associated with
care are rising
A heart failure admission increases the risk of
readmission and death
Goals of therapy are well defined according to
evidence and HF Guidelines
Quality measures have been designed to improve
quality of HF care
Whether we agree with the measures or not, there
are many opportunities for pharmacy involvement