Hickey Annabel, Suna Jessica, Marquart Louise, Denaro Charles, Javorsky George, Munns Andrew, Mudge Alison, Atherton John J
Advanced Heart Failure and Cardiac Transplant Unit, The Prince Charles Hospital, Brisbane, Australia.
Department of Internal Medicine & Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Australia.
Int J Cardiol. 2016 Dec 1;224:99-106. doi: 10.1016/j.ijcard.2016.09.001. Epub 2016 Sep 7.
To improve up-titration of medications to target dose in heart failure patients by improving communication from hospital to primary care.
This quality improvement project was undertaken within three heart failure disease management (HFDM) services in Queensland, Australia. A structured medication plan was collaboratively designed and implemented in an iterative manner, using methods including awareness raising and education, audit and feedback, integration into existing work practice, and incentive payments. Evaluation was undertaken using sequential audits, and included process measures (use of the titration plan, assignment of responsibility) and outcome measures (proportion of patients achieving target dose) in HFDM service patients with reduced left ventricular ejection fraction.
Comparison of the three patient cohorts (pre-intervention cohort A n=96, intervention cohort B n=95, intervention cohort C n=89) showed increase use of the titration plan, a shift to greater primary care responsibility for titration, and an increase in the proportion of patients achieving target doses of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (A 37% vs B 48% vs C 55%, p=0.051) and beta-blockers (A 38% vs B 33% vs C 51%, p=0.045). Combining all three cohorts, patients not on target doses when discharged from hospital were more likely to achieve target doses of ACEI/ARB (p<0.0001) and beta blockers (p<0.0001) within six months if they received a medication titration plan.
A medication titration plan was successfully implemented in three HFDM services and improved transitional communication and achievement of target doses of evidence-based therapies within six months of hospital discharge.
通过改善医院与初级保健机构之间的沟通，提高心力衰竭患者药物滴定至目标剂量的比例。
本质量改进项目在澳大利亚昆士兰州的三个心力衰竭疾病管理（HFDM）服务机构内开展。通过提高认识和教育、审核与反馈、融入现有工作流程以及激励性支付等方法，以迭代方式协同设计并实施了结构化药物治疗计划。采用序贯审核进行评估，评估内容包括HFDM服务中左心室射血分数降低患者的过程指标（滴定计划的使用、责任分配）和结果指标（达到目标剂量的患者比例）。
对三组患者队列（干预前队列A，n = 96；干预队列B，n = 95；干预队列C，n = 89）进行比较，结果显示滴定计划的使用增加，滴定责任更多地转向初级保健机构，并且达到血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB）目标剂量的患者比例有所增加（A组37%，B组48%，C组55%，p = 0.051），β受体阻滞剂方面也有类似情况（A组38%，B组33%，C组51%，p = 0.045）。综合所有三个队列来看，出院时未达到目标剂量的患者，如果接受了药物滴定计划，则在六个月内更有可能达到ACEI/ARB（p < 0.0001）和β受体阻滞剂（p < 0.0001）的目标剂量。
在三个HFDM服务机构中成功实施了药物滴定计划，改善了过渡期间的沟通，并在出院后六个月内提高了循证治疗目标剂量的达成率。
