About CERTs
Annual Report Year 3
CERTs Progress
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Duke University Medical Center—
Adherence and Survival: Taking the Long View on Saving Lives
The CERTs mission at Duke is to conduct research and provide education that will advance the optimal use of cardiovascular drugs, medical devices, and biological products. Duke has focused on the gap between research evidence and clinical practice, looking both at errors of omission (failure to prescribe drugs known to improve survival) and errors of commission (failure to heed labeled contraindications, warnings, or drug interactions for high-risk medications or devices).
Key Projects:
- Multi-tiered quality improvement intervention to increase the appropriate use of beta blockers in patients with heart failure
- Post-market surveillance of recently FDA-approved transmyocardial revascularization procedure
- Development of educational module on QT-prolonging medications
Much of the focus in patient safety is on the prevention of medication errors. One important, yet often overlooked, type of medication error is an error of omission. Indeed, for epidemic problems such as atherosclerosis, errors of omission may dwarf errors of commission as a cause of death and disability. Simply stated, patients frequently do not receive medicines that have been proven to save lives.
Improving the use of medications for the nation's leading cause of death, coronary artery disease, is a daunting task. While many national efforts are emphasizing the hospital phase of care, the Duke CERTs is focusing on the long-term, outpatient phase. Numerous studies over the last two decades have shown significant survival advantages from aspirin, beta-blockers, and cholesterol-lowering agents in patients who have obstructed coronary arteries. In the last decade, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers have also been found to improve substantially the survival of patients with heart failure.
“Information from the Duke CERTs Research program was instrumental in helping the Council for Affordable Quality Healthcare [CAQH] select the subject of our national cardiac quality improvement initiative. Duke had found, in their databank of patients with coronary heart disease that consistent use of beta-blockers was only around 35%. This was in stark contrast to estimates collected by health plans indicating that use of beta-blockers at hospital discharge after heart attack is closer to 90%. Thus, CAQH's cardiac initiative will focus on long-term adherence to beta-blocker therapy in patients who have suffered a heart attack.”
—Robin Thomashauer, CAQH Executive Director
With this strong evidence, one would expect that almost all patients without a contraindication who have blocked coronary arteries or who have heart failure would be taking these critical medications. Surprisingly, many studies, including those performed at Duke, show this is not the case.
Numerous quality improvement initiatives across the country are trying to change this by working with doctors and hospitals to improve the number of patients who receive these medications appropriately, both in the hospital and upon discharge. These initiatives include programs by the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Medicare & Medicaid Services, the National Committee for Quality Assurance, the American Heart Association, and the American College of Cardiology.
One program, administered by the Duke Clinical Research Institute (DCRI), and endorsed by the American Heart Association, has already demonstrated improved use of beneficial therapies in over 200 hospitals caring for patients with acute coronary syndromes.
A second program with the Society of Thoracic Surgeons and the DCRI, funded by a grant from AHRQ, has recently reported a significant improvement in the use of beta blockers and internal thoracic artery grafting in patients undergoing coronary artery bypass grafting. This program is particularly important because it provides a model for a partnership, including a professional society, a major government agency, and an academic coordinating center, to inform practice nationally.
While hospital discharge is a critical time to get patients started on these medications, the Duke CERTs is also concerned about what happens after the patients go home. These life-saving therapies will only be life-saving if patients continue to take them. Compared with prescribing in the hospital environment, this issue of long-term use of life-saving medications has received relatively little public attention or resources directed at either measurement or solutions.
The Duke CERTs has approached this issue with the valuable asset of long-term, patient-reported follow-up in patients with underlying coronary heart disease (CHD). These data are captured in the Duke Databank for Cardiovascular Diseases. In a series of projects evaluating long-term use of life-saving medications for CHD and heart failure (HF), Duke researchers have detected a consistent pattern. Not only is the proportion of patients who annually report outpatient use of each life-saving drug lower than nationally reported rates at hospital discharge, but also the percentage of individual patients who consistently take a given life-saving medication over a period of years is considerably lower.
Of over 20,000 CHD patients with follow-up information in the year 2000, 46% reported taking beta-blockers. The percentage of individual patients who consistently reported using beta-blockers over the period 1995-2000 was only 37%.
Even more disappointing are the data on combination use of life-saving therapies for CHD. In the year 2000, only 41% of patients with CHD reported taking both aspirin and beta-blockers. For the follow-up period from 1995 to 2000, only 30% of patients consistently reported use of both aspirin and beta-blockers. A mere 16% of patients consistently reported use of the three-drug regimen of aspirin, beta-blocker, and a cholesterol-lowering drug. Chronic treatment of heart failure was even worse, with only 31% of over 7300 HF patients consistently reporting use of a beta-blocker; 33% consistently reporting use of an ACE inhibitor, and only 13% using both regularly.
One of the main goals of the Duke CERTs is to keep patients on all the necessary life-saving therapies over the long term. Critical to attaining this goal is addressing the impediments to consistent use for the individual patient and developing workable solutions for these obstacles. The Duke CERTs is evaluating whether busy physicians could be assisted by other healthcare practitioners, such as community pharmacists, in assessing and overcoming barriers to long-term medication use for individual patients.
In the coming year, the Duke CERTs will be pulling together community and hospital pharmacists along with physicians in both settings to work on increasing adherence to long-term medication regimens for CHD and HF. Central to this process will be effective communication among all members of a patient's treatment “team,” combined with empowering the patients themselves through improved education and feedback about their care. In the near future, the Duke CERTs hopes to demonstrate the same progress in preventing cardiac events in the outpatient setting that it has shown in the hospital setting.