Containment of heart failure hospitalizations and cost by angiotensin-converting enzyme inhibitor dosage optimization.
Using our model relating angiotensin-converting enzyme (ACE) inhibitor dosing and outcomes in heart failure (HF), we designed a prospective intervention trial for patients with systolic dysfunction. A clinical pharmacist initiated or titrated ACE inhibitor therapy or adjusted other medications within an HF management program based on Agency for Healthcare Policy and Research guidelines. Entry into the protocol required the approval of the attending physician. All patients received dietary, nursing, rehabilitation, social service, and clinical pharmacy consultations. Treatment conformed to Agency for Healthcare Policy and Research guidelines in 25% of patients (group A). Suboptimal therapy (75% of patients) was usually due to failure to administer an ACE inhibitor (48%) or inadequate dosing of an ACE inhibitor (46%). In 62% of suboptimal cases, the attending physician agreed to follow the clinical pharmacist's recommendations (group B). Patients of physicians who declined pharmacist intervention served as a negative control (group C). On admission, mean enalapril-equivalent daily doses in groups A, B, and C were 30, 4, and 6 mg, respectively, and at discharge, 36, 18, and 6 mg, respectively. At 180 days, rehospitalization frequency and total charges were lower in groups A (31% and $5,600) and B (35% and $3,800) than in group C (63% [p <0.004] and $9,800 [p <0.04]). Thus, optimization of ACE inhibitor doses by a clinical pharmacist can greatly improve rehospitalization rates and significantly lower cost of care in an HF management program.