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The American Journal of Managed Care October 2014
Quality of Care at Retail Clinics for 3 Common Conditions
William H. Shrank, MD, MSHS; Alexis A. Krumme, MS; Angela Y. Tong, MS; Claire M. Spettell, PhD; Olga S. Matlin, PhD; Andrew Sussman, MD; Troyen A. Brennan, MD, JD; and Niteesh K. Choudhry, MD, PhD
A Comprehensive Hospital-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial
Ariel Linden, DrPH; and Susan W. Butterworth, PhD
Physician Compensation Strategies and Quality of Care for Medicare Beneficiaries
Bruce E. Landon, MD, MBA; A. James O'Malley, PhD; M. Richard McKellar, BA; James D. Reschovsky, PhD; and Jack Hadley, PhD
Increasing Access to Specialty Care: Patient Discharges From a Gastroenterology Clinic
Delphine S. Tuot, MDCM, MAS; Justin L. Sewell, MD, MPH; Lukejohn Day, MD; Kiren Leeds, BA; and Alice Hm Chen, MD, MPH
Increasing Preventive Health Services via Tailored Health Communications
Kathleen T. Durant, PhD; Jack Newsom, ScD; Elizabeth Rubin, MPA; Jan Berger, MD, MJ; and Glenn Pomerantz, MD
The Duration of Office Visits in the United States, 1993 to 2010
Meredith K. Shaw; Scott A. Davis, MA; Alan B. Fleischer, Jr, MD; and Steven R. Feldman, MD, PhD
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Evaluation of Collaborative Therapy Review to Improve Care of Heart Failure Patients
Harleen Singh, PharmD; Jessina C. McGregor, PhD; Sarah J. Nigro, PharmD; Amy Higginson, BS; and Greg C. Larsen, MD
Caregiver Presence and Patient Completion of a Transitional Care Intervention
Gary Epstein-Lubow, MD; Rosa R. Baier, MPH; Kristen Butterfield, MPH; Rebekah Gardner, MD; Elizabeth Babalola, BA; Eric A. Coleman, MD, MPH; and Stefan Gravenstein, MD, MPH
Ninety-Day Readmission Risks, Rates, and Costs After Common Vascular Surgeries
Eleftherios S. Xenos, MD, PhD; Jessica A. Lyden, BSc; Ryan L. Korosec, MBA, CPA; and Daniel L. Davenport, PhD
Using Electronic Health Record Clinical Decision Support Is Associated With Improved Quality of Care
Rebecca G. Mishuris, MD, MS; Jeffrey A. Linder, MD, MPH; David W. Bates, MD, MSc; and Asaf Bitton, MD, MPH
The Impact of Pay-for-Performance on Quality of Care for Minority Patients
Arnold M. Epstein, MD, MA; Ashish K. Jha, MD, MPH; and E. John Orav, PhD
Healthcare Utilization and Diabetes Management Programs: Indiana 2006-2010
Tilicia L. Mayo-Gamble, MA, MPH; and Hsien-Chang Lin, PhD
Predictors of High-Risk Prescribing Among Elderly Medicare Advantage Beneficiaries
Alicia L. Cooper, MPH, PhD; David D. Dore, PharmD, PhD; Lewis E. Kazis, ScD; Vincent Mor, PhD; and Amal N. Trivedi, MD, MPH

Evaluation of Collaborative Therapy Review to Improve Care of Heart Failure Patients

Harleen Singh, PharmD; Jessina C. McGregor, PhD; Sarah J. Nigro, PharmD; Amy Higginson, BS; and Greg C. Larsen, MD
We implemented and evaluated a collaborative therapy review process aimed at optimizing heart failure therapy among patients managed by their primary care providers.
As more demands are placed on primary care providers, new innovative models are required to optimize heart failure (HF) care. The purpose of this study was to evaluate a collaborative therapy review (CTR) program that was implemented to improve guideline-based therapy among HF outpatients.

Study Design and Methods
We screened patient lists of 18 PCPs at the Portland Veterans Affairs Medical Center to identify patients with an ICD-9 code for HF. The charts of patients with ejection fractions (EFs) <40% were then abstracted in more detail. The CTR team reviewed each patient and provided specific guideline-based recommendations. The team then gave specific recommendations to providers through the electronic medical record system. We categorized recommendations relating to drug or device therapies, or need for laboratory testing, and calculated provider acceptance rates by recommendation type.

Of the 641 patients reviewed, 156 patients had detailed chart reviews. We found opportunities for improvement in care in 70 (45%) patients who received 100 recommendations. Among the 100 recommendations, 62 (55%) were for guideline-based drugs, 12 (17%) were for consideration of device therapy, and 26 (24%) were to update lab tests or echocardiograms. Eighty percent of the recommendations were acted on within 90 days.

The CTR program was able to facilitate guideline-based management for HF patients by identifying treatment gaps and making specific guideline-based recommendations to PCPs. While further evaluations are needed, this approach may serve as an efficient method of leveraging the expertise of specialty-trained clinicians to optimize patient care.

Am J Manag Care. 2014;20(10):e425-e431
  • Primary care providers manage the majority of heart failure (HF) patients; efforts to improve care should target the primary care delivery system.
  • Leveraging the expertise of specialty-trained clinicians can help in the management of HF patients without placing major new demands on busy primary care providers.
  • The collaborative medication review process can improve the quality of patient care by maximizing resources.
While there have been many therapeutic advances in treating heart failure (HF) that have decreased morbidity and mortality, HF continues to be a major public health burden that consumes significant resources. Treatment of HF requires intensive medical, dietary, behavioral, and lifestyle modification to achieve improved quality of life, fewer hospitalizations, and decreased mortality.1 Evidence from randomized clinical trials has clearly demonstrated the benefits of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, aldosterone antagonists, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy for improving survival in patients with left ventricle systolic dysfunction.1 Despite the strength of evidence for these therapies, implementation is still suboptimal, particularly for aldosterone antagonists and device therapy (ie, cardiac resynchronization and ICD).2,3

In the US healthcare system, the collaborative care model represents an evolving philosophy that integrates the expertise of healthcare providers across different disciplines to provide efficient high-quality patient care. The accumulating body of evidence supports the theory that collaborative care models can overcome treatment gaps for patients with chronic diseases.4-8 At the Portland Veterans Affairs Medical Center (PVAMC), we have developed a collaborative care model to optimize HF management. Under this model, a collaborative therapy review (CTR) team was formed that consisted of HF specialty-trained clinicians, including a pharmacist, cardiologist, hospitalist, and senior internist from the Primary Care Division of PVAMC. These providers regularly staffed the HF clinic and thus had extensive HF experience.

Our methods were patterned after a recently published study that employed a collaborative care model to optimize care of patients with ischemic heart disease.6 Specifically, we implemented a CTR program to review charts of outpatients with HF and an ejection fraction (EF) ≤40%. Our objective was to increase the proportion of patients receiving guideline-directed therapy by evaluating all medications and monitoring parameters that could potentially influence the ability to titrate or initiate life-prolonging medications. After assessment, recommendations were made for the initiation or up-titration of life-prolonging medications, updating laboratory values, and/or referral for ICD. In this study, we report the prevalence of treatment gaps identified by the CTR team, describe the recommendations made, and document the proportion of recommendations accepted by providers in addressing these gaps.


Study Patient Population

The study was conducted in an academically affiliated PVAMC healthcare system. The PVAMC Institutional Review Board approved this investigation as a quality improvement and assessment study. At PVAMC, an outpatient heart failure clinic has been in operation since 2006. The clinic is staffed by a team that consists of a cardiologist, HF nurse practitioners, and an HF-trained pharmacist. Since its inception, the clinic has offered specialized training in HF management to PVAMC primary care providers (PCPs). The PCPs participate in a 3-month HF practicum in which they attend weekly half-day clinics and receive individualized one-on-one teaching and practical experience in HF management.

The CTR process started in August 2009 and continued until August 2010. At the time of the study’s initiation, 18 PCPs had participated in the 3-month practicum. Since these PCPs knew the HF clinic staff and were supportive of its quality improvement goals, the CTR team asked to review the charts of their patients. All 18 PCPs assented to this review. Consequently, each of their patient panels was searched for any patients who had received a treatment at the clinic for an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for HF in the past 2 years (n = 641). The team pharmacist then reviewed each patient’s chart and those with an EF ≤ 40% were included in the sample targeted to receive CTR. Patients who had died (n = 51), had no EF recorded (n = 62) in the VA records or scanned documents, or were no longer under the participating PCP’s care (n = 10) were excluded. Of the remaining patients, 173 (34%) had an EF ≤40%. Because 17 of the 173 patients with EF ≤40% were already being actively followed by the HF clinic, they were also excluded. Thus, the CTR intervention group included 156 patients (30%) (Figure).

Collaborative Therapy Review

To conduct the CTR, a team was formed, consisiting of the HF clinic cardiologist and pharmacist, a hospitalist who saw newly discharged HF patients in the clinic, and a senior internist from the Primary Care Division, who had oversight over the PCPs and worked regularly in the clinic. To assist with the initial detailed chart extracting and review, 3 to 4 rotating PharmD students also contributed to the team. Extracted data included at least 1 year of trends in vital signs and serum creatinine levels and 5-year trends in serum potassium levels. Both Veterans Affairs (VA) and any available non-VA medical records were reviewed for any documented EFs. Patients who had not had an EF within the previous 3 years received an echocardiogram or multigated acquisition (MUGA) scan recommendation. Information about medications and active medical problems were also collected.

In assessing each patient’s optimal HF treatment, the CTR team considered 3 key elements: 1) Can new life-prolonging medications be initiated safely? 2) Can lifeprolonging medications be up-titrated safely to target doses? and 3) Is the patient a candidate for a primary prevention ICD? We developed a standardized data collection tool to extract data (Appendix A, available at www. The team assessed the possibility for initiation or up-titration of beta-blockers, ACE inhibitors, ARBs, and spironolactone using vital signs and laboratory data to ensure that the patients were likely to tolerate the new doses without complications. Target doses of life-prolonging medications included lisinopril 40 mg daily, metoprolol succinate 200 mg daily, carvedilol 25 mg twice daily for patients weighing <85 kg and 50 mg twice daily for patients weighing >85 kg, and spironolactone 25 mg daily. If the chart reflected that a patient was taking the highest dose tolerated without side effects, the patient was classified as being at the target dose.

The team pharmacist then made recommendations to the patient’s PCP via a brief note in the electronic medical record. When applicable, pre-prepared electronic orders were also included; the PCPs could choose to accept these orders based on clinical judgment (see Appendix B, available at The number of recommendations was deliberately kept to a minimum and staggered over time to distribute the PCPs’ workload evenly.

Data Analysis

We summarized patient demographics, comorbidities, and medication utilization using frequencies. We classified recommendations made to PCPs into 3 general categories: guideline-based medications, laboratory testing, or device therapy consultation. Medication and laboratory recommendations were then subclassified to describe drug and laboratory test categories (eg, ACE inhibitors, ARBs, a basic metabolic panel, vitals). The frequency of PCP acceptance of CTR recommendations was calculated overall and stratified by recommendation class. We also assessed the time taken to accept these recommendations. All analyses were performed using SAS version 9.2 (Cary, North Carolina).


The team identified 641 patients as potential targets for CTR based on ICD-9-CM codes for HF in the past 2 years. This represented 3% to 6% of each PCP’s patient panel. A total of 18 panels were reviewed. On average, 10 patients per panel received a detailed chart review and each review took approximately 30 to 40 minutes. Overall, the extraction time was about 6 hours per panel (or approximately 30 minutes per patient), or approximately 100 hours in total. In addition to the time members spent individually reviewing charts, the CTR team met for 1.5 to 2 hours every 1 to 3 weeks to discuss the reviews of approximately 12 to 14 patients and to collectively decide on final recommendations. The CTR team limited the recommendations to 3 to 4 per week to any 1 provider. Overall, the time spent per patient was approximately 45 minutes.

The baseline characteristics for the 156 patients are shown in Table 1. They were predominantly male (99%) and their median age was 68 years (range: 46-90 years). The primary etiology for patients’ HF was ischemic (72%), and the most common comorbidities were hypertension (81%), coronary artery disease (68%), and diabetes (53%). The majority of patients were receiving a beta-blocker (90%) and an ACE inhibitor (85%) at the time of CTR. However, at least half of these patients had not reached target doses for either of those medication classes (Table 1).

Among the 156 patients reviewed, 86 (55%) were found to be on maximum tolerated doses of life-prolonging medications, had current laboratory and EF evaluations, and had either already received or declined ICD therapy. For the remaining 70 (45%) patients, a total of 100 recommendations (mean: 1.4 recommendations per patient; range: 1-4) were made. Among these recommendations, 62 were for guideline-based drugs, 11 for updating laboratory tests, 15 for EF measurements, and 12 for consideration of ICD therapy (Table 2).

For guideline-based drugs, 27 recommendations were made for up-titration and 35 for initiation of therapy; the majority of drug recommendations were for lisinopril and metoprolol succinate. For patients receiving up-titration, the median (interquartile range, [IQR] doses for these drugs prior to up-titration were 10 mg (IQR: 3-20 mg) for lisinopril and 50 mg (IQR: 50-100 mg) for metoprolol succinate. After up-titration, the median doses were 20 mg (IQR: 10-28 mg) and 100 mg (IQR: 75-200 mg), respectively. Some of the recommendations for drugs included a 2-step titration to target doses based on patient tolerability. However, the recommendations were considered accepted after the first step titration was performed.

Twelve of the 15 patient recommendations for MUGA, 5 of 11 recommendations for updated labs, and 10 of 12 recommendations for discussion of ICD implants were accepted. Among those who had a recommendation for either an updated MUGA or ICD discussion, 10 had an improved EF >35% and were thus no longer eligible for an ICD, 5 refused an ICD, 2 had an ICD placed, 4 moved and did not have recommendations acted on, and 3 were lost to follow-up. Only 12 (60%) recommendations for beta blockers were accepted. There were 2 recommendations for initiating digoxin in patients who had concomitant atrial fibrillation and had elevated heart rates despite being on target doses of beta-blockers. Overall, 70% of all recommendations were carried out and the majority (80%) were acted on within 90 days.


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