UCLA hospital starting patients on drugs before they are discharged
A deceptively simple program being conducted at the University of California Los Angeles Medical Center has cut the risk of a second myocardial infarct (MI) or death within one year by 57%. The program, called CHAMP (Cardiovascular Hospitalization Atherosclerosis Management Program), is an in-hospital effort to boost patient and physician compliance with standard drug therapy and exercise guidelines.
Focusing on the four major drug groups used in treating coronary heart disease, researchers compared MI patients pre-CHAMP (1992-93) and post-CHAMP (1994-95). They found that:
UCLA said its compliance rates are the highest ever reported for MI patients at discharge. A complete program description can be found on the Web at www.med.ucla.edu/champ .
"There isn't anything new in CHAMP except the setting," said Rita Jue, clinical coordinator in the department of pharmaceutical services at the hospital. "We're just implementing key points in standard therapy recommendations within the institution. Patients admitted with an MI have an incentive to pay very close attention to anything that will keep them from coming back again."
The American Heart Association is paying attention, too. When CHAMP published its results in the American Journal of Cardiology in March, AHA applauded the program. "This shows that the key to keeping heart disease patients alive is providing them with immediate and thorough treatment before they walk out of the hospital," said AHA's chief science officer, Sidney Smith, M.D.
AHA is rolling out its own version of CHAMP through regional affiliates over the next few months. "Get with the Guidelines" is designed to help hospitals launch their own CHAMP-like programs to boost compliance with the recommended four-drug cardiac regimen.
Jue emphasized that daily exercise; no tobacco use; and a regular regimen of aspirin, ACE inhibitors, beta-blockers, and statins are essential for long-term survival.
According to CHAMP program designer Gregg Fanarow, M.D, associate professor of medicine at UCLA's division of cardiology, it is not a difficult regimen. "These are standard recommendations that have been around for years," he explained. "The problem is that the therapies are still not being implemented, despite widespread recommendations."
UCLA decided to treat every hospitalization for coronary artery disease or diabetes as an opportunity to reach both patients and physicians. "Aspirin and statins are lifestyle-changing drugs that don't obviously make patients feel any better. We know we have a greater impact on patients when they're in our care than after discharge. We start teaching as soon as they're admitted, down to a final discharge counseling session."
Nurses handle most of the day-to-day patient contact, including focused discussions on the need for each of the four drugs. While direct-to-consumer drug advertising has boosted patient awareness of aspirin and statins, beta-blockers and ACE inhibitors are a harder sell because few patients know the products or what they can do. But, Jue noted, patients pay close attention when they realize the potential gains from taking a combination of the four medications. "The Internet is also making patients much more savvy than in past years," she said.
An aspirin a day can cut the risk of MI by 48% and the risk of death by 51%. Cholesterol-reducing agents can lower the risk of cardiovascular mortality by 42% and the risk of death from all causes by 30%. ACE inhibitors and beta-blockers are also associated with a reduction in cardiovascular events, cardiovascular mortality, and mortality from other causes. These percentages, taken from the AHA's Secondary Prevention Guideline (1995), can also be found on the CHAMP Web site.
Physicians don't object to the drug recommendations, but studies of prescribing habits suggest that they don't always act on them, either.
"We're a large teaching hospital, so we need to help guide prescribing habits," Jue said. "Educating physicians helps improve compliance from the prescribing end."
UCLA uses preprinted treatment guidelines and drug orders to train physicians to follow the guidelines. Regular staff training for physicians, nurses, and pharmacists reinforces the message.
"The treatment program works better if everybody is on the same page in terms of goals and methods," Jue said. "You have to get all the players involved."
Fred Gebhart. UCLA pharmacists take patient education to heart.