Manage heart patients 5 ways

April 1, 2009

Heart disease is considered the costliest condition, outranking cancer. Some 80 million people require care for coronary heart disease

Each year, nearly 630,000 Americans die of heart disease and more than 4.2 million are hospitalized. It is considered the costliest condition overall, even outranking cancer.

Coronary heart disease makes up more than half of all cardiovascular events in men and women under age 75, based on the National Heart, Lung, and Blood Institute's Framingham Heart Study. In 2005, it accounted for one in every five deaths in the United States. The AHA estimates the direct and indirect costs of coronary heart disease in 2009 will reach $165.4 billion.

1 CLINICIANS: APPLYING PERFORMANCE MEASURES

While clinical guidelines make evidence-backed recommendations for physicians to consider when managing patients, performance measures enable them to see how closely they're sticking to guidelines in caring for myocardial infarction (MI, or "heart attack") patients.

Last fall, the American College of Cardiology and AHA jointly released a new set of clinical performance measures that enable hospitals and doctors to benchmark the quality of heart-attack care in several areas, including prescribing statins upon discharge, the timeliness of percutaneous coronary intervention (PCI) when a patient must be transferred to another hospital, referral to a cardiac rehabilitation program, and evaluation of the heart's pumping function (left ventricular systolic function) during hospitalization.

"Performance measures are extraordinarily important in helping us learn how well we are doing and in providing targets for improving quality," Harlan Krumholz, MD, who chaired the performance measures writing committee, said in a statement announcing the new measures. "They guide us to areas of opportunity where we can do better-and our patients benefit from that."

2 REHAB: PUSHING COMPLIANCE

Cardiac rehabilitation is essential to patients' recovery, but just over one-third of myocardial infarction survivors participate in outpatient cardiac rehabilitation, according to a nationwide survey released last year by the Centers for Disease Control and Prevention (CDC).

But even rehabilitation, as it's currently provided, may not be enough. Most cardiac rehab programs are limited to 36 sessions or about three months. Upon discharge from the programs, many patients stop complying with their medication therapy and resume many of their bad health habits, such as smoking, poor diet and lack of exercise.

In a recent study published in the Journal of Cardiopulmonary Rehabilitation and Prevention, the Mayo Clinic found patients who participated in a three-year cardiac rehabilitation program demonstrated better therapy adherence and heart health. Participants initially followed a typical rehab pattern of supervised exercise sessions, advice on exercising at home and group education meetings with a case manager. Subsequently they met with non-physician case managers every three to six months for three years to discuss risk factor management, proper use of prescribed medicines and lifestyle factors.

At the end of the three years, the researchers found 91% of patients still took aspirin and cholesterol-lowering statins, 78% were taking beta-blockers to control blood pressure and 76% were still on angiotensin-converting enzyme blockers to control blood pressure. What's more, most had increased their level of exercise, quit smoking and achieved their blood pressure and LDL cholesterol treatment goals. Patient mortality among enrollees with at least one heart condition was just 1.9%, relative to 1.6% for the population as a whole, with or without heart-conditions or events.

While earlier randomized studies showed longer rehab can improve long-term outcomes, "this study shows it can be done in a normal clinical setting," says lead researcher Ray Squires. "We look at coronary disease as a chronic condition. We don't think it makes much sense to put a patient in a three-month program and then say, 'You're done.'"