Disease Management Update
Volume V, No. 36
January 22, 2009
Dear Healthcare Intelligence Network Client,
Heart disease is the single-leading cause of death among Americans today. This week's DM Update showcases new heart attack management guidelines from the AAFP as well as a new blood flow measurement tool that could save the healthcare industry money — and lives.
Your colleague in the business of healthcare,
Editor, Disease Management Update
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Table of Contents
- New Guidelines for Diagnosis and Management of Post-Heart Attack Depression
- Disease Management Q&A: How-to's of Home Visits
- HealthSounds: Improving Chronic Care Outcomes
- New Tool Could Prevent Needless Stents, Save Money
- Survey of the Month: ED Access and Overcrowding
- Effective Care Management
1. New Guidelines for Diagnosis and Management of Post-Heart Attack Depression
The AAFP released new clinical practice guidelines for the diagnosis and management of depression in patients who have suffered a heart attack, or myocardial infarction (MI). The guidelines call for patients who have experienced a heart attack to be screened for depression regularly, and for patients diagnosed with depression to be treated with antidepressant medication, psychotherapeutic counseling or both. Depression has been shown to correlate with increased morbidity and mortality among patients who have suffered a heart attack, independent of the patients’ previous cardiac history or the severity of their coronary artery disease (CAD). As many as 65 percent of patients with acute MI report experiencing symptoms of depression, and major depression is present in 15 to 22 percent of these patients. Depression is common during hospitalization and often persists for several months if left untreated.
The AAFP’s clinical practice guidelines are designed to assist the clinician and patients in making decisions about appropriate health care for specific clinical circumstances. The four guidelines are: (1) patients having an MI should be screened for depression using a standardized depression symptom checklist at regular intervals during the post-MI period, including during hospitalization; (2) post-MI patients with a diagnosis of depression should be treated to improve their depression symptoms, with systems in place to ensure regular follow up and monitoring of their treatment response and adherence to treatment; (3) selective serotonin reuptake inhibitors are preferred to tricyclic antidepressants for treatment of depression in post-MI patients; and (4) psychotherapy may be beneficial for treatment of depression in post-MI patients. The existing evidence base does not establish what form of psychotherapy is preferred.
“Depression is relatively common among patients recovering from heart attacks, and causes significant suffering. Fortunately, it can readily be diagnosed and treated, helping patients to feel better,” said Lee A. Green, M.D., M.P.H., lead author of the guideline panel.
Many studies have shown depression to be associated with an increase in subsequent coronary events and with coronary-related mortality. The correlation of depression with adverse cardiac outcomes has led to a number of trials examining the effect of depression treatment on coronary outcomes as well as depression outcomes. Controlled trials using antidepressants, specifically selective serotonin reuptake inhibitors, and psychotherapy have shown reductions in the symptoms of depression among post-MI patients. Selective serotonin reuptake inhibitors have been shown to be safe in patients who have experienced a heart attack and are preferred over tricyclic antidepressants because of the heart rate and conduction effects of tricyclic antidepressants.
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2. Disease Management Q&A: How-to's of Home Visits
Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Michele Gilbert, education coordinator of the heart failure team at Hackensack University Medical Center (HUMC).
Question: What are the components and goals of the home visits conducted by the heart failure team?
Response: (Michele Gilbert) We have spent a lot of time teaching our home care nurses to be astute observers. One thing the nurse will do is interview the patient regarding their health practices and understanding of the disease. We give patients basic educational information. When the nurse conducts the visit, she does a complete physical assessment, as well as an assessment of the patient’s functional abilities. We use the Minnesota Living With Heart Failure Questionnaire, which addresses functional status for the patient. We use that at the first and last visits to ensure that the patient’s functional status and ability to self-manage is improving. We find out what the patient has been eating and what they’re doing. We get our baseline.
On subsequent visits, the nurse might empty the patient’s pantry and show them how much sodium they’ve been eating. They ensure the patient understands where to find hidden sources of sodium. The nurse continues to assess the patient’s progress. They will provide them with a daily system for weighing themselves and recording their weight. The patient’s ability to self-medicate is also assessed. If they don’t have a system for taking their medications, we provide one, such as a seven-day pillbox with four compartments.
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3. HealthSounds Podcast: Improving Chronic Care Outcomes
Collaborative patient care models that empower the primary care nurse to communicate patient needs to physicians has not only improved patient care and outcomes but also fostered a cultural change at HUMC, explains Lenore Blank, a nurse practitioner and administrative manager of HUMC's heart failure and pulmonary hypertension team. Her team is part of Pursuing Perfection, a healthcare quality initiative from the Institute of Healthcare Improvement. As HUMC creates the partnerships mandated by Pursuing Perfection, it is extending the knowledge and benefits they've gained with other organizations — and reducing hospital readmissions in the process.
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New Tool Could Prevent Needless Stents, Save Money
Doctors may be implanting too many artery-opening stents and could avoid needless operations — and ultimately save lives — if they did more in-depth measurements of blood flow in the vessels to the heart. That’s the finding of a study that evaluated the benefits of a new diagnostic tool to measure blood flow and determine whether stenting was the best option. The study suggests that doctors should go one step beyond the traditional method of relying solely on X-rays from a coronary angiogram to determine which arteries should be stented for patients with coronary artery disease. In many cases, cardiologists will routinely prop open with a stent any arteries that look significantly narrowed on the angiogram, but the problem is you can’t always tell from the angiogram whether this is absolutely necessary.
By using a method called fractional flow reserve (FFR), which involves inserting a coronary pressure guidewire into the artery, doctors can measure whether blood flow is actually reduced to a dangerous level beyond any apparent narrowing. In certain cases, medication may be a better option to stenting. Patients included in the study either suffered from chest pains or were recovering from mild heart attacks. All patients had multiple coronary arteries with narrowings. About half the patients were treated with the traditional method of using an angiogram to decide which narrowings to stent. The other half of the patients underwent the angiogram with the additional pressure wire technique. To measure blood flow beyond the areas in the arteries that appear narrowed, the pressure wire was threaded through the same catheter used for the angiogram. Researchers found that patients who received the additional blood flow test received one-third fewer stents than the group examined only with an angiogram. Those patients received 2.7 stents on average. The other half who had their blood flow measured in each artery, received only 1.9 stents on average.
“Not only were the outcomes better, the cost was less,” said William Fearon, M.D., co-principal investigator of the multicenter international study called FAME and assistant professor of cardiovascular medicine at the Stanford University School of Medicine. The new procedure didn’t require any extra procedural time and resulted in decreased medical costs. “Each stent on average costs roughly $2,000,” Dr. Fearon said. “The pressure wire test runs an additional $700.” Using fewer stents also results in using a decreased amount of contrast dye that can cause kidney failure.
“The take-home message is that the wire is able to give you more information about whether a coronary narrowing is truly causing abnormal blood flow to the heart,” Dr. Fearon said. “Some narrowings that might look bad would respond just as well to medication, while others that appear innocent may benefit from stenting. By measuring FFR, one is better able to make this distinction and improve the patient’s outcome, while also saving healthcare dollars.”
To learn more about this research, please visit:
5. Survey of the Month: ED Access and Overcrowding
An economy that is creating more unemployed and uninsured individuals is just one factor contributing to a rise in ER use and a decline in patient satisfaction. In its National Report Card on the State of Emergency Medicine for 2009, the American College of Emergency Physicians has given the United States an overall grade of C-, largely due to poor ratings for access to emergency care. Is emergency room overcrowding an issue for your organization, and if so, how are you responding to this? Complete HIN's Survey of the Month on emergency room access and overcrowding and receive a free executive summary of the compiled results.
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6. Effective Care Management
As healthcare costs and complexity continue to rise, care management must become more efficient. Collaboration across the entire healthcare spectrum is the key. As payers, providers and members/patients come together — enabled by automated technologies — care management will at last deliver on its promise.
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