Role of a management team in improving ACE inhibitor dosing for heart failure

Underdosing of ACE inhibitors (ACEI) for CHF [using 5 mg or less of enalapril equivalent (EE) daily] causes unnecessary rehospitalization (Luzier, Am J of Cardiol 82:465-469, 1998). This pattern of underdosing persisted in our center during 1993-95 despite repeated efforts at physician education (multiple conferences and discussion groups). In 1996, an interdisciplinary team (PharmD, RN, and MD) began implementation of a voluntary clinical pathway that included optimizing ACEI dosing (using at least 10 mg enalapril or EE). During 1997, about 1/3 of all new heart failure patients were placed in this pathway. The following changes in ACEI dosing were evidenced by a relational database of heart failure, defined as DRG 127. Data is expressed in % Rx's after conversion to EE. Ineffective Possibly Definitely No dose effective effective ACEI (0-5 mg EE) (6-19 mg EE) (≥20 mg EE) 93-95 33 28 25 14 97 30 7*44*19*p<0.05 We conclude that in contrast to previous educational failures, a case-directed team can modify physician prescribing. About 30% of cases demonstrated improved dosing. More work is needed to improve target doses and physician use of the heart failure team.