BACKGROUND

Chart-Based Collaborative Medication Review (CMR) to Improve Care of 641 Patients with Congestive Heart Failure (CHF) in a Veterans Affair Medical Center(VAMC)

Harleen Singh, PharmD, BCPS1, Jessina C. McGregor, PhD1, Justin Bednar BS1, Elva Van Devender, PhD1, Tammy Chan BS1, Sharon Shiraga, PharmD1 , Greg C. Larsen MD2

(1)Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon and (2) Portland Veterans Affairs Medical Center (PVAMC), Portland, OR

METHODS

RESULTS As more demands are placed on primary care providers, new innovative models of care

are required to optimize heart failure (HF) care. The core of the HF clinic at the Portland Veterans Affairs Medical Center (PVAMC) involves

a close collaboration between Portland’s primary care division, the cardiology section, and pharmacy.

This obligation is met by rotating two new primary care physicians (PCPs) into the clinic every three months for a three month “practicum.”

PVAMC now has 28 primary practitioners, providing the medical center with a new “reservoir” of HF management talent.

The intent of the current proposal is to leverage that talent to reach a larger number of HF patients that cannot be seen easily in the HF clinic and do it without additional cardiologist or clinic resources.

The objective of this research was to characterize guideline-based drug or device therapy recommendations by a CMR team and to evaluate the rate of acceptance of these recommendations by PCPs.

A preliminary assessment of the management of HF patients by CMR Inclusion criteria: Patient followed by one of the sixteen selected providers ICD-9 code for HF EF ≤ 40% Exclusion criteria: Currently being followed by the PVAMC HF Clinic Patient is deceased

Electronic medical records for 641 patients followed by the sixteen selected PCPs were screened for an ICD-9 code for HF.

The charts of patients with ejection fractions (EF) <40% were then abstracted in more detail to include a list of active medical problems, current medications, one to five year trends in vital signs, weights, renal function tests, and potassium levels.

Each patient’s data was then presented to the CMR team comprised of a cardiologist, hospitalist, and pharmacist at the PVAMC, all of whom work in the HF clinic.

For each patient three questions were asked: (1) can new life-prolonging medications safely be prescribed?; (2) can previously prescribed life-prolonging medications be up-titrated to more optimal levels?; and (3) might the patient be a candidate for a primary prevention implantable defibrillator?

Providers were then given specific recommendations in the form of a brief electronic chart note.

Baseline characteristics of patients were compared between those patients from whom recommendations were made and for whom no recommendations were made using the Fisher’s exact test and t-test.

SUMMARY/CONCLUSIONS Parallel chart review by a multidisciplinary group is feasible and effective 69% of the patients had HF with preserved EFs (>40%), for which no guideline-prescribed

life-prolonging therapies are known. 156 (90%) patients were identified for detailed chart review Our acceptance rates for recommendations are promising Patients with chronic kidney disease or a history of hyperkalemia were significantly less

likely to receive a recommendation We believe that parallel chart review aimed at identifying opportunities to optimize HF

therapy can improve the effectiveness of PCP-managed HF care. Further follow-up will evaluate the impact of these recommendations on patient outcomes.

Figure 2. Electronic Chart Note Showing Recommendations

Initial Review presented to the CMR Team Initial Review presented to the CMR Team

Figure 1.Initial Review presented to the CMR Team

Initial Review presented to the CMR Team

Harleen Singh: singhh@ohsu.edu

METHODS (CONTINUED)

Figure 3: Identification of patients and recommendations

641 patient charts screened

51 (8%) patients died62 (10%) patients had no EF’s10 (2%) patients were no longer followed by PCP reviewed

516 patients selected for further evaluation

343 (66%) patients had EF ≥ 40%

173 patients had EF ≤ 40%

17 (10%) patients followed by HF clinic

156 patients who had detailed chart review

70 patients received 98 recommendations• 58 (59%) recommendations were for

guideline-based therapies• 13 (13%) recommendations were for

consideration of device therapy• 24 (24%) recommendations were to

update lab tests or echocardiograms

• 3 (3%) recommendations were for additional drug therapy

32 recommendations are pending PCP consultation with patient

66 (67%) recommendations have so far been accepted by the PCPs

• Median time to acceptance of recommendations was 15 days (range: 0-265 days)

RESULTS (CONTINUED)Table 1. Baseline Characteristics of 156 Systolic HF Patients

Characteristic Patients given Recommendations

Patients not given Recommendations

p-value

Age, median (SD) 67.8 (9.6) 68.7 (8.7) 0.55

Male sex 70 (100%) 85 (98.8%) >0.99

Race, White 34 (48.6%) 38 (44.2%) 0.63

Chronic Kidney Disease 9 (12.9%) 35 (40.7%) <0.01

Diabetes 32 (45.7%) 50 (58.1%) 0.15

Hyperlipidemia 53 (75.7%) 65 (75.6%) >0.99

Hypertension 60 (85.7%) 67 (77.9%) 0.30

COPD/Asthma 22 (31.4%) 27 (31.4%) >0.99

History of Hyperkalemia 18 (25.7%) 43 (50.0%) <0.01

Atrial Fibrillation 27 (38.6%) 27 (31.4%) 0.40

Patients at Lipid Goal 61 (91.04) 70 (83.33) 0.23

DM patients at A1c Goal 31 (64.58) 30 (51.72) 0.24

Patients at Blood Pressure Goal 52 (74.29) 67 (78.82) 0.567