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IMPROVING PATIENT CARE

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Improvements in 1-Year Cardiovascular Clinical Outcomes Associated with a Hospital-Based Discharge Medication Program

Jason M. Lappé, MS; Joseph B. Muhlestein, MD; Donald L. Lappé, MD; Rodney S. Badger, MD; Tami L. Bair, BS; Ruth Brockman, RN, MBA; Thomas K. French, MStat; Linda C. Hofmann, MS, BSN; Benjamin D. Horne, MStat, MPH; Susan Kralick-Goldberg, RN, MSN; Nan Nicponski, RN, MBA; Janette A. Orton, RN, MS; Robert R. Pearson, BS; Dale G. Renlund, MD; Holly Rimmasch, RN, MSN; Colleen Roberts, RN, MS; and Jeffrey L. Anderson, MD

21 September 2004 | Volume 141 Issue 6 | Pages 446-453

Background: Despite recent advances in the treatment and prevention of cardiovascular disease, a treatment gap for secondary prevention medications still exists.

Objective: To develop and implement a program ensuring appropriate prescription of aspirin, statins, ß-blockers, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge.

Design: A nonrandomized before–after study comparing patients hospitalized before (1996–1998) and after (1999–2002) implementation of a discharge medication program (DMP). Patients were followed for up to 1 year.

Setting: The 10 largest hospitals in the Utah-based Intermountain Health Care system.

Patients: In the pre-DMP and DMP time periods, 26 000 and 31 465 patients, respectively, were admitted to cardiovascular services (n = 57 465).

Measurements: Prescription of indicated medications at hospital discharge; postdischarge death or readmission.

Results: By 1 year, the rate of prescription of each medication increased significantly to more than 90% (P < 0.001); this rate was sustained. At 1 year, unadjusted absolute event rates for readmission and death, respectively, were 210 per 1000 person-years and 96 per 1000 person-years before DMP implementation and 191 per 1000 person-years and 70 per 1000 person-years afterward. Relative risk for death and readmission at 30 days decreased after DMP implementation; hazard ratios (HRs) for death and readmission were 0.81 (95% CI, 0.73 to 0.89) and 0.92 (CI, 0.87 to 0.99) (P < 0.001 and P = 0.017, respectively). At 1 year, risk for death continued to decrease (hazard ratio, 0.79 [CI, 0.75 to 0.84]; P < 0.001) while risk for readmission stabilized (hazard ratio, 0.94 [CI, 0.90 to 0.98]; P = 0.002), probably because survivors had more opportunities to be readmitted.

Limitations: The study design was observational and nonrandomized, and the authors could not control for potential confounders or determine the extent to which secular trends accounted for the observed improvements.

Conclusions: A relatively simple quality improvement program aimed at enhancing the prescription of appropriate discharge medications among cardiovascular patients is feasible and can be sustained within an integrated multihospital system. Such a program may be associated with improvements in cardiovascular readmission rates and mortality.

Editors' Notes Context Despite evidence to support the effectiveness of a variety of interventions for the secondary prevention of cardiovascular disease, many eligible patients do not receive these interventions. Contribution Compared with a baseline period, patients hospitalized with cardiovascular disease who received an intervention that focused on discharge medications had higher rates of prescription of aspirin, ß-blockers, statins, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge. The risk for death and readmission was lower in the intervention period than in the baseline period. Cautions The pre–post design of this study does not permit conclusions about a causal relationship between the intervention and the observed improvements. –The Editors

 

Author and Article Information

From Intermountain Health Care, LDS Hospital, Salt Lake City, Utah.

Acknowledgments: The authors thank Julie Burchell, RN, BSN; Michael Carnley; Dal C. Coleman, RPh; Kim Henrichsen, RN, MS, CCRN; Diane Marshall, MAM; Mikelle D. Moore, MBA, MHSA; Lynn R. Nimer, MD; Katey Roundy; Shane R. Stevenson, BS; Diane S. Wallace, RN, MSN, ANP-C; Sharon L. Watson, RHIT; Marie M. Wright, RN; Scott Yardley, RPh; Michelle LeBaron, RN; Susan E. Pollock, BS; Jeanette Wheeler, RN; and the administrative, cardiovascular nursing, and physician staff of Intermountain Health Care for valuable contributions and assistance.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joseph B. Muhlestein, MD, LDS Hospital Cardiovascular Department, 8th Avenue and C Street, Salt Lake City, UT 84143.

Current Author Addresses: Mr. Lappé; Drs. Muhlestein, Lappé, Badger, Renlund, and Anderson; Ms. Bair; Ms. Brockman; Mr. French; Ms. Hofmann; Mr. Horne; Ms. Kralick-Goldberg; Ms. Nicponski; Ms. Orton; Mr. Pearson; Ms. Rimmasch; and Ms. Roberts: LDS Hospital Cardiovascular Department, 8th Avenue and C Street, Salt Lake City, UT 84143.

Related articles in Annals:

Summaries for Patients
Improvements in 1-Year Outcomes before and after a Discharge Medication Program for Patients Hospitalized with Heart Disease

Annals 2004 141: I-43. [Full Text]  

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