title: ACEi/ARB for systolic heart failure: closing the quality gap with a sustainable intervention at an academic medical center.
abstract: BACKGROUND
  National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge.
  
  
  METHODS
  The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention.
  
  
  RESULTS
  Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel.
  
  
  CONCLUSIONS
  A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.
authors.affiliation: Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA. qian.qi@mayo.edu
authors.forename: Qi
authors.initials: Q
authors.lastname: Qian
authors.forename: Dennis M
authors.initials: DM
authors.lastname: Manning
authors.forename: Narith
authors.initials: N
authors.lastname: Ou
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Klarich
authors.forename: Dorinda J
authors.initials: DJ
authors.lastname: Leutink
authors.forename: Ann R
authors.initials: AR
authors.lastname: Loth
authors.forename: Francisco
authors.initials: F
authors.lastname: Lopez-Jimenez
mesh_terms: D000046:Academic Medical Centers / Q000379:methods / Q000592:standards*; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D003658:Decision Making, Computer-Assisted; D019983:Guideline Adherence / Q000592:standards*; D054143:Heart Failure, Systolic / Q000188:drug therapy*; D006760:Hospitalization; D006801:Humans; D011787:Quality of Health Care / Q000592:standards*; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000592:standards
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors