J Clin Outcomes Manage
Spironolactone: the missing drug in the treatment of patients hospitalized with congestive heart failure
Abstract Objective: To assess the impact of interventions to increase the use of spironolactone in patients with congestive heart failure (CHF) due to ventricular systolic dysfunction. Methods: Charts of patients admitted to the medicine department of a single hospital with a primary diagnosis of class IV CHF and left ventricular ejection fraction of 40% or less were randomly selected and reviewed. Data were obtained for 30 preintervention and 30 postintervention patients. Measures included rates of use of spironolactone, b blockers, and angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor blockers (ARBs) and documentation of contraindications to these therapies. Interventions: Interventions consisted of adding a clinical decision support reminder to the physician order entry system that alerted physicians ordering ACE inhibitors/ARBs for CHF to consider adding b blockers and spironolactone, an educational program to raise awareness of guideline recommendations, and multidisciplinary efforts to identify patients with CHF on admission and communicate appropriate recommendations to the medical team. Results: The rate of spironolactone use was 0% in the preintervention sample and 40% in the postintervention sample. Use of ACE inhibitors/ARBs and b blockers did not differ between the preintervention group (73% and 66%) and postintervention group (67% and 60%). Documentation of contraindications to ACE inhibitors/ARBs and b blockers increased from 40% and 0% preintervention, respectively, to 100% and 60% postintervention. Conclusion: There was a substantial increase in the utilization of spironolactone in patients with systolic dysfunction after the implementation of relatively inexpensive interventions. We continue to look for systems improvements to further increase appropriate use of spironolactone and other evidence-based therapies.
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