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Regards to all our listeners!

I'm Rob Logan, Ph.D., senior staff, U.S. National Library of Medicine substituting this week for Donald Lindberg, M.D, the Director of the National Library of Medicine.

Here is what's new this week in MedlinePlus.

To listen to Dr. Lindberg's comments, click here

Beta-blocker prescriptions are now so routine that the New England Journal of Medicine reports,  the monitoring of its use (to assess the quality of health care for heart attack patients) stopped this spring.
                                            
The widespread use of beta-blockers (close to 100 percent nationwide) completes an interesting 25 year journey that provides insights into the health care delivery system's adoption of clinical innovations. Just seven years ago, about 80 percent of acute heart attack patients in some hospitals --measured by the National Committee for Quality Assurance -- received beta-blockers. A decade ago only about 50 percent of acute heart attack patients received beta-blockers.

Beta-blockers are one of several types of drugs used to treat heart disease -- and also are used to care for high blood pressure. In heart disease, Consumers Union notes beta-blockers are used to treat angina (chest pain due to coronary artery disease), a high heart rate, certain abnormal heart rhythms, heart failure (when the heart muscle weakens), and when someone has a recent or previous heart attack. 

Generic beta-blockers are among Consumers Union's 'best buy drugs,' which means consumers pay less for beta blockers than many other prescription medications.
 
An article by Dr. Thomas Lee, an associate editor of the New England Journal of Medicine, reflects on the recent success of beta-blockers as a widely accepted clinical intervention. Dr. Lee notes the history of the acceptance of beta-blockers provides a primer on how diffusion occurs within the nation's health care community -- and its journey adds insights that could accelerate the future pathway from applied research to patient care.

Dr. Lee explains the journey to the implementation of beta-blockers featured several steps. He notes the first clinically significant evidence of the success of beta-blockers to prevent acute heart attack reoccurrence and death occurred 25 years ago. A 1982 study by the U.S. National Heart, Lung, and Blood Institute ended nine months early after the therapeutic impact of beta-blockers (to help a variety of heart attack patients, including seniors), became statistically evident.

The 25 year delay to beta-blockers' implementation is significant, Lee notes, because it suggests that successful results from a high quality clinical trial are insufficient to encourage widespread use among the nation's physicians without some additional steps.

Dr. Lee finds the initial encouragement for clinicians to use beta-blockers came from academic medical texts published as early as 1984. Then, in the mid-1990s, Dr. Lee reports groups, such as the American College of Cardiology and the American Heart Association, accelerated developing new guidelines for physicians and recommended using beta-blockers as standard drug therapy for some heart attack patients.

Once these expert guidelines were published, Dr. Lee notes that some organizations which measure clinical quality, such as the Joint Commission on the Accreditation of Health Care Organizations (today called the Joint Commission), began to measure the use of some beta-blockers for acute heart attack patients as standard of good practice. This action resulted in the ability of Medicare patients to compare hospital data about the use of beta-blockers by the late 1990s.

Similar standards of practices were added to the accreditation of health maintenance organizations (or HMOs) -- especially among employer health plans. As a result of these actions, health plans placed beta-blockers into the 'scripts' used by case managers to assess the quality of care for the heart attack patients the plans insured. In addition, Lee describes some health plans began to offer financial incentives to hospitals under pay-for-performance contracts to use beta-blockers to treat acute heart attack patients.

To backup, while Dr. Lee emphasizes these steps were important, national data showed beta-blockers were routinely prescribed for acute heart attack patients a little more than 80 percent of the time at the start of the 21st century.

Lee explains beta-blocker acceptance received a recent boost when medical professional societies reinforced previous guidelines and began campaigns designed to increase use among clinicians.

However, Dr. Lee concludes it was the momentum built up by all the above steps over time that resulted in the routine use of beta-blockers within medical practice.

While Lee notes that no single organization or event can take credit for today's widespread acceptance, he emphasizes the success of journey is qualified by its length. Lee rhetorically asks (and we quote) ' how many lives might have been extended if beta-blocker use had become routine in, say, 10 years instead of 25' (end of quote).
 
Rather than critique beta-blockers' journey to acceptance, Lee notes its steps provide a model to accelerate the pace of future clinical innovations. Certainly, the history of beta-blockers suggests that to succeed, a medical innovation needs a track record of rigorous research, coupled with consensus guidelines which create performance measures by health plans, hospitals and physicians. In turn, these foster new benchmarks, internal quality controls programs, the reporting of results to the public, and pay-for-performance contracts to implement new clinical therapy.

Accordingly, the model provides what Lee calls a 'recipe' that can be used by medical organizations to speed the future acceptance of drugs and other medical innovations that help patients live longer and recover faster.

So, the journey of beta-blockers may demonstrate how to accelerate --  (and critique) -- the pace from the launch of important research innovations to bedside care.  

While patient acceptance is not discussed in Dr. Lee's article, one predictor of consumer confidence is to find reliable information about a physician's clinical recommendations, such as routinely prescribed drugs. Access to information about widely prescribed drugs, including beta-blockers, is one of MedlinePlus' core services. For example, a website accessible from MedlinePlus compares the cost and use of 27 beta-blockers from a patient's or caregiver's perspective.

The Consumers Union web site lists a beta-blocker's generic name and dose, brand name, frequency of use, estimated monthly cost and if the medication is listed as a best buy. The beta-blockers intended for heart disease and angina are clearly listed.

The information on the web site is intended to help patients and caregivers participate in clinical decisions.

To find Consumer Union's information within MedlinePlus, type 'beta blocker' in the search box on MedlinePlus' home page. Then, click on 'Treating High Blood Pressure and Heart Disease – The Beta Blockers (Consumers Union of U.S.).' It is the second listing on the page and is listed within sections on the same page for 'high blood pressure,' 'heart failure,' and 'angina.'

MedlinePlus also has extensive background information about heart failure and its diagnosis/symptoms, treatment, prevention, screening, and disease management. MedlinePlus' information includes: overviews, a narrated, interactive tutorial about congestive heart failure as well as information about coping, nutrition, and current research findings.

To find all this information, type 'heart failure' in the search box on MedlinePlus' home page. Then, click on 'Heart Failure (National Library of Medicine).'

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Dr. Lindberg returns in the future.

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