Diuretics are a mainstay of heart failure treatment, particularly during exacerbations, but that doesn't mean hospitalists, cardiologists, and primary care physicians are using them in any consistent way during and after hospitalization.
Take, for example, a recent study that looked at patterns in therapy for more than 20,000 patients hospitalized for heart failure with reduced ejection fraction, published by JACC: Heart Failure on Aug. 12.
“Among patients receiving IV diuretics, about one in five patients had therapy discontinued for at least one day, and then restarted IV diuretic therapy during the same hospitalization,” said lead author Stephen Greene, MD, assistant professor of medicine in the division of cardiology at Duke University Medical Center in Durham, N.C. “Our data don't address the reasons for these decisions, but it suggests that there's a lot going on and that we would benefit from a more standardized approach in how we use diuretics in the inpatient setting.”
Hospitals certainly have an incentive to use these drugs in the most beneficial way. In 2017, 79% of hospitals nationwide were assessed penalties by CMS for excess 30-day readmissions for heart failure, according to a study in the September 2019 Journal of Hospital Medicine.
Challenges to optimal use include mixed evidence on the effects of diuretics, limited guideline support for them, and uncertain division of responsibility for postdischarge prescribing. Hospitalists play a key role in addressing these issues to prevent readmissions and improve patients' health, said experts, who also offered their tips for improvement.
Diuretics are widely considered the most effective way to relieve congestion in hospitalized patients with heart failure, yet current recommendations are graded C for level of evidence, said Zachary L. Cox, PharmD, associate professor at Lipscomb University College of Pharmacy in Nashville, Tenn. The paucity of evidence to guide inhospital diuretic therapy has led to unfounded concerns about their impact on kidney function, which may contribute to underuse, he added.
Past observational studies have raised concerns that sustained use and high doses of diuretics may increase mortality, he added. However, subsequent studies suggested that higher intensity diuretic use is more likely a marker of severity of illness, and Dr. Cox believes it is more important to adequately decongest patients than to leave congestion untreated because of concerns about diuretic dose intensity.
In a recent study, researchers compared outcomes among a matched cohort of just over 2,000 pairs of Medicare patients hospitalized for heart failure who were prescribed diuretics during hospitalization and discharged with or without loop diuretics. Patients who were not taking diuretics prior to admission but were discharged with a prescription had significantly fewer readmissions and deaths within the first 30 days, according to findings published in the August Journal of the American College of Cardiology (JACC).
“Our study highlights that for patients who were congested prior to admission, loop diuretics are an important component of ongoing therapy,” said study coauthor Gregg C. Fonarow, MD, professor of medicine and interim chief of the division of cardiology at the University of California, Los Angeles (UCLA). “Patients who are sent out without a prescription are at higher risk for subsequently regaining fluid and requiring rehospitalization.”
According to Dr. Cox, who wrote an accompanying editorial, the study, while observational, provides evidence to strengthen the recommendation on diuretics from C to B, in line with European guidelines. Of importance, the study highlights a gap in current guidelines, which do not address diuretic therapy beyond acute symptom resolution, he said. More than one-quarter of the patients were not on diuretics at admission, and the therapy was stopped at discharge in a significant number of patients who were considered stable.
“It isn't that physicians don't think these patients need diuretics, it's that they don't think they need them at the exact moment of discharge,” said Dr. Cox. “The inpatient clinician may assume that diuretics will be prescribed at follow-up or may think a break from therapy is warranted, but that's usually where things go awry because patients don't always follow up and the medication never gets restarted.”
The often-repeated mantra of “diurese and discharge” is fundamentally misguided, said Dr. Greene. Hospitalization is a chance not only to address the immediate problem of congestion but also to get patients on medications that could potentially change the trajectory of their illness.
“As soon as a patient is admitted, we should be looking at their regimen, thinking about what needs to be changed, and making those changes early in the hospitalization,” said Dr. Fonarow.
Not just diuretics
Although diuretics are an essential component of therapy for heart failure, they must be prescribed as part of a regimen of recommended therapies, said Dr. Fonarow.
Five classes of medications, in combination with loop diuretics, are recommended by current American Heart Association/American College of Cardiology guidelines for effective treatment of patients with reduced ejection fraction, who represent about half of all heart failure patients, according to current guidelines. They include angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists (MRAs).
“Diuretics help with congestion, but they do not change the fundamental history of the disease and they do cause activation of the neurohormonal system,” noted Dr. Fonarow. “The only way to counter those effects is with neurohormonal antagonists, such as angiotensin-converting enzyme inhibitors or angiotensin receptor neprilysin inhibitors and beta-blockers.”
Adding more of these treatment options during hospitalization was associated with reduced risk of death and readmission, according to a study of patients with heart failure and reduced ejection fraction published in the Aug. 18 Journal of the American Heart Association. However, it also found that this was relatively rarely done. Only 41% of the patients were on dual therapy in the year after hospitalization, and 13% were on three of the therapies. Almost half of the patients who received postdischarge medication had no escalation in dose.
Similarly, while the study led by Dr. Greene indicated that use of all guideline-directed medical therapies increased at discharge versus admission, a substantial proportion of patients were still discharged without them (73% for MRAs, 50% for ACE inhibitor/ARBs, and 29% for beta-blockers), a finding the authors described as “disappointing.”
“When you consider the high morbidity and mortality these patients face after discharge—close to one in three won't be alive over the next year—it really puts an onus on all clinicians to give these patients the best chance of not having an early readmission and to live out the next year or more,” said Dr. Fonarow. “It is not enough to relieve patients' congestion and send them out on the same medications they came in on.”
A quality improvement initiative at Altamonte Springs, Fla.-based AdventHealth recently attempted to address this problem.
Hospitalists at eight of the health system's facilities in five states were given online simulated patient case studies of heart failure and sepsis care and were scored on how closely they adhered to evidence-based recommendations. Physicians then received personalized feedback reports—including how their scores compared to the group average—and met for group discussions.
Over two years, participants improved their scores by nearly 8% in both types of care. Ordering of essential medical treatments for heart failure, defined as prescribing diuretics, ACE inhibitors, and beta-blockers for appropriate patients, increased from 58% to 72%, which translated into lower costs and reduced length of stay compared to a control group of nonparticipating hospitals, according to results published in the September 2019 Journal of Hospital Medicine.
“The gold standard for measuring the quality of clinical practice is using standardized patients, but that's not practical when measuring at scale and across groups of providers,” said the study's senior author, John W. Peabody, MD, PhD, FACP, president of San Francisco-based consultancy QURE Healthcare and a professor at University of California, San Francisco, and UCLA. “With this study, we used validated, simulated patients to prospectively evaluate care in multiple hospitals so that everyone took care of the same patients at the same time. The results are striking in two ways—how much variation there is in caring for heart failure patients and how important feedback and serial measurement are if we are to improve the care for these patients.”
Dr. Fonarow noted that hospitalists don't have to tackle the task of improving diuretic use alone. “Multidisciplinary teams can help. Hospitalists should work with pharmacists, social workers, heart failure nurses, and others to ensure that no key therapies are overlooked and any potential barriers to refills or authorizations can be taken care of prior to discharge.”
Clinical inertia is a major driver of the gap between heart failure evidence and practice, said Dr. Greene. Inpatient clinicians often assume that medications will be optimized by the outpatient clinician at follow-up, but research suggests that doesn't happen in the majority of cases—potentially putting patients at higher risk for death, re-hospitalization, and lower quality of life.
“We know that if you prescribe a medication at discharge, that patient has an exceedingly higher chance of being on it for the full year after discharge,” Dr. Greene said. “While someone's hospitalized, we should make sure they go home with recommended prescriptions. The medications we prescribe at discharge don't just impact the medications patients receive in the short term. These discharge medication decisions have a lasting impact on the medications patients receive over the longer term.”