Primary Objective:
To determine the effect of an in-hospital intervention in patients with congestive heart failure on the use of ACEIs.
Secondary Objective:
To determine the effect of a patient-centered support program started prior to hospital discharge in patients with CHF, by evaluating:
- ACEI persistence and discontinuation
- ACEI use
- ACEI dosage titration
- its economic implications
Principal Investigator:
Tsuyuki RT
Co-Investigators:
Ashton T, Gordon W, Ikuta R, Kornder J, MacKay E, Manyari D, O’Reilly K, Semchuk W, Witt I.
Time Line:
September 1999 – April 2000
Status:
Completed
ABSTRACT
Improving the Use of ACE Inhibitors in Patients with Congestive Heart Failure: The Review of Education on ACE Inhibitors in Congestive Heart Failure Treatment (REACT) Study, Stage I
R.T. Tsuyuki, M. Fradette, T.J. Bungard, J.A. Johnson, T. Ashton, W. Gordon, R. Ikuta, J. Kornder, E. MacKay, D.E. Manyari, K.V. O’Reilly, W. Semchuk, I.D. Witt, for the REACT Study Investigators Edmonton, Alberta
Although ACE inhibitors (ACEI) are of proven benefit in the management of congestive heart failure (CHF), only about one-half of such patients receive them and many receive sub-optimal doses.
Purpose: To determine the effect of a simple in-hospital intervention on ACEI usage and dosage titration in patients with CHF.
Methods:
REACT was a 2-stage trial conducted in 10 centres across Western Canada. During Stage I, consecutive patients with CHF (primary, secondary or most responsible diagnosis) were identified in hospital by a pharmacist or nurse, assessed for ACEI eligibility and/or dosage titration, and where appropriate, recommendations were made to the physician. Patients were excluded if they had secondary causes of CHF, known diastolic dysfunction, cognitive impairment, or received care from a specialized CHF clinic. The primary endpoint was the proportion of patients receiving ACEI at hospital discharge compared to upon admission. The secondary endpoint was ACEI dose at discharge compared to hospital admission.
Results:
Of the 2,310 patients screened, two-thirds were excluded from entry, most often for preserved systolic function or cognitive impairment. Of the 764 patients enrolled, 55% were males, mean age was 75 (±13) years and mean ejection fraction was 0.31 (±0.12). Eight percent were in New York Heart Association Functional Class I, 48% in II, 37% in III, and 5% in IV. The primary etiology of heart failure was coronary artery disease in 59% and hypertension in 13%, and 41% had heart failure for >1 year. As a result of the intervention, ACE inhibitor use increased from 58% on admission to 83% at discharge (p<0.0001). Average daily dose (in enalapril equivalents) also increased from admission 11.3 (+8.8)mg to 14.5 (+8.8)mg at discharge (p<0.0001).
Conclusion: Simple targeted clinical interventions by pharmacists and nurses improved the use of ACEI in patients with CHF.
A Randomized Trial of a Patient Support Program for Patients with Congestive Heart Failure: The Review of Education on ACE Inhibitors in Congestive Heart Failure Treatment (REACT) Study, Stage II
R.T. Tsuyuki, M. Fradette, J.A. Johnson, T.J. Bungard, T. Ashton, W. Gordon, R. Ikuta, J. Kornder, E. MacKay, D.E. Manyari, K.V. O’Reilly, W. Semchuk, I.D. Witt, for the REACT Investigators. Edmonton, Alberta
Education and support for patients with CHF is important, however are often performed without comprehensive evaluation.
Purpose:
To evaluate the effect of a patient support program (PSP) in outpatients with CHF on medication adherence, clinical events, and costs.
Methods:
REACT was multi-centre, 2-stage trial. Stage I was an in-hospital program to improve ACE inhibitor (ACEI) use and titration in consecutive patients admitted with CHF. In Stage II, patients were randomized to the PSP vs. usual care (UC) prior to discharge. The PSP included: education about CHF and medications, self-monitoring, adherence aids, monthly newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months post-discharge. UC patients received no formal counseling or support. The primary endpoint was ACEI adherence at 6 months between groups, measured by dispensing records. Secondary endpoints included clinical events and costs (government payor perspective, including drug, physician, and hospital costs).
Results:
Baseline characteristics of the 276 patients randomized were similar in both groups: 42% were female, age 71 (+ 12) years and ejection fraction of 0.32 (+0.12). Thirteen percent were NYHA class I, 50% in II, 33% in III and 4% in IV.
| Endpoint | UC (n=136) | PSP (n=140) | P |
| Adherence (%) | 86.2 | 83.5 | 0.69 |
| Clinical events: | |||
| Emergency room visits | 70 | 41 | <0.01 |
| Hospital days | 1112 | 594 | <0.0001 |
| Total cost/Patient / Six months | $6312 | $3526 | — |
The 6-month cost difference between the PSP and UC was $2786 per patient.
Conclusion:
The PSP did not enhance ACEI adherence, however, the PSP was associated with reduced clinical events and costs in patients with CHF.
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