disease management for heart failure

Disease Managementfor Heart Failure

DISCLAIMER: The information contained in this annotated bibliography was obtained from the publications listed. The NationalPharmaceutical Council (NPC) has worked to ensure that the annotations accurately reflect the information contained in the publi-cations, but cannot guarantee the accuracy of the annotations or the publications. There are articles available on the treatment ofheart failure that are not included in this bibliography and that may include relevant information not covered herein. The inclusion ofany publication in this bibliography does not constitute an endorsement of that publication by NPC or an endorsement of the serv-ices, programs, treatments, or other information contained in such publication.

This bibliography is designed for informational purposes only, and should not be construed as professional advice on any specificset of facts and circumstances. This bibliography is not intended to be a comprehensive source of disease management servicesor programs for the treatment of heart failure, or a substitute for informed medical advice. If medical advice or other expert assis-tance is required, readers are urged to consult a qualified health care provider or other professional. NPC is not responsible forany claims or losses that may arise from any errors or omissions in the information contained in this bibliography or in the listedpublications, whether caused by NPC or originating in any of the listed publications, or any reliance thereon, whether in a clinicalor other setting.

© October 2004 National Pharmaceutical Council, Inc.

IntroductionThe Disease Management Association of America

defines disease management as a system of coordinatedhealth care interventions and communications forpopulations with conditions in which patient self-careefforts are significant.1 Disease management supports theclinician-patient relationship and plan of care, andemphasizes prevention of exacerbations andcomplications using evidence-based practice guidelinesand patient empowerment strategies.1 It also evaluatesclinical, humanistic, and economic outcomes on anongoing basis with the goal of improving overall health.1

More specific goals of disease management include:2

• Improving patient self-care through means such aspatient education, monitoring, and communication.

• Improving physician performance through feedbackand/or reports on patient progress in compliance withprotocols.

• Improving communication and coordination of servicesbetween the patient, the physician, the diseasemanagement organization, and other providers.

• Improving access to services, including preventionservices and prescription drugs as needed.

The following functions are components of diseasemanagement:2

• Identification of patient populations.• Use of evidence-based practice guidelines.• Support of adherence to evidence-based medical

practice guidelines by providing medical treatmentguidelines to physicians and other providers,reporting on the patient’s progress in complying withprotocols, and providing support services to assistthe physician in monitoring the patient.

• Provision of services designed to enhance thepatient’s self-management and adherence to his orher treatment plan.

• Routine reporting and feedback.• Communication and collaboration among providers

and between the patient and his or her providers.• Collection and analysis of process and outcomes

measures.

Disease management programs are widely used forasthma, diabetes mellitus, and heart failure.3-5

Considerations in selecting a disease for diseasemanagement include:

• Availability of treatment guidelines with consensusabout what constitutes appropriate and effective care.

• Presence of generally recognized problems intherapy that are well documented in the medicalliterature.

• Large practice variation and a range of drugtreatment modalities.

• Large number of patients with the disease whosetherapy could be improved.

• Preventable acute events that often are associatedwith the chronic disease (e.g., emergencydepartment or urgent care visits).

• Outcomes that can be defined and measured instandardized and objective ways and that can bemodified by application of appropriate therapy (e.g.,decreased number of emergency department visits orhospitalizations).

• Potential for costs savings within a short period (e.g.,less than 3 years).

Three major not-for-profit organizations whose missionis to promote quality health care have recognized thecontribution of disease management activities to qualityhealth care by establishing disease managementcertification or accreditation programs. The JointCommission on Accreditation of Healthcare Organizations,an independent, not-for-profit organization and the nation’spredominant standards-setting and accrediting body inhealth care, offers disease-specific care programcertification. Program certification is based on anassessment of compliance with consensus-based nationalstandards, effective use of established clinical practiceguidelines to manage and optimize care, and anorganized approach to performance measurement andimprovement activities.6

The National Committee for Quality Assurance accreditsdisease management programs on the basis of standardsthat are patient oriented, practitioner oriented, or both. Italso offers organizations certification for program design(i.e., content development), systems (i.e., clinicalinformation and other support systems), or patient orpractitioner contact (e.g., for nurse call centers and otherorganizations without comprehensive activities).7

The Utilization Review Accreditation Commission(URAC), also known as the American AccreditationHealthCare Commission, establishes standards for thehealth care and insurance industries. URAC’s goal is to

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promote excellence among purchasers, providers, andpatients through continuous improvement in the qualityand efficiency of health care delivery. It achieves this goalby establishing standards, education and communicationprograms, and a process of accreditation. URAC hasaccreditation programs for disease management as wellas case management, claims processing, coreaccreditation, credential verification, health call centers,health networks, health plans, health providercredentialing, health utilization management, health Websites, Health Insurance Portability and Accountability Actprivacy and security, independent review, and workers’compensation utilization management.8

Penetration And TrendsThe ultimate goal of disease management is to produce

optimal health outcomes for patients. Therefore, virtually allstakeholders in health care want to be involved. Diseasemanagement is of interest to providers, patients, managedcare organizations, insurance companies, governmentagencies, pharmacy benefit management (PBM) firms,and employer purchasing coalitions.9 Most diseasemanagement programs are implemented through healthmaintenance organizations (HMOs), PBM firms, orMedicaid agencies.4 Some organizations choose to hire avendor and contract out disease management services,whereas others choose to develop their own programs.Each method has advantages and disadvantages;success often depends on the organization and its level ofresources and commitment.

Managed Care Organizations andPharmacy Benefit Management Firms

Managed care organizations and PBM firms were thefirst to implement disease management programs. PBMfirms offer disease management programs and services toemployers and managed care clients as part of theiroverall benefit management services.10 The 1998 Novartis

Pharmacy Benefit Report indicated that 75% of PBMpharmacy directors were expending resources to developdisease management programs for conditions thatrespond to or depend on pharmaceutical products andservices. HMOs reported that 16% of their diseasemanagement programs were provided thorough a PBM.10

Most employers reported using PBM firms to managecosts, and many employers used PBM firms to providedisease management services.10

America’s Health Insurance Plans (a trade associationcreated by the joining of the American Association ofHealth Plans and the Health Insurance Association ofAmerica) represents more than 1300 HMOs, preferredprovider organizations, and other network-based plans.Members of the association provide health care to morethan 200 million Americans nationwide. In a 2000 survey ofa random sample of association members, 99% ofmember health plans offered a disease managementprogram.5

State Medicaid ProgramsIn the rapidly changing environment of Medicaid

managed care, it is essential for Medicaid directors andtheir top managed care staff to remain abreast ofinnovations in organization and payment that are occurringto serve the special needs of the Medicaid population.Traditionally, state Medicaid programs either have retainedinsurance risk and paid on a fee-for-service basis or haveoutsourced risk and contracted with Medicaid HMOs.Disease management represents a method of managedcare in the middle between traditional fee-for-service andHMOs. Four types of models are emerging:

1. Medicaid health outcomes partnerships areusually applied to an existing fee-for-serviceprimary care case management program.Medicaid programs focus on high-prioritydiseases, offering a number of support systemsto help existing Medicaid providers better servethe patients assigned to them.11

2. Disease management organizations are outsidecontractors who are retained by the state toaddress particular diseases, either bysupplementing existing Medicaid providers andtheir case management activities or by takingover responsibility for targeted patients.

3. Pay-for-performance approaches establish newrules for scope of practice or referrals and involvenontraditional providers in the care of patientswith specific diseases. The nontraditionalproviders are paid a special fee contingent onimproving health outcomes or lowering costs.

4. Centers of Excellence focus on particular diseaseepisodes for high-cost, high-volume diseases andselect a network of hospitals, physicians, andother providers who are already organized toreceive a prospective, bundled payment perepisode of care. To meet criteria for designation

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as a center of excellence, an organization mustprovide written documentation of the quality andoutcomes of care for a selected disease.

Most states are actively involved in the diseasemanagement process. By far, the diseases most oftenfocused on in these programs are asthma and diabetes.Other diseases and conditions included in state diseasemanagement programs are arthritis, heart failure,depression, gastrointestinal disease, hemophilia, HIVinfection/AIDS, hyperkinetic activity, dyslipidemia, mentalhealth, otitis media, pregnancy, smoking, ulcer, and upper-respiratory infections. Current information about statedisease and case management activities is available onthe Web at http://www.dmnow.org/state_activities/.

Why Focus on Heart Failure?Over the last decade, managed care organizations

began an intense utilization review process to identifyareas where cost control measures would beappropriate.12 Heart failure was one of the first diseasesselected because there is great opportunity to treat thisdisease more effectively and to develop programs that willhelp payers and plans manage the high costs associatedwith it.12

Economic ImpactIn the United States, the direct and indirect costs of

heart failure in 2004 are estimated at $25.8 billion.13 Thisfigure includes $23.7 billion in direct costs for expensesrelated to hospitalization, nursing home care, physiciansand other health professionals, medications, and homehealth care. The indirect costs for lost productivity andearnings due to death from heart failure amount to $2.1billion.

Hospitalization is the largest component of the directcosts of heart failure, and the rate of hospitalization forheart failure has increased substantially over the pastdecade.14,15 In 1999, Medicare payments to beneficiarieshospitalized with heart failure amounted to more than$5000 per patient discharged and a total of $3.6 billion.13

Nearly 75% of the hospitalization expense is incurredwithin the first 48 hours of hospitalization (except for thedaily room charge).14 Annual expenditures for medicationsto treat heart failure amount to approximately $500million.15

EpidemiologyAn estimated 5 million Americans have heart failure, and

approximately 550,000 new cases are diagnosed eachyear.13 The prevalence of heart failure increases with age; itis approximately 1% at age 50 and 5% at age 75.16 Fourout of five cases of heart failure occur in persons 65 yearsof age or older.17 Heart failure is the most common cause ofhospitalization in this age group, and nearly half of elderlypatients with a discharge diagnosis of heart failure arereadmitted within 6 months.17 Men are more likely to beaffected by heart failure than are women, probablybecause the incidence of ischemic heart disease is greaterin men than in women.13,18 Roughly 9 out of 10 patients witha diagnosis of heart failure survive for 1 year.19 However,only 5 out of 10 patients are alive 5 years after diagnosis,and the quality of life is impaired in many of thesepatients.19 Approximately 39,000 Americans die from heartdisease annually, and the disease contributes to the deathsof another 225,000 people each year.16 Death is sudden in40% of patients, suggesting that it is the result of seriousventricular arrhythmia.18 Mortality from heart failure is twiceas high for African Americans as it is for whites.16

What Is Heart Failure?Heart failure is the result of dysfunction of the cardiac

ventricles during diastole (filling), systole (contraction), orboth.18 This dysfunction may have a variety of causes,including hypertension (which increases the workload forthe heart) and diseases of the cardiac valves, muscle, andpericardium (the sac surrounding the heart). Myocardialinfarction is a common cause of decreased contractility;damage to heart muscle fibers due to an insufficientoxygen supply impairs the ability of the fibers to shortenduring systole. Myocardial infarction also can increase thestiffness of the ventricles and restrict filling during diastole.In most cases, heart failure is characterized bydysfunction of the left ventricle during systole and a lowcardiac output (the volume of blood pumped per minute)and ejection fraction (the portion of the left ventriclevolume expelled during systole).18 Common causes of leftventricular systolic dysfunction include hypertension,coronary artery disease, and idiopathic dilatedcardiomyopathy.18

Heart failure is a condition in which the heart cannotpump enough blood to meet the needs of the body’s otherorgans. It can result from:

• Narrowed arteries that supply blood to the heartmuscle (i.e., coronary artery disease).

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• A past heart attack, or myocardial infarction, withscar tissue that interferes with the heart muscle’snormal work.

• High blood pressure.• Heart valve disease due to past rheumatic fever

or other causes.• Primary disease of the heart muscle itself, called

cardiomyopathy.• Defects in the heart present at birth (i.e.,

congenital heart disease).• Infection of the heart valves and/or heart muscle

itself (i.e., endocarditis and/or myocarditis).

The “failing” heart keeps working, but it doesn’t work asefficiently as it should. People with heart failure cannotphysically exert themselves because they become short ofbreath and fatigued. As blood flow out of the heart slows,blood returning to the heart through the veins often backs up,causing congestion in the tissues. Swelling (edema) results,most commonly in the lower legs, ankles, and feet, butpossibly in other parts of the body as well. Sometimes fluidcollects in the lungs and interferes with breathing, causingshortness of breath, especially when a person is lying down.Heart failure also affects the ability of the kidneys to excretesodium and water. Water retention worsens the edema.

Compensatory mechanisms involving the bloodvessels, kidneys, nervous system, and hormones (e.g., therenin-angiotensin-aldosterone system) allow thecardiovascular system to temporarily adapt to underlyingpathologic conditions, maintain a normal cardiac output,and forestall the onset of heart failure signs andsymptoms.18 These mechanisms include hypertrophy of theventricles (an increase in muscle mass and wallthickness), dilatation of the ventricles (i.e., increasedvolume), and sympathetic nervous stimulation (to increaseheart rate, contractility, and cardiac output). However,some compensatory mechanisms can worsen heart failure;these mechanisms are referred to as maladaptiveresponses. For example, low renal blood flow due to lowcardiac output results in activation of the renin-angiotensin-aldosterone system, which increases bloodpressure and promotes sodium and water retention andvolume overload.18 Although sympathetic stimulationincreases the heart rate, contractility, and cardiac output, italso increases blood pressure and oxygen demand on theheart. Heart failure signs and symptoms manifest when themaladaptive responses overwhelm the beneficial effects of

compensatory mechanisms.18 Maladaptive responsescontribute to disease progression in patients with heartfailure.

Signs and symptoms of heart failure include fatigue,shortness of breath, difficulty breathing (especially atnight, when lying down, or during physical exertion),cough, weight gain (from fluid retention), and swelling ofthe feet and ankles.16,18 The New York Heart Associationfunctional classification may be used to classify functionaldisability in patients with heart failure on the basis of theextent to which physical activity is limited because ofsymptoms. Class I is no impairment (i.e., symptoms only atlevels of physical activity that limit normal persons), andClass IV is severe impairment (i.e., symptoms at rest).

Table 1 lists commonly used authoritative guidelines formanaging heart failure. Up-to-date information on treatmentguidelines from various sources also is available from theNational Guideline Clearinghouse (http://www.guideline.gov/).The management of heart failure, based on information inthe guidelines, is discussed in Appendix A. Table 2provides a list of organizations with information about heartfailure for patients.

Health Goals in Patients with HeartFailure

Some of the conditions that cause heart failure (e.g.,diseased heart valves) can be corrected. However, in mostcases, a cure is not possible. Nevertheless, lifestylemodifications and drug therapies may be used to managechronic illness. The goals of treatment are to increasesurvival, reduce symptoms, and improve functional statusand quality of life.16

Review of Heart Failure DiseaseManagement Literature

A comprehensive search of the heart failure diseasemanagement literature was conducted in preparing thisbibliography. The goal was to identify reports describingeducational interventions or disease managementprograms designed to improve the management of heartfailure. Thus, whereas some reports describecomprehensive disease management programs, othersdescribe educational interventions directed at patients,health care providers, or both.

MEDLINE is the National Library of Medicine’s premierdatabase. It contains more than 12 million citations andabstracts from more than 4800 biomedical journals

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published in the United States and 70 other countries.

Topics span the fields of medicine, nursing, dentistry,

veterinary medicine, the health care system, and the

preclinical sciences. Earlier versions of this bibliography

were based on searches of the MEDLINE database for the

period from January 1985 to May 2002 using the search

terms “disease” AND “management” AND “congestive

heart failure.” In preparing this updated version of this

bibliography, an additional search of the MEDLINE

database was performed for the period from May 2002

through May 2004 using the search terms “disease

management” AND “heart failure” to reflect changes to the

National Library of Medicine’s controlled vocabulary. This

search was limited to clinical trials.

The primary criteria for inclusion of a report in this

analysis were:

• An educational intervention undertaken to

improve the management of heart failure.

• Measurement of the impact of the intervention or

program.

Reports on 68 disease management programs met

these criteria. Appendix B presents summaries of these

reports, and Appendix C displays associated

methodological information and outcome data in tabular

form.

MethodologiesThe educational interventions or disease management

programs were targeted at adults, including a large

percentage of patients more than 55 years of age. Aside

from three studies with mixed patient populations (one study

included patients with chronic obstructive pulmonary

disease [COPD] or congestive heart failure [CHF], another

included patients with CHF or cardiomyopathy, and a third

included patients with CHF, COPD, or diabetes), all

interventions and programs were targeted at individuals with

heart failure, including the congestive state. The size of the

patient population ranged from to 15 to nearly 5000 patients.

Patient participants in the disease management

programs and educational interventions were recruited

1. American Heart AssociationExercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, andprevention. Available in print (Circulation. 2003;107:1210-1225) and online at: http://circ.ahajournals.org/cgi/reprint/107/8/1210.

2. Canadian Cardiovascular SocietyThe 2002-2003 Canadian Cardiovascular Society consensus guideline update for the diagnosis and managementof heart failure. Available in print (Can J Cardiol. 2003;19:347-356).

3. Heart Failure Society of AmericaHeart Failure Society of America guidelines for management of patients with heart failure caused by left ventricular systolicdysfunction: pharmacological approaches. Available in print (J Card Fail. 1999;5:357-382, Pharmacotherapy. 2000;20:495-522,or Congestive Heart Failure. 2000;6:11-39) and online at: http://www.hfsa.org/pdf/lvsd_heart_failure.pdf. Update in progress.

4. Institute for Clinical Systems ImprovementHealth care guidelines on (1) Inpatient Management of Heart Failure (2004) and (2) Heart Failure in Adults (2003). Availableonline at: http://www.icsi.org.

5. European Society of CardiologyGuidelines for the diagnosis and treatment of chronic heart failure. Available in print (Eur Heart J. 2001;22:1527-1560) andonline at: http://www.escardio.org/NR/rdonlyres/83B0E854-D56A-47C1-988F-585F4EBFEAF8/0/CHF_diagnosis.pdf.

aClinical practice is subject to constant change, and the guidelines in this list may become outdated or be superseded by newer ones. The reader isencouraged to consult the National Guideline Clearinghouse (http://www.guideline.gov/), a public resource for evidence-based clinical practiceguidelines sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), in partnershipwith the American Medical Association and the American Association of Health Plans (now America’s Health Insurance Plans), for the most currentguidelines.

Table 1. Authoritative Guidelines for Managing Congestive HeartFailurea

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from various sites, including hospitals, clinics, privatemedical groups, and special heart failure centers. Someinterventions and programs focused on patients withspecific risk factors for hospital readmission. For example,14 interventions and programs were conducted withpatients who were elderly or had severe heart failure,including 2 programs affiliated with heart transplantationcenters. In one case, a medical claims database was usedto identify all patients with a heart failure-based claim ofmore than $50 as well as a recent hospital admission oremergency department visit.

Fifty-two of the educational interventions or diseasemanagement programs were specifically intended forpatients; families of the patients were involved in ninecases. The program content typically included informationabout:

• Heart failure (e.g., pathophysiology, signs,symptoms).

• Appropriate diet, weight, activity level, and otherlifestyle factors.

• Medications and the importance of treatmentadherence.

• Self-monitoring techniques to facilitate the dailymeasurement and reporting of body weight,dietary intake, and evidence of acute heart failureexacerbation (e.g., weight gain, edema,shortness of breath).

Various settings and formats were used to present theeducational material, including individualized and small-group sessions held at a hospital, outpatient clinic, or thepatient’s home. Information presented orally usually wassupplemented by audiovisual or printed materials (e.g.,workbooks, medication calendars, brochures). Commonmethods to reinforce educational material and promotetreatment adherence included home visits by a nurse andoutpatient clinic visits by patients.

Telemonitoring—ranging from regular, provider-initiatedtelephone calls to the transmission of patient self-reporteddata via an automated telemanagement system—wasused in many interventions and programs. Newtechnologies allow for the education of patients at homeby health care professionals at a remote location. Somedevices also provide for the measurement and transmittalof patient health data from the home to the remote locationfor review by a health care professional. The use of thesetechnologies has reduced the need for frequent homevisits by health care professionals and patient trips to ahealth care facility.

Thirteen educational interventions or diseasemanagement programs were directed at both patients andhealth care professionals. In addition to offering patienteducation, these programs and interventions providedhealth care professionals (including physicians) withinformation about:

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American Heart Association7272 Greenville AvenueDallas, TX 752311-800-AHA-USA-1or 1-800-242-8721http://www.americanheart.org

Heart Failure Society of AmericaCourt International—Suite 240 S2550 University Avenue WestSaint Paul, MN 55114651-642-1633http://www.hfsa.org

Heart Rhythm SocietySix Strathmore RoadNatick, MA 01760-2499508-647-0100http://hrspatients.org/

National Heart, Lung, and Blood InstituteP.O. Box 30105Bethesda, MD 20824-0105301-592-8573http://www.nhlbi.nih.gov/

Texas Heart InstituteP.O. Box 20345Houston, TX 77225-03451-800-292-2221http://www.tmc.edu/thi/topics.html

Table 2. Organizations With Information About Congestive Heart Failure for Patients

•The program itself or patient status (i.e., patientself-monitoring data).

• The appropriate use of practice guidelinesdeveloped locally or nationally.

• Techniques for improving patient adherence.• The early management of complications.

Three interventions were directly solely at health careproviders. These interventions involved the developmentand implementation of critical and clinical pathways formanagement of patients with heart failure.

All or certain aspects (e.g., patient teaching,medication dosage adjustments, critical pathways) of 20disease management programs or educationalinterventions were based on guidelines widely accepted inthe medical community. These include guidelines issuedby the Agency for Health Care Policy and Research (nowthe Agency for Healthcare Research and Quality), theAmerican Heart Association, and the American College ofCardiology. Eighteen other interventions or programs reliedon internally developed guidelines or critical pathways, orwere based partly or entirely on:

• Unspecified protocols, guidelines, or criticalpathways.

• Guidelines issued by federal agencies (e.g.,Medicare), nursing agencies, or home health careagencies.

• Published research.

For example, target angiotensin converting-enzyme(ACE) inhibitor dosages in one disease managementprogram were based on the results from randomizedclinical trials.

Most of the educational interventions and diseasemanagement programs targeting patients wereadministered by specially trained nurses or pharmacists.Some interventions and programs were administered by amultidisciplinary team of providers, including physicians,nurses, pharmacists, dietitians, social workers,psychologists, and home health care workers. However, anurse often coordinated the activities of thesemultidisciplinary teams. Physicians, working alone or inconjunction with another health care professional, oftenconducted interventions or programs directed at healthcare providers (i.e., the development and implementationof critical pathways).

The studies included 27 randomized, controlled trials;18 observational, pre- and post-intervention comparisonstudies; and 5 retrospective chart reviews. Outcomes wereassessed over various periods after the intervention (e.g.,30 days, 90 days, 6 months), with 29 studies providingpatient follow-up data for 1 year or longer.

OutcomesA commonly measured outcome was the hospital

admission or readmission rate (readmissions), reflectingthe goal of most educational interventions and diseasemanagement programs to reduce resource utilization.These rates were measured over relatively short periods(e.g., 30 or 90 days) in some studies and over longerperiods (e.g., 1 year) in others. Forty- nine of the 68educational programs and disease management programsused hospital admission or readmission rate as a measureof effectiveness. Following the intervention, rates droppedin 39 studies, remained unchanged in 7 studies, andincreased in 3 studies.

Other common hospital-related outcome measuresincluded total number of hospital days and average lengthof stay (LOS). The average LOS decreased amongpatients receiving the intervention in 13 of 14 studies inwhich LOS was assessed. These changes were paralleledby a decrease in the total number of hospital days in 17 ofthe 18 studies in which this outcome measure wasevaluated. Other measures of resource utilization (e.g.,emergency department visits) also showed similarimprovements.

Several studies evaluated the effect of the educationalintervention or disease management program on patients’emotional or physical status. Patient-related outcomemeasures in these studies included quality of life, mood,and functional status. Improvement in quality-of-life scoreswas found among patients participating in the interventionin 17 of the 22 studies in which this parameter wasassessed; improved mood also was observed in 3 studies.In 12 studies that assessed functional status, significantimprovements were noted among patients participating inthe program or intervention compared with controls.

Several studies focused on the effectiveness of theeducational intervention or disease management programin improving the disease-related knowledge or self-management behavior of patients with heart failure. Forexample, eight studies assessed patient knowledge of

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topics such as appropriate medication use, diet, andexercise; improvements attributed to the intervention wereobserved in seven of these studies. Eleven studies usedobjective measures of adherence to the medicationregimen, dietary restrictions, and other aspects oftreatment. All of these studies documented improvedadherence among patients who participated in theeducational intervention or disease management program.

Knowledge of and compliance with practice guidelinesamong providers were indirectly measured by evaluatingthe appropriateness of medical management (e.g.,appropriate use of an ACE inhibitor to reduce afterload ina patient with heart failure who can tolerate such therapy).Of the six studies that evaluated appropriate medicalmanagement, five documented improved care associatedwith the educational intervention or disease managementprogram, including more appropriate use or dosing of ACEinhibitors in three studies.

Health-related costs were evaluated or projected in 37studies. Thirty-two reports described reduced health-related costs among patients who participated in theeducational intervention or disease management program.The intervention had no impact on costs in one study. Acost savings was projected in another four reports.

The Future of Disease ManagementDisease management can improve patient outcomes

and quality of life while potentially reducing overall costs. Itis an important approach to integrated care.

As health care payers incorporate diseasemanagement principles into the delivery of care, they needto become more sophisticated in contracting with outsidevendors for these services. The Disease ManagementAssociation of America works with potential customers toaddress issues associated with contracting, such as datacontracting and risk sharing. Currently, the DiseaseManagement Association of America has more than 100corporate members that provide disease managementservices.

Disease management vendors have begun using theInternet to reach out to target populations. The Internetallows two-way communication between clinicians andpatients, as well as immediate and free access toeducational materials. Compared with traditional officevisits and postal mailings, the Internet may save time andmoney. Initially the Internet may be used to educateMedicaid physicians, nurses, pharmacists, and otherproviders about disease management. As more peoplegain access to personal computers and enter the“information superhighway,” the Internet will become anincreasingly powerful tool.

Disease management is a useful, efficient approach tohealth care. It will continue to gain widespreadacceptance among health plans that provide care forpatients with chronic disease.

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Heart failure usually requires a treatment regimen thatincludes rest, proper diet, modified daily activities, andmedications that include angiotensin-converting enzyme (ACE)inhibitors, beta-blockers, digitalis, diuretics, and vasodilators.The various medications used to treat heart failure performdifferent functions. For example, ACE inhibitors and vasodilatorsexpand blood vessels and decrease resistance, allowing bloodto flow more easily and making the heart’s work easier or moreefficient. Beta-blockers can improve the function of the leftventricle. Digitalis increases the pumping action of the heart,while diuretics help the body eliminate excess salt and water.

When a specific cause of heart failure is discovered, it shouldbe treated or, if possible, corrected. For example, in some casestreating high blood pressure can ameliorate heart failure. Somepatients are treated surgically by replacing abnormal heartvalves. When the heart becomes so damaged that it cannot berepaired, a more drastic treatment such as a heart transplantmay be considered.

Most cases of mild or moderate heart failure are treatable.With proper medical supervision, people with heart failure neednot become invalids.

Nonpharmacologic TherapyRegular exercise is recommended for patients with stable

heart failure because it may improve functional status anddecrease symptoms.15,20 Moderate restriction of dietary sodiumintake is recommended.18 Excessive fluid intake should beavoided, although fluid restriction is not necessary. Smokingcessation, restriction of dietary fat intake, and treatment of lipiddisorders also may be recommended.15 Alcohol and illicit druguse should be discouraged because they may increase the riskof heart failure.15

Pharmacologic TherapyDiuretics, ACE inhibitors, beta-blockers, and digitalis are

used to treat patients with heart failure.15 Aldosteroneantagonists (e.g., eplerenone), angiotensin receptor blockers(e.g., losartan), hydralazine, and isosorbide dinitrate may beconsidered for certain patients.15,21

Diuretics. Diuretics are used to correct and prevent fluidretention.15 They promote the elimination of sodium and water bythe kidneys. Loop diuretics (e.g., furosemide) are the mostwidely used diuretics for heart failure.18 Thiazide diuretics (e.g.,hydrochlorothiazide) are weaker diuretics than loop diuretics,although they may be used in combination with loop diuretics.Adverse effects of loop and thiazide diuretics include the loss ofexcessive amounts of potassium, weakness, muscle cramps,joint pain, and impotence.16 The potassium-sparing diureticspironolactone acts as an aldosterone antagonist, which can bebeneficial in patients with moderate to severe heart failure.18

However, it can cause gynecomastia (breast pain) andhyperkalemia.

Angiotensin-Converting Enzyme Inhibitors. ACE inhibitorsare recommended for patients with left ventricular dysfunction(unless the patient has hyperkalemia, symptomatic hypotension,a history of adverse reactions to ACE inhibitors, or anothercontraindication to the use of ACE inhibitors).15 ACE inhibitorsreduce the conversion of angiotensin I to angiotensin II.

Angiotensin II is a vasoconstrictor that increases sympatheticnervous activity and causes aldosterone release, which in turnpromotes sodium and water retention by the kidneys. ACEinhibitors also may diminish local production of angiotensin II,which is thought to contribute to ventricular hypertrophy anddilatation in patients with heart failure.22 ACE inhibitors reducemortality from heart failure, delay the progression of the disease,improve functional status, and decrease the need forhospitalization.23,24 These agents also are recommended forasymptomatic patients with moderately or severely impaired left-ventricular systolic function (e.g., to prevent heart failure fromdeveloping after a myocardial infarction).15 The use of ACEinhibitors reduces the risk of heart failure in these patients.25

ACE inhibitors also are recommended for patients at high risk ofdeveloping heart failure (e.g., patients with a history ofatherosclerotic vascular disease, diabetes mellitus, orhypertension and associated cardiovascular risk factors).15

Agents that have been shown to reduce mortality in patients withheart failure (e.g., captopril, enalapril, lisinopril, quinapril,ramipril, trandolapril) are preferred over those without adocumented survival benefit.18 Cough is a common adverseeffect from ACE inhibitor therapy.16 Angiotensin receptorblockers may be an alternative for patients who are unable totolerate ACE inhibitors.

Beta-Blockers. In the past, clinicians were advised to usebeta-blockers with care in patients with heart failure because ofthe negative inotropic effect of these drugs.19 However, the useof beta-blockers for asymptomatic and symptomatic heart failureis now widely accepted because chronic sympathetic activationis thought to play an important role in heart failure.15,18 Beta-blockers have been shown to slow the progression of heartfailure and reduce hospitalization and mortality, possibly byblocking sympathetic stimulation.26,27 Beta-blockers with intrinsicsympathomimetic activity (e.g., acebutolol, pindolol) should beavoided. Reductions in mortality have been demonstrated withbisoprolol, carvedilol, and metoprolol.18 Small beta-blockerdosages should be used initially, and dosages should beincreased gradually to avoid aggravating heart failure.18

Digoxin. Digoxin is recommended (in conjunction with anACE inhibitor and diuretic) for patients with symptomatic heartfailure.15 It is particularly useful for patients with certainarrhythmias.18 Digoxin has a positive inotropic effect (i.e., itincreases the force of contraction) and increases cardiac output.It also has antiarrhythmic activity and beneficial effects onnervous and hormonal mechanisms that contribute to heartfailure. Digoxin reduces symptoms, improves physical functionand quality of life, and decreases the rate of hospitalization inpatients with heart failure, although it does not appear to affectmortality.28 Adverse effects from digoxin include arrhythmias,anorexia, nausea, vomiting, diarrhea, confusion, visiondisturbances, fatigue, and dizziness.16,18

Nitrates and Hydralazine. Nitrates (e.g., isosorbide dinitrate)and hydralazine are vasodilators that may be used in patientswho are unable to take ACE inhibitors because ofcontraindications or adverse effects.18 Nitrates and hydralazinerelax vascular smooth muscle and often are used incombination.18 They reduce mortality from heart failure, althoughto a lesser extent than ACE inhibitors.29 Headache is a commonadverse effect from these agents.

Appendix A. Management of Heart Failure

Humana Congestive Heart Failure program cuts costs,admissions.Anon.Healthcare Benchmarks. 1998;5:173-175.

The effects of a disease management program on hospital admis-sions, hospital days, inpatient costs, and emergency departmentvisits were studied in nearly 5000 members of the Humana Inc.health plan diagnosed with congestive heart failure (CHF). The pro-gram, offered by a private Illinois-based company (CardiacSolutions), began with a home visit from a contracted home healthagency to assess the patient’s physical and psychosocial status,diet, and medication compliance. Patients then received a simpleworkbook that taught them how to manage the disease.Experienced cardiac nurses reviewed the material with patientsindividually by telephone using a script. The nurses also worked toestablish a relationship with each patient, using frequent phonecalls and postcards. Protocols for the program were based onguidelines from the Agency for Health Care Policy and Research(now the Agency for Healthcare Research and Quality) and theAmerican Heart Association. The nurses also followed protocols onlaboratory, medication, lifestyle, and symptom management, andreported urgent patient problems or discrepancies between guide-lines and treatments to attending physicians for clarification abouttreatment. The content of all nurse-patient and nurse-physicianencounters was shared with physicians and patients.

In a 2-year study of the program’s effectiveness, the Humana Inc.health plan observed a 58% drop in hospital admissions for alldiagnoses and a 61% reduction in inpatient health care costs overa 2-year period. Hospital admissions decreased from 7,795 in1995 to 3,309 in the period between 1996 and 1998. The numberof hospital days for CHF patients participating in the programdecreased by 58%, and emergency department visits decreasedby 49%. Health plan administrators concluded that the efficiency oftelephone contacts and the personal touch of as-needed home vis-its improves care for CHF patients.

DM programs take different roads to CHF success.Anon.Healthcare Demand & Disease Management. 2000 Jun;6(6):80-85.[Also reported in Clinical Resource Management. 2001 Feb;2(2):20-25.]

A controlled study of a telephone case management system inwhich nurses provided congestive heart failure patients with educa-tion about the disease, symptoms, importance of measuring bodyweight daily, medications, and other aspects of disease manage-ment is described. The nurses had specialized training in cardiaccare. Phone calls to patients were made weekly for 4 weeks,biweekly for another 4 weeks, and monthly thereafter. Scales wereprovided to patients who had none so that they could weigh them-selves daily. The control group received usual care.

After 6 months of the program, the New York Heart Associationfunctional class and quality of life improved in a significant numberof patients in the intervention group (i.e., patients enrolled in thetelephone case management system). The annualized hospitaliza-tion rate and costs decreased by 49% and 64%, respectively, inthe 6-month period after program enrollment compared with the 6-month period before enrollment (the reductions in rate and costswere 32% and 36%, respectively, for the control group).Emergency department visits increased by 10% in the controlgroup and did not change in the intervention group. Total costsdecreased by 68% and 44% in the intervention group and the con-trol group, respectively, after program enrollment.

Solid outcomes show e-health and chronically ill senior pop-ulations are compatible.Anon.Disease Management Advisor. 2001 Jul;7(7):103-106.

A 1-year randomized, controlled pilot study comparing the cardiaccosts and rate and length of hospitalization associated with a com-puter-based disease management program, interactive voiceresponse (IVR), and usual care in 69 elderly patients with moderateto severe congestive heart failure (CHF) is described. Patients in thecomputer group and the IVR group were taught to measure theirown blood pressure using a blood pressure cuff, as well as meas-uring their pulse and their weight. These vital signs and varioussymptoms of worsening CHF were reported to a nurse via theInternet for the computer group or telephone for the IVR group(using voice response or the telephone key pad). In-home assis-tance with computer set up was provided for the computer group.

There were 20 hospitalizations for a total of 149 days in the com-puter group and 39 hospitalizations for 258 days in the IVR groupover a 1-year period. Hospitalization data were not reported for theusual care (control) group. Cardiac costs per patient per monthdecreased by $247 in the computer group and $265 in the IVRgroup and increased by $135 in the usual care group.

Web-based educational effort for CHF patients boosts out-comes while cutting costs.Anon.Disease Management Advisor. 2001 Jun;7(6):92-96.

A computerized disease management program for 159 patientswith congestive heart failure (CHF) is described. Computer softwarewas developed to automatically sort Blue Cross/Blue Shield claimsdata by International Classification of Diseases, 9th Revision codesand utilization and pharmacy data using an algorithm. The softwarealso stratified patients by risk (to facilitate prioritization by the pro-gram coordinator) and generated letters to all patients inviting themto enroll in the disease management program. Patients completed

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Appendix B. Reports of the Impact of Disease Management Interventions onTreatment of Congestive Heart Failure

questionnaires that assessed education level, readiness to change,and medical history; the forms were automatically read by comput-er and a plan of action was generated. Physicians completed ques-tionnaires about patients’ medications, medical history, contraindi-cations, heart failure classification, target weight, and adherence tomedications and diet. Program coordinators used this informationand the action plan to conduct telephone counseling sessions withpatients 1 to 3 times per month. Patient education was provided inthese sessions to improve patients’ self-management skills.Additional information was available on the Internet (on the programWeb site and through links to Web sites with good information).Patients were advised to contact their physician if medical prob-lems arose. Physicians received feedback about specific patientsand data for their patients as a group (e.g., rates of flu vaccination,angiotensin-converting enzyme [ACE] inhibitor use).

After 18 months, 93% of participants reported improved diseaseknowledge, 56% reported improved functional status, and 96%were satisfied with the program. ACE inhibitor use increased bymore than 20% to 65%. Overall costs decreased by about 35%due to decreases in emergency department use, hospital admis-sions, and hospital length of stay.

[see also the summary for Hinkle AJ. Disease management: a“smart” way to interact with patients. Health ManagementTechnology. 2000;21:38.]

DM programs take different roads to CHF success.Anon.Clinical Resource Management. 2001 Feb;2(2):20-25. [Also report-ed in Healthcare Demand & Disease Management. 2000Jun;6(6):80-85.]

The impact of a disease management program on angiotensin-converting enzyme (ACE) inhibitor and beta-blocker use, use of tar-get dosages of these medications, clinic visit rate, hospitalizationrate and length of stay, and costs for 117 patients with congestiveheart failure (CHF) at Duke University Medical Center is described.The disease management program involved planning before hospi-tal discharge, periodic follow-up and emergent care at a CHF clinic,telephone follow-up, and patient education about medications, diet,and what to do if symptoms of worsening CHF develop. The CHFteam comprised attending physicians, nurse practitioners, a nursespecialist, a pharmacist, a social worker, and a nutritionist. Thepharmacist ensured that drug therapy was appropriate and the riskof adverse drug reactions was minimized. Patients hospitalized forCHF within the previous 6 months with New York Heart Associationfunctional class III or IV and an ejection fraction less than 20% (i.e.,severe illness) were included.

The use of ACE inhibitors did not change after implementation ofthe program, probably because most patients were receiving them

before program implementation. However, the percentage ofpatients receiving the target dosage increased from 74% beforeprogram implementation to 97% after implementation. The percent-age of patients receiving beta-blockers increased from 52% atbaseline to 76% after program implementation, and the percentageof patients receiving the target dosage increased from 24% to 40%during that period. The average rate of hospitalization decreasedfrom 1.86 times per patient per year at baseline to 1.21 times perpatient per year after program implementation, and the averagelength of stay decreased from 7.67 days to 6.07 days during thatperiod. The rate of clinic visits increased from 7.8 visits per patientyear to 12.9 visits per patient year. The outpatient costs increasedby 27%, and the inpatient costs decreased by 38%. The total costof care decreased by $1.1 million for the 117 patients, which is a37% decrease.

Sacramento hospital boosts outcomes by focusing on high-risk CHF patients.Anon.Data Strategies & Benchmarks. 2001 May;5(5):68-70.

A software program called Health Hero was implemented in a hos-pital-based disease management program for patients with con-gestive heart failure (CHF). Patients responded at home to prepro-grammed questions about general health, diet, and medicationsand transmitted their responses through an electronic appliance toa nurse case manager. The program compiled a report for thenurse case manager in which patients with potential problems are“flagged.” Health Hero also provided patient education andreminders to patients about diet and self-monitoring activities (e.g.,measuring body weight).

The monthly cost of the Health Hero program was about $30 to$60 per patient, but this cost was offset by savings in nursing time.The use of Health Hero did not affect hospitalizations or visits tothe emergency department for CHF, but it reduced all-cause hospi-talizations and emergency department visits by 23%. The totalnumber of bed days for all causes was reduced by about 50%.The annual savings in direct costs for all causes amounted to$1,266 per patient.

CHF managers make the case for home-monitoring technol-ogy.Anon.Disease Management Advisor. 2002 Oct;8(10):156-158, 145.

The usefulness of a home health-monitoring device was evaluatedin a 3-month pilot program involving 10 patients with congestiveheart failure (CHF). The device was programmed to measureweight, blood pressure, heart rate, oxygen saturation, and temper-ature on a daily basis at a convenient time selected by the patient.

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ent for Heart Failure

Appendix B. Reports of the Impact of Disease Management Interventions onTreatment of Congestive Heart Failure (continued)

A recorded voice was used to cue patients to take the measure-ments. The device had the capability to ask up to 10 questions.Data were transmitted by pager or modem to a central location forreview by a nurse practitioner, who contacted the physician ifchanges in drug therapy were needed.

The patient compliance rate with daily measurements was 97% onaverage. Hospitalizations and emergency department visits wereeliminated during the 3-month pilot study. Patients experienced sig-nificant improvements in how they felt and in their understanding ofthe disease process.

Most insurance plans did not pay for the device. Arranging for visit-ing nurses to install the device in patient homes and teach patientsto use the device properly is a strategy that was used becauseinsurance plans cover visiting nurse services.

Individualized care in patients with chronic congestive heartfailure.Bertel O, Conen D.Journal of Cardiovascular Pharmacology. 1987;2:S68–S72.

The impact of a comprehensive treatment program for congestiveheart failure (CHF) was evaluated in a nonrandomized, observation-al study of 25 patients with similar degrees of disease despite ther-apy. Program enrollees consisted of 25 consecutive patientsreferred to this university-based hospital in Switzerland because ofsevere CHF that was refractory to treatment.

The program focused on three issues: (1) individualized medicaltherapy for CHF, (2) antiarrhythmic treatment and close follow-upvisits, and (3) continuing education of patients and physicians toimprove treatment compliance and facilitate the early managementof complications. Medical treatment was based on diuretic andvasodilator therapy in all the patients, while positive inotropic sub-stances were selectively administered. Patient education related tothe problems and complications of CHF. Education also addressednecessary lifestyle adjustments (e.g., physical activity, reduction insalt intake), and patients were asked to keep a diary of daily bodyweight measurements, drug intake, and symptoms. All patientswere followed at short intervals of 1 to 2 weeks, independent oftheir symptoms. However, daily visits were scheduled if symptomsincreased. To minimize unnecessary changes in the treatment regi-men, patients were consistently evaluated by the same physician.

The outcomes of patients in the special-care program (interventionpatients) were compared with those of 21 consecutive patientsdescribed in a previous study. Patients in the control group werealso referred to the institution for severe CHF refractory to treat-ment, but were treated prior to development of the CHF program.After evaluation, patients in the control group were sent back totheir family physicians, with a detailed letter containing treatment

recommendations. They were then followed only by telephone callsfrom their treating physicians.

Reported outcomes for this study consisted of survival rates,results of medical treatment for CHF, and results of medical treat-ment for arrhythmias. The 1-year survival of all intervention-grouppatients was 92%, which was significantly higher than the 1-yearsurvival rate in the control group of only 43%. In addition, the 2-year survival rate for the intervention group was 83%, which report-edly compares favorably with previously reported survival rates.

All patients received intensive diuretic and vasodilator therapy asmedical treatment of CHF. Vasodilator treatment was started withprazosin in 22 patients and angiotensin-converting enzyme (ACE)inhibitors in 3 patients. However, 55% of the patients on prazosinhad to be changed over to ACE inhibitors because of fading clinicalefficacy. Digoxin was used effectively in 8 of the 25 patients to con-trol heart rates and/or arrhythmias. These 8 patients remained insinus rhythm after digoxin was withdrawn. Amiodarone was usedas the first-line drug to treat two patients with symptomatic ventric-ular tachycardia and two survivors of ventricular fibrillation. Six ofthe 11 patients treated for ventricular arrhythmias remained free ofsymptoms from malignant ventricular arrhythmias.

Effect of a pharmacist-led intervention on diuretic compli-ance in heart failure patients: a randomized controlled study.Bouvy ML, Heerdink ER, Urquhart J, et al.Journal of Cardiac Failure. 2003 Oct;9(5):404-411.

The effect of a pharmacist-led intervention on mediation compli-ance was evaluated in a randomized controlled trial involving 7 hos-pitals, 79 pharmacists, and 152 patients with congestive heart fail-ure (CHF) that was treated with loop diuretics. Patients were ran-domized to the intervention or a control group that received usualcare. The intervention involved an interview by the pharmacist inwhich the patient medication history and reasons for noncompli-ance were discussed. The pharmacist contacted the patient after-wards on a monthly basis for up to 6 months. Compliance with theprescribed loop diuretic was assessed in both groups by using acontainer with a microchip that recorded the time and date ofopening.

Medication compliance during the 6-month study was greater inthe intervention group than in the control group. The interventiongroup had 140 days without loop diuretic use out of 7,556 days,and the control group had 337 days without loop diuretic use outof 6,196 days. There were two consecutive days of loop diureticnonuse on 18 days out of 7,656 days in the intervention group and46 days out of 6,196 days in the control group. There were no sig-nificant differences between the two groups in rehospitalization,mortality, or quality of life.

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Cost/utility ratio in chronic heart failure: comparisonbetween heart failure management program delivered byday-hospital and usual care.Capomolla S, Febo O, Ceresa M, et al.Journal of the American College of Cardiology. 2002;40:1259-1266.

The effectiveness of a heart failure (HF) management programdelivered by a day hospital was compared with usual care in 234chronic HF outpatients in a 12-month randomized controlled trial.Patients were randomized to the intervention or usual care. Theintervention involved creation of a plan of care by a day hospital-based multidisciplinary team comprising a cardiologist, nurses,physiotherapists, dietitian, psychologist, and social assistant.Cardiovascular risk stratification and tailoring of therapy accordingto evidence-based criteria were performed, and health care educa-tion and counseling were provided to the intervention group.

After 12 months, significantly fewer patients in the interventiongroup had died than patients in the usual-care group. The hospitalreadmission rate was significantly lower in the intervention group(14%) than in the usual-care group (86%). In the intervention group,New York Heart Association (NYHA) functional class was improvedin 23% of patients and it had worsened in 11% of patients, a differ-ence that is significant. However, in the usual-care group, NYHAfunctional class was improved in 13% of patients and it had wors-ened in 16% of patients, a difference that is not significant.

The intervention was cost-effective, with a cost of $19,462 for eachquality-adjusted life-year saved. The cost/utility ratios for the inter-vention and usual- care groups were similar ($2,244 for the inter-vention group and $2,409 for the usual-care group). There was acost savings of $1,068 for each quality-adjusted life-year gained byusing the intervention instead of usual care.

Assessing the efficacy of a clinical pathway in the manage-ment of older patients hospitalized with congestive heartfailure.Cardozo L, Aherns S.Journal of Healthcare Quality. 1999;21:12-16.

Hospital length of stay (LOS), cost of care, mortality, readmissionstatistics, and performance rates of processes of care were evalu-ated in a 12-month randomized retrospective study of 95 elderlypatients with congestive heart failure (CHF) who were managedaccording to a clinical pathway. These data were compared withthose from a historical cohort of 200 patients who had been treat-ed for CHF in a traditional manner. Study participants consisted ofpatients who had been admitted to a tertiary-care teaching hospitalin metropolitan Detroit for management of CHF. These patientswere randomly admitted to medical wards, including two wardsparticipating in the pathway for the study’s duration. The CHF path-

way had been developed as part of a quality enhancement andclinical resource management project designed to enhance care inthe elderly and improve resource management. Health careproviders were instructed to follow the clinical pathway, and a clini-cal nurse manager monitored all processes of care. Any variancesin processes of care were reported to the attending physician forcorrective action. The control group consisted of patients who hadbeen hospitalized for CHF the year preceding the study, prior topathway implementation. Randomization was achieved in the con-trol population by retrieving every third chart from a computerizeddischarge log of patients with a primary diagnosis of CHF.

All patients were older than 65 years of age, and there were no sta-tistically significant differences between groups in terms of sex orNew York Heart Association functional classification. Analysis ofoutcome data revealed a significant reduction in LOS, from 6.36days for the prepathway group (controls) to 5.25 days for the path-way group. This reduction in LOS was accompanied by a signifi-cant reduction in variable cost of $776 per patient. The mortalityrate during hospitalization remained unchanged at 3.5%. However,the rate of readmission (at 31 days) showed a significant increase,from 9.25% in the prepathway group to 13.5% for the pathwaygroup. Significant improvements were noted in performance ofthree of the six processes of care evaluated (early discharge plan-ning, patient education, and early patient mobilization); lesserimprovements were documented for the three remaining processes(heparin prescription, recording of daily weights, use of echocardio-graphy). The authors concluded that the lower costs of care in thepathway patients compared with the prepathway patients reflectedthe shorter LOS. The significant increase in hospital readmissionsobserved in the pathway patients was considered “a matter forconcern” and is currently being investigated. Potential reasons for ahigher admission rate include sicker patients, comorbid illnesses,premature discharges, and inadequate discharge plans.

Development of a heart failure center: a medical center andcardiology practice join forces to improve care and reducecosts.Chapman DB, Torpy J.American Journal of Managed Care. 1997;3:431-437.

The effectiveness of The Heart Failure Center’s comprehensive out-patient program in reducing hospital admissions, number of hospi-tal days, and average length of stay was evaluated in 67 patientswith congestive heart failure (CHF). The Omaha-based HeartInstitute’s Heart Failure Center represented a partnership between aprivate-practice cardiology group and a tertiary-care medical cen-ter. Its program for CHF patients emphasized continuity of care andpatient education. Patients were assigned to a clinician group thatprovided education and treatment using internally generated proto-cols and standardized clinic visit forms. These protocols werebased on both the 1994 Cardiology Preeminence Report on CHF

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and a 2-day Cardiology Roundtable meeting. A medical directorphysician helped to implement the program (and protocols) bymeeting with all department personnel and educating all staff mem-bers. A registered nurse, with experience in treating CHF, was theidentified program coordinator.

Patient education was provided by a multidisciplinary team (nurse,physician, pharmacist, dietician, nurse program coordinator). Itaddressed a variety of issues (pathophysiology, appropriate diet,medication compliance, weight loss). Patient education began witha formal one-on-one curriculum prior to hospital discharge andcontinued at later outpatient visits. Other elements of the programincluded outpatient infusions of inotropic agents (to help reducehospital readmissions), electronic linkages between the clinic andthe emergency department (to reduce unnecessary clinic patientadmissions), and home health care visits by nurses. The latter wereintended to detect signs of clinical decompensation between clinicvisits. The nurses also saw the patients regularly at the clinic toreinforce the need for adherence to medications, diet, and officevisits.

The 67 patients in this study were followed for a minimum of 1 yearbefore enrollment in the program and 16 months after enrollment.The mean age of the patients was 64.7 years, and 50% hadadvanced heart failure (New York Heart Association functional classIII or class IV). Comparison of pre- and post-enrollment datarevealed that hospital admissions dropped 30%, from 38 beforeprogram enrollment to 27 after implementation. In addition, thenumber of hospital days decreased by 42% from 202 to 118, andthe average length of stay decreased from 5.3 days to 4.4 days (adecrease of 17%). The investigators also noted that a year of fre-quent visits to the center costs less than one hospital admission.Each year, the average patient was seen 15 to 20 times at the clin-ic for an average cost of $2,000; the average cost of a hospitaliza-tion was about $9,000. The authors concluded that an effectiveheart failure outpatient program can reduce the economic burdenof CHF and improve the quality of patient care.

Congestive heart failure clinical outcomes study in a privatecommunity medical group.Civitarese LA, DeGregorio N.Journal of the American Board of Family Practice. 1999;12:467-472.

A 21-month, prospective study was conducted to assess whethercongestive heart failure (CHF) clinical practice guidelines, imple-mented with a continuous quality improvement program, wouldoptimize use of angiotensin-converting enzyme (ACE) inhibitorsand, thus, decrease hospital admissions for systolic CHF. Therecipients of the program included 10 family practitioners and 10internists at an independent medical group. The patients consistedof all 275 patients admitted to the group’s primary community-

based hospital during the study with a confirmed discharge diagno-sis of CHF.

The group physicians developed CHF guidelines by reviewing theliterature and guidelines from other hospital systems and healthplans. The new guidelines were presented to the group’s physi-cians at a formal continuing medical education session at thestudy’s outset. Physicians were provided an opportunity to modifythe guidelines, and each physician endorsed the final version. Theguidelines, available for reference at office and hospital sites, werethen reinforced at monthly quality improvement meetings. Otherpoints emphasized at each meeting included (1) assessment of leftventricular function to optimize treatment, (2) appropriate use ofACE inhibitors in patients with systolic CHF, and (3) instruction ofpatients to obtain daily weights and contact the physician to reporta weight gain. Standardized inpatient orders were also developedto parallel the guidelines, and physicians reviewed their own per-formance data at quarterly meetings.

Rates of classifying systolic and diastolic dysfunction remainedunchanged during the study, and documentation of patient dis-charge instructions was suboptimal. However, use of ACE inhibitortherapy substantially improved for patients with systolic dysfunc-tion. Pharmacy utilization data from Aetna U.S. Healthcare showeda 39% increase in ACE inhibitor use by patients cared for by partic-ipating physicians. By the study’s end, 100% of these patients hadbeen prescribed ACE inhibitors or had documentation that theymet exclusion criteria for such therapy. There was also a 49%reduction in quarterly admissions for CHF due to systolic dysfunc-tion during the study; patient admissions for diastolic dysfunctionremained stable. Associated economic effects were not addressed.Thus, use of disease management guidelines, ongoing physicianeducation, and review of performance data significantly reducequarterly admissions for systolic dysfunction-based CHF and opti-mized the use of ACE inhibitors.

Cost effective management programme for heart failurereduces hospitalisation.Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR.Heart. 1998;80:442-446.

A 1-year prospective, randomized trial evaluated the effects of aheart failure (HF) management program on outcomes in 190patients with HF. Patients age 65-84 years who were hospitalizedat a Swedish university hospital for HF were eligible to participate.Patients were randomly assigned to the intervention or controlgroup. Control patients received standard care at the university car-diology department’s outpatient clinic following discharge.Intervention-group patients underwent an educational programmanaged by registered nurses followed by treatment at a HF clinic.

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The intervention began with two 30-minute hospital visits by anurse, followed by a 1-hour informational visit for patients and fami-lies 2 weeks after discharge. Information about the pathophysiologyand treatment of HF was presented, with emphasis on compliancewith medications. Patients next received guidelines for the self-management of diuretic therapy based on symptoms and signs ofworsening HF and were asked to record such data in a diary.Finally, patients were followed at an easy-access, nurse-directedoutpatient clinic, in which patients could call or be seen on shortnotice. Patients were also offered outpatient visits with doctors at 1and 4 months after discharge and at the study nurse’s discretion.

Clinical assessment followed a protocol, but no guidelines for evalu-ation or treatment specific to the study were used. Data on hospital-ization and outpatient visits were obtained from hospital records andquestionnaires. All patients were followed for 1 year, and final resultswere obtained from 135 surviving patients. The 1-year survival ratedid not differ significantly between groups. However, the mean num-ber of days until readmission was significantly longer in the interven-tion group (141) than in the control group (106), and the number ofdays spent in the hospital by the intervention group tended to befewer than those spent by the control group (4.2 vs. 8.2, respective-ly). There was also a trend toward fewer patients being hospitalizedin the intervention group than in the control group, with a similarnumber of outpatient visits in the two groups. The mean cost of theintervention per patient was $208. Costs for doctors’ outpatient vis-its tended to be $55 less per patient in the intervention group com-pared with the control group. In addition, the mean cost per patientfor hospital readmission tended to be lower in the intervention group($1,628 vs. $3,081), which contributed to a mean annual reductionin overall costs of $1,300 per patient.

Impact of a guideline-based disease management team onoutcomes of hospitalized patients with congestive heart fail-ure.Costantini O, Huck K, Carlson MD, et al.Archives of Internal Medicine. 2001;161:177-182.

The impact of daily use of new guideline-based recommendationsfor treating congestive heart failure (CHF) by a care managementteam (a nurse care manager, faculty cardiologist, and physicianrepresentative from the part-time faculty) at a large university-basedmedical center was assessed. All participating patients were hospi-tal inpatients. Care-managed patients were compared with non-care-managed patients who were not followed by the team andwith baseline patients (i.e., patients hospitalized before implementa-tion of the new care management approach). National guidelineswere available during the baseline period, but care-managedpatients were monitored daily by the care management team andrecommendations consistent with the guidelines were made.

Clinical measures of quality of care (the use of angiotensin-convert-

ing enzyme inhibitors, documentation of assessment of left ventric-ular function using echocardiography, and the consistent dailymeasurement of body weight) were significantly improved and hos-pital length of stay and costs were significantly reduced in care-managed patients compared with non-care-managed patients andbaseline. The median hospital length of stay was 3 days with caremanagement and 5 days without care management. Care manage-ment was associated with a $2,204 reduction in hospital costs.

The relationship between hospital readmissions of Medicarebeneficiaries with chronic illnesses and home care nursinginterventions.Dennis LI, Blue CL, Stahl SM, Benge ME, Shaw CJ.Home Healthcare Nurse. 1996;14:303-309.

A 12-month retrospective audit of the charts of 62 Medicarepatients with a diagnosis of congestive heart failure (CHF) or chron-ic obstructive pulmonary disease (COPD) was conducted to evalu-ate the relationship between various home health care nursinginterventions and hospital readmissions. Criteria for patient selec-tion included those who were (1) admitted with a primary diagnosisof CHF or COPD of given severity, (2) under the care of a visitinghome health care nurse within a 1-year interval, (3) Medicare bene-ficiaries, and (4) receiving services provided by an agency that hadMedicare reimbursement.

Interventions for patients with CHF consisted of assessment of vitalsigns; lip, skin, and nail bed color; presence of edema; presence ofchest pain; specific signs/symptoms of CHF; activity tolerance; andweight measurement. Patient educational interventions included thesigns/symptoms of CHF, prevention of an exacerbation, compo-nents of a low-sodium diet, medication actions/side effects, and useof medications. Interventions (assessment and teaching) specific toCOPD were also carried out. A home health care nurse document-ed each intervention, and the total number of hospital readmissionswas determined in a “convenience” sample of 42 patients.Interventions were selected from agency nursing care plans andMedicare regulations appropriate for patients with CHF or COPD.

Fifty-seven percent of the patients (n=24) had CHF versus 43%(n=18) with COPD. Sixty-four percent of the patients were neverreadmitted to a hospital during the study. Of those who were read-mitted once (n=15), 20% were readmitted twice and another 29%,three times. No patients were readmitted more than three timesduring the interval studied. As the number of home health carenursing visits increased, hospital readmissions decreased. Hospitalreadmissions also decreased as the total number of assessmentinterventions implemented increased. Interventions most stronglyrelated to readmission rates were assessment of lungs, cough, andrespiratory rate. The teaching interventions were more weakly relat-ed to the hospitalization rate and were only implemented 29% ofthe time.

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Outcomes of an integrated telehealth network demonstra-tion project.Dimmick SL, Burgiss SG, Robbins S, Black D, Jarnagin B, AndersM.Telemedicine Journal and E-Health. 2003 Spring;9(1):13-23.

A disease management program for congestive heart failure (CHF)was implemented for residents of a Tennessee county using anintegrated telehealth/telemedicine network with home videoconfer-encing, telephone conversations, and remote monitoring of bloodpressure, blood oxygen saturation, and pulse. The number of pro-gram participants varied over time because of deaths anddropouts.

Weight control (a measure of medication and dietary compliance)was achieved by more than 50% of patients after program imple-mentation. Sleep problems (a measure of mood) improved,although feelings of fatigue, depression, and loss of appetiteincreased.

Only 14% of patients were hospitalized in the first 6 months afterprogram implementation. The hospitalization rate decreased from1.7 times per patient per year to 0.6 times per patient per year as aresult of program implementation. The hospital length of staydecreased from a national benchmark of 6.2 days to 4 days.

The cost per patient per year for the program included $2,353 fornursing labor and $833 for equipment. A reduction in annual costsfor hospital care for CHF from $8 billion to $4.2 billion was project-ed on a national basis.

Heart failure disease management: impact on hospital care,length of stay, and reimbursement.Discher CL, Klein D, Pierce L, Levine AB, Levine TB.Congestive Heart Failure. 2003 Mar-Apr;9(2):77-83.

A congestive heart failure (CHF) disease management program wasdeveloped for use in an inpatient setting. The program involved atreatment algorithm/clinical pathway for the time from hospitaladmission to discharge and inservice education programs forphysicians, nurses, and other health care professionals. Patientswere assigned to a managed group unless the physician objectedor cognitive impairment or inadequate living conditions interferedwith patient participation. Of 593 patients enrolled in the study, 396patients were assigned to the managed group and 197 patientswere assigned to an unmanaged group. The latter group did notparticipate in the program.

Documentation of left ventricular ejection fraction improved signifi-cantly in the first quarter and throughout the first year after programimplementation in the managed group but not in the unmanagedgroup. Documentation of angiotensin converting-enzyme (ACE)

inhibitor use (or intolerance) increased significantly in both groups inthe first quarter after program implementation, but the improvementwas greater in the managed group than in the unmanaged groupand further improvement in subsequent quarters was observedonly in the managed group.

The average hospital length of stay in the managed groupdecreased significantly from 6.1 days before program implementa-tion to 3.9 days after implementation. There was no significantchange in average length of stay over the course of the study in theunmanaged group. The average cost per patient after programimplementation was lower for managed patients ($4,404) thanunmanaged patients ($6,828), despite intensified involvement ofnursing staff. Nurse satisfaction was high.

Randomized, controlled trial of integrated heart failure man-agement: The Auckland Heart Failure Management Study. Doughty RN, Wright SP, Pearl A, et al.European Heart Journal. 2002;23:139-146.

The impact of an integrated heart failure (HF) management programon mortality, hospital readmissions, and quality of life was evaluatedin 197 patients hospitalized with HF. General practitioners were ran-domized to the intervention group or a control group so that all ofthe patients treated by that practitioner were assigned to the samegroup as a cluster. The intervention involved clinical review at ahospital-based clinic shortly after hospital discharge, individual andgroup education sessions, a personal diary to record medicationadministration and body weight measurements, information book-lets, and regular clinical follow-up alternating between the generalpractitioner and clinic. The control group received usual care.

There was no significant difference between the two groups in thenumber of patients who died or were readmitted to the hospitalduring 12 months of follow up (68 patients in the intervention groupand 61 patients in the control group). The number of first readmis-sions for HF and the number of hospital bed days for first readmis-sions were similar for the two groups. However, fewer subsequentreadmissions for HF and fewer bed days during subsequent read-missions were associated with the intervention compared with thecontrol group.

Quality of life was markedly impaired at baseline in both groups.There was a significantly greater improvement in the physical-func-tioning component of quality of life in the intervention group than inthe control group.

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Effects of an exercise adherence intervention on outcomesin patients with heart failure.Duncan K, Pozehl B.Rehabilitation Nursing. 2003 Jul-Aug;28(4):117-122.

The effectiveness of an intervention designed to facilitate patientadherence to an exercise regimen was tested in 16 patients withheart failure (HF). Patients were randomized to the intervention oran exercise-only (i.e., control) group. Both groups participated in a12-week supervised exercise program (phase 1), which was fol-lowed by 12 weeks of unsupervised home exercise (phase 2).Goals were established for exercise frequency and duration forboth groups. The adherence facilitation intervention involved theprovision of graphic feedback about exercise frequency and dura-tion, positive feedback when goals were achieved, and help withproblem solving when goals were not achieved. Physiologic out-comes that were assessed include maximum oxygen consumption(a measure of exercise capacity), baseline dyspnea index (a meas-ure of breathlessness), and level of fatigue. Functional status wasevaluated using a 6-minute walk test. A validated questionnairewas used to assess quality of life.

In phase 1, there was no significant difference between the twogroups in adherence (i.e., the number of exercise sessions com-pleted). Improvement in all physiologic outcomes and functionalstatus but not in quality of life was observed in phase 1 in the inter-vention group. In the control group, improvement was observedonly in functional status and level of fatigue in phase 1. In phase 2,quality of life and symptoms of dyspnea and fatigue improved andmaximum oxygen consumption decreased in the interventiongroup, although all outcomes were better than at baseline at theend of phase 2. In the control group, maximum oxygen consump-tion, functional capacity, and qualify of life were worse and dyspneaand fatigue were improved at the end of phase 2 compared withbaseline. Adherence during phase 2 was significantly higher in theintervention group than in the control group. Thus, the patientadherence intervention has the potential to improve physiologic,functional, and quality of life outcomes in patients with HF.

Impact of a comprehensive heart failure management pro-gram on hospital readmission and functional status ofpatients with advanced heart failure.Fonarow GC, Stevenson LW, Walden JA, et al.Journal of the American College of Cardiology. 1997;30:725-732.

The impact of a comprehensive heart failure (HF) management pro-gram on hospital admissions and functional status was assessed in214 patients with HF in a nonrandomized observational studyspanning 3 years. Subjects included patients referred to theAhmanson-UCLA Cardiomyopathy Center as potential candidatesfor heart transplantation who met study inclusion criteria (i.e., can-didates for transplantation with no contraindications; discharged,

but not “too well”). All patients were initially hospitalized for formaltransplant evaluation, which included invasive testing, medicationevaluation, and a review of all medical records. Intensive medicaltherapy was then initiated (or systematically adjusted) to control HFsymptoms, optimize hemodynamics, and address concomitantconditions (e.g., angina, arrhythmias). Comprehensive patient edu-cation was also provided to patients and their families in accor-dance with Heart Failure Practice Guidelines. This included a reviewof diet, lifestyle factors, and exercise, as well as symptoms andsigns of worsening HF and complications. This information wasconveyed by a HF clinical nurse specialist and was reinforced withpatient brochures. After discharge, patients were followed by HFcardiologists in conjunction with referring physicians. This follow-upincluded weekly visits to the HF center until the patient was clinical-ly stable, followed by telephone calls and clinic visits at variousintervals. At each visit, medications were adjusted and patient edu-cation was reinforced.

Reassessment 6 months after the intervention revealed improvedNew York Heart Association functional classification and exercisetolerance (i.e., improved functional status). Hospitalization rateswere significantly lower, with only 63 admissions for HF during the6 months following the program compared with 429 admissionsduring the 6 months prior to the program (i.e., an 85% reduction).Ninety-two percent of the patients required hospitalization prior tothe program, compared with 26% after the program. Qualitativelysimilar results were obtained when the analysis was confined to the179 patients who completed 6 months of follow-up without deathor transplantation. For the entire group, the cost of hospital read-mission after the program was estimated at $578,000 comparedwith $3,937,000 prior to the program. After considering the cost ofthe initial hospitalization for management and cost of the nursespecialist’s services during follow-up (estimated at $200 to $400per patient), the net savings was estimated at about $9,800 perpatient.

Reduction in heart failure events by the addition of a clinicalpharmacist to the heart failure management team: results ofthe Pharmacist in Heart Failure AssessmentRecommendation and Monitoring (PHARM) Study.Gattis WA, Hasselblad V, Whellan DJ, O’Connor CM.Archives of Internal Medicine. 1999;159:1939-1945.

The effect of involving a clinical pharmacist in the management ofoutpatients with heart failure (HF) was evaluated in a controlledstudy. Of 1,568 patients with HF evaluated at a Duke Universitycardiology faculty clinic, 181 patients satisfied the enrollment crite-ria (e.g., presence of signs and symptoms of HF, an ejection frac-tion less than 45%) and agreed to participate. These patients wererandomized to an intervention (n = 90) or control (n = 91) group. Allpatients answered questions about current drug treatment toassess the regimen, compliance, and any adverse effects.

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Patients in the intervention group underwent evaluation by a clinicalpharmacist, including medication review, therapeutic recommenda-tions to the attending physician, patient education, and follow-uptelemonitoring. Therapeutic recommendations included increasinguse of angiotensin-converting enzyme (ACE) inhibitors, raising ACEinhibitor dosages to target levels, and using alternative vasodilators inACE-intolerant patients, in accordance with published results fromclinical research. Patient education consisted of detailed informationabout the purpose of each drug, importance of adherence to theprescribed regimen, directions for use, and potential adverse effects.Patients were encouraged to ask questions and were given the phar-macist’s telephone number for future contact. The pharmacist alsoprovided telephone follow-up 2, 12, and 24 weeks after the initialclinic visit to identify problems, answer questions, and evaluate HFclinical events (i.e., emergency department visits, hospitalizations forHF). Pharmacists communicated information to physicians andreferred patients for evaluation when appropriate. Control subjectsreceived standard care and were assessed and educated by physi-cians, physician assistants, and/or nurse practitioners. Pharmacistscontacted patients in the control group at 12 and 24 weeks to identi-fy HF clinical events but provided no recommendations or education.

The median follow-up interval was 6 months. All-cause mortalityand HF events (emergency department visits, hospitalizations) weresignificantly lower in the intervention group compared with the con-trol group (4 events vs. 16 events). At the 6-month follow-up,patients in the intervention group were also significantly closer tothe target ACE inhibitor dosage, with higher rates of use of othervasodilators in ACE inhibitor–intolerant patients (75% vs. 26%). Noeconomic effects were assessed. The authors concluded thatincluding a clinical pharmacist in the management of HF patientsimproved outcomes, possibly because of increased use of ACEinhibitors and closer follow-up care.

Disease management hits home.Gilbert JA.Health Data Management. 1998;6:54-56, 58-60.

Crozer-Keystone Health System, a Springfield, Pennsylvania–basedintegrated delivery system, developed a disease management pro-gram for patients with congestive heart failure (CHF). This program,called Heart Success, was a multidisciplinary program designed tomonitor patients after hospital visits and provide them with educa-tion and support to keep them as healthy and independent as pos-sible. Central to the Heart Success program was a personal com-puter-based, automated patient follow-up system, which madeautomatic telephone calls to certain patients to determine theircondition. The system was designed to ask a series of customizedquestions when the patient answers the telephone. Patients usedthe keypad of their touch-tone telephone to respond to the ques-tions. The patient also had the option of speaking with a nurse afteranswering the last question.

In 1996, Crozer-Keystone compared hospital readmission rates foran unspecified number of patients enrolled in the Heart Successprogram with readmission rates among patients receiving traditionalhome care follow-up. Results of this 9-week pilot study showedthat 76% of the patients receiving home care (home visits by nurs-es) were readmitted to the hospital within 3 to 4 weeks after dis-charge. In contrast, only 18% of the patients enrolled in the HeartSuccess program were readmitted after 9 weeks of monitoring.The program director concluded that telemanagement is effectivebecause it keeps patients in contact with clinicians long after dis-charge and it also provides a cost-effective way of identifying the20% of patients who require additional attention.

Does encouraging good compliance improve patients’ clini-cal condition in heart failure?Goodyer LI, Miskelly F, Milligan P.British Journal of Clinical Practice. 1995;49:173-176.

A prospective, randomized controlled trial was conducted to evalu-ate whether improving medication compliance in elderly patientswith chronic stable heart failure (HF) would influence objective andsubjective measures of HF severity. Patients (age >70 years) at aLondon clinic who (1) had a diagnosis of chronic stable HF, (2)supervised their own medication use, (3) required no medicationchanges, and (4) met no physical or mental exclusion criteria wereinvited to participate. Fifty elderly patients were randomly assignedto a 3-month, intensive medication counseling program carried outby a pharmacist. Instruction about the correct use of medicationsproceeded according to a standard written protocol using verbalcommunication, medication calendars, and informationalbrochures. Another 50 patients constituted a no-counseling (i.e.,control) group.

Tablet counts and patient questionnaires were completed at thebeginning and end of the study to assess knowledge and compli-ance. Other measures recorded at the beginning and end of thestudy included results on a submaximal 6-minute exercise test,visual analogue scores of breathlessness, Nottingham Health Profilescores, and clinical signs of HF. Use of clinical practice guidelineswas not specified.

Baseline measures were similar in the two groups. Complianceimproved significantly (by 32%) in the counseled group butremained unchanged for the control group. Medication knowledgeimproved only for the counseled patients. Results for the 6-minuteexercise test improved by 20 meters for the counseled group butworsened by 22 meters for the control patients. Distance to breath-lessness also improved for the counseled patients and worsenedfor patients in the control group. In contrast, body weights, jugularvenous pressures, and Nottingham Health Profile scores did notchange significantly for either group. Peripheral and pulmonaryedema scores improved for the counseled group only, along with a

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small improvement in the visual analogue scores. Associated eco-nomic effects were not assessed.

The authors concluded that improved compliance attributed tointensive medication counseling had a small, but measurable, ben-eficial effect on objective measures of HF. However, the smallnature of this benefit relative to the level of improved complianceled them to doubt whether improved compliance produces a clini-cally relevant benefit in older patients with HF.

A disease management program for heart failure: collabora-tion between a home care agency and a care managementorganization. Gorski LA, Johnson K.Lippincott’s Case Management. 2003 Nov-Dec;8(6):265-273.

The impact of a disease management program developed througha collaborative arrangement between a home health care agencyand a care management organization on outcomes was assessedin 51 patients with heart failure (HF). A nurse employed by the caremanagement organization coordinated the program, which empha-sized patient self-management skills (e.g., daily weight measure-ments, medication management, diet, physical activity, depressionand stress management, regular medical follow-up, and notificationof the physician of changes in condition). The program involvedpatient education (e.g., regular telephone calls, mailings) and coor-dination and promotion of interdisciplinary patient care using com-munity resources, newsletters, and referrals to a home health careprogram.

There was a 35% decrease in the hospitalization rate from 22.6 per1,000 enrollees to 14.6 per 1,000 enrollees within 9 months afterimplementation of the program. Assuming a hospitalization cost of$5,000, a cost savings of $165,000 from the reduced hospitaliza-tion of patients participating in the program was projected.

Daily weight measurement was assessed as an outcome repre-senting self-care behavior. The percentage of patients performingdaily weight measurements increased significantly from less than10% before program implementation to more than 60% after imple-mentation. Patient satisfaction was good, very good, or excellent.

Effect of a heart failure program on hospitalization frequencyand exercise tolerance.Hanumanthu S, Butler J, Chomsky D, Davis S, Wilson JR.Circulation. 1997;96:2842-2848.

An observational, pre- and post-intervention comparison studyevaluated whether hospitalization rates and functional outcomesimprove when patients with heart failure (HF) are managed byphysicians with special HF expertise, working within a dedicatedHF program. All 187 patients with HF who were referred to theVanderbilt Heart Failure and Heart Transplantation Programbetween July 1994 and June 1995 were identified. Most (n = 138)were referred as outpatients, and some (n = 49) were transferredfrom other hospitals. The mean patient age was 52 years and themean ejection fraction was 26%.

The program consisted of long-term follow-up by three physicianswho work exclusively with HF and heart transplantation patients.Two nurse coordinators assisted with patient management duringhospitalizations and outpatient care; home health care agencieswere involved in the care of 10% of patients. All patients underwentechocardiographic evaluation as well as cardiopulmonary exercisetesting, when possible. These tests were performed by programstaff at a nearby outpatient laboratory. Exercise testing was repeat-ed 3 to 6 months after enrollment to monitor status. A subgroup ofpatients also completed the 21-question Minnesota Living withHeart Failure Questionnaire, which assessed emotional and physi-cal impairment due to HF. Patient information and outcomes weremaintained in a computerized database, and periodic meetingswere held at the Vanderbilt Home Health Agency and local hospicecare programs to integrate care.

The program was evaluated by comparing annual hospitalizationrates, peak exercise capacity, and medication use before and afterreferral among patients followed for more than 30 days. Of the 187patients referred to the program, 134 (72%) were followed for atleast 30 days. During the year prior to referral, 94% of the patientshad been hospitalized (210 cardiovascular hospitalizations) versus44% during the year after referral (104 hospitalizations), which is a53% reduction. Hospitalizations for HF decreased from 164 to 60for all patients (regardless of follow-up duration) and decreasedfrom 97 to 30 (a 69% reduction) for patients followed for at least 1year after referral. Survival was 83% after the 1-year follow up.

Composite scores on the Minnesota Living with Heart FailureQuestionnaire improved. The authors concluded that patients withHF have fewer HF-related hospitalizations and significantly betterfunction when managed by HF specialists working in a dedicatedHF program versus physicians with limited expertise in managingHF.

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Quality of life of individuals with heart failure: a randomizedtrial of the effectiveness of two models of hospital-to-hometransition.Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, GrahamID.Medical Care. 2002;40:271-282.

The impact of a transitional-care intervention designed to facilitatethe transition from hospital to home for patients with congestiveheart failure (CHF) was assessed in a 12-week, randomized con-trolled trial. The impact of transitional care on health-related qualityof life and rates of hospital readmission and emergency departmentuse was compared with that of usual care in patients hospitalizedfor CHF in one of two large urban teaching hospitals in Canada.The transitional-care intervention involved telephone outreach within24 hours after hospital discharge and consultations between hospi-tal nurses and home care nurses. Patient education and supportivecare for self-management were provided. Patients in both groupswere visited by community nurses twice in the first 2 weeks afterdischarge.

After 12 weeks, health-related quality of life was significantly betterin the transitional-care group than in the usual-care group. Thehospital readmission rate was 23% in the transitional-care groupand 31% in the usual-care group, a difference that is not signifi-cant. The number of emergency department visits was significantlylower in the transitional-care group than in the usual-care group(29% vs. 46%).

Effect of a home monitoring system on hospitalization andresource use for patients with heart failure.Heidenreich PA, Ruggerio CM, Massie BM.American Heart Journal. 1999;138:633-640.

The effect of a low-intensity monitoring program on outcomes,including hospitalizations and cost of care, were assessed in 68patients with heart failure (HF) in this nonrandomized, matched-control study. Eligible patients were identified from a claims data-base and included those with symptomatic HF who were cared forby one of 31 community physicians within a multidisciplinary med-ical group.

The intervention consisted of patient education, daily self-monitor-ing, and physician notification of abnormal weight gain, vital signs,and symptoms. Each patient received weekly educational mailingsdescribing 52 topics related to HF. These materials were based onAgency for Health Care Policy and Research (now the Agency forHealthcare Research and Quality) guidelines for patients with HFand were reinforced during weekly telephone calls by a nurse.Patients also received a digital scale and an automatic blood pres-sure cuff, and were instructed in the use of these items. Thepatients were then provided a toll-free number to use daily in trans-

mitting blood pressure, pulse, weight, and symptom data to acomputer. If data fell outside an established normal range, a nursefollowed up with the patient and faxed the information to the physi-cian. Patients could also contact the physician directly with anyhealth concern.

The patients were followed for a mean of 7.4 months. During thisinterval, there were 294 physician notifications of abnormal signs orsymptoms in 53 patients; approximately 1 in 8 notifications resultedin a change in the patient’s medical regimen. The average compli-ance with call-ins by patients was 85%. Quality-of-life measures didnot change significantly over the course of the study. To furtherassess the impact of the intervention, average claims per yearbefore the intervention were compared with claims per year duringthe intervention. In addition, claims by intervention-group patientswere compared with those of a matched control group (n = 86patients) to control for technological improvements or disease pro-gression. Compared with the previous year, medical claims per yeardecreased in the intervention group ($8,500 to $7,400) butincreased in the control group ($9,200 to $18,800). Similarly, hospi-tal days per year significantly decreased from 8.6 to 4.8 in interven-tion patients, while increasing from 8.9 to 17 in control patients.The number of admissions per year did not differ significantlybetween the two groups. The program’s effectiveness was unrelat-ed to age, sex, or type of left ventricular dysfunction. The averagecost of the program was estimated at $200 per patient per month.Considering this cost, the cost of care per year for interventionpatients was $9,800 vs. $18,800 for control patients.

Prospective evaluation of an outpatient heart failure man-agement program.Hershberger RE, Ni H, Nauman DJ, et al.Journal of Cardiac Failure. 2001;7:64-74.

The effects of a heart failure outpatient management program onclinical and cost outcomes of care were assessed in 108 patientswith chronic, symptomatic CHF. The 6-month period before referralto the program was compared with the 6-month period after refer-ral. The program involved the use of current practice guidelines fortreating CHF, frequent telephone contact between nurses andpatients, pre-emptive hospitalization (hospitalization for impendingdecompensation based on clinical assessment), patient educationalneeds assessment, and patient counseling, which were providedby a team of cardiologists, specially trained and experienced nurs-es, and a social worker.

Patients’ self-care knowledge (e.g., the warning signs of heart fail-ure progression, the importance of daily body weight measurementand dietary salt intake restriction) and the percentage of patientsweighing themselves daily increased significantly after participationin the program, although patient adherence to the prescribed med-

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ications and diet did not change (adherence at baseline was good).The severity of illness (New York Heart Association functional class)and need for emergency department visits and hospitalization forcardiovascular causes decreased significantly, and quality of lifeimproved significantly. The hospitalization rate decreased from 56%before referral to the program to 27% after participation in the pro-gram. The corresponding before and after figures for emergencydepartment use were 54% and 15%, respectively. The averageestimated cost savings associated with reduced hospitalization was$4,307 per patient.

Disease management: a “smart” way to interact withpatients.Hinkle AJ.Health Management Technology. 2000;Apr. 21(4):38.

Blue Cross and Blue Shield of New Hampshire used an Internet-based disease management program for patients with congestiveheart failure (CHF) identified electronically through claims data. TheWeb-based program was designed to assess patients’ willingnessto change, educate patients about CHF, and promote positivebehavioral change.

Enrollment in the program increased 125% over a 4-month period.Frustration with CHF decreased in more than 90% of patients, andknowledge of the disease increased in more than 82% of patients.Quality of life improved in at least half of patients.

[See the summary of Anon. Web-based educational effort for CHFpatients boosts outcomes while cutting costs. DiseaseManagement Advisor. 2001 Jun;7(6):92-96.]

A randomized trial of telenursing to reduce hospitalizationfor heart failure: patient-centered outcomes and nursingindicators. Jerant AF, Azari R, Martinez C, Nesbitt TS.Home Health Care Services Quarterly. 2003;22(1):1-20.

The impact on hospital readmission charges and emergencydepartment visits of two types of telenursing—(1) home telecarewith real-time video interactions between patients and health careproviders and (2) telephone calls—was compared with usual careafter hospitalization over a 180-day period in 37 patients with con-gestive heart failure (CHF). In-person visits were made by nurses topatient homes shortly after hospital discharge and about 60 dayslater for all treatment groups. Nurses made recommendations toprimary care providers for changes in therapy as appropriate.Patient self-care teaching by nurses addressed the diseaseprocess, daily weight monitoring, sodium restriction, smoking ces-sation, moderation in alcohol intake, weight loss (for obesepatients), aerobic exercise, and medication use and adherence.

CHF-related readmission charges were more than 80% lower in thetelenursing groups (i.e., home telecare group and telephone group)compared with the usual-care group. The number of emergencydepartment visits was significantly lower with telenursing than withusual care.

A randomized trial of the efficacy of multidisciplinary care inheart failure outpatients at high risk of hospital readmission.Kasper EK, Gerstenblith G, Hefter G, et al.Journal of the American College of Cardiology. 2002;39:471-480.

A randomized controlled trial was conducted to compare theeffects of an outpatient management program and usual care onhospital readmissions and mortality over a 6-month period in 200patients hospitalized with congestive heart failure (CHF) who wereat increased risk for readmission. Patients were judged at increasedrisk for readmission because of age greater than 70 years, left ven-tricular ejection fraction less than 35%, at least one additional CHF-related hospital admission in the previous year, ischemic cardiomy-opathy, peripheral edema at the time of hospital discharge, aweight loss of less than 3 kg while in the hospital, peripheral vascu-lar disease, or a low cardiac index or high systolic or diastolic bloodpressure or pulmonary capillary wedge pressure.

The intervention was provided by a multidisciplinary team compris-ing a cardiologist, CHF nurse, telephone nurse coordinator, and thepatient’s primary physician. The intervention involved periodic fol-low-up telephone calls by the telephone nurse coordinator; devel-opment of an individualized treatment plan; patient visits with theCHF nurse, who followed a treatment algorithm for adjusting med-ications; and provision of a scale, low-sodium meals, telephone,and transportation if needed by the patient. Patients receiving usualcare served as controls.

There were significantly fewer hospital readmissions and deaths inthe intervention group (43 readmissions and 7 deaths) than in theusual-care group (59 readmissions and 13 deaths) during the 6-month study. At the end of the study, patients were less sympto-matic and quality of life had improved to a greater extent in theintervention group compared with the control group.

There was no significant difference between the intervention groupand the control group in inpatient or outpatient resource use. Thecost per patient was similar with the intervention and usual care.

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Implementing a congestive heart failure disease manage-ment program to decrease length of stay and cost.Knox D, Mischke L.Journal of Cardiovascular Nursing. 1999;14:55-74.

Beginning in 1995, Evanston Northwestern Healthcare (ENH) creat-ed a multidisciplinary disease management program for congestiveheart failure (CHF) designed to decrease length of stay (LOS),reduce costs, prevent readmissions, and improve compliance withtreatment. ENH is an integrated delivery system consisting of twoteaching hospitals affiliated with Northwestern University. It hasabout 800 admissions for CHF per year.

The program consisted of an integrated program of inpatient con-sultation and education, patient visits to an outpatient clinic, car-diac home care, and monitoring of compliance through an auto-mated telemanagement program. The inpatient component con-sisted of a 5-day LOS pathway created by members of a multidis-ciplinary treatment team. This clinical pathway is based on theAgency for Health Care Policy and Research (now the Agency forHealthcare Research and Quality) heart failure guidelines and finan-cial information from the institution. Informational inservice educa-tional conferences were presented to hospital personnel caring forCHF patients to ensure successful pathway implementation. Thephysician leader of the treatment team also introduced the pathwayto attending physicians, and quarterly reports summarized clinicaland financial outcomes following implementation.

The core of the educational program embodied in the pathway wasindividualized patient education. The goal of such education was toexplore reasons for treatment nonadherence, develop strategies foreffective disease management, and encourage health promotion(i.e., allow patients to become “comanagers” of their disease).Material was presented to the patients in written and audio form.The outpatient clinic was designed to optimize medications andstratify patients by risk to allow more frequent visits for noncompli-ant and high-risk (end-stage CHF) patients. To reduce emergencyvisits, cardiac home care was also available. Lastly, compliancemonitoring, via an automated telemanagement program (CHF Tel-Assurance program), was used to reinforce education, identify earlywarning signs, and reduce the likelihood of hospitalization. Patientscalled in their daily weights and answered CHF-related questions.They also received information about exercise and diet, their med-ical regimen, and the next clinic appointment. Advanced practicalnurses monitored this system and communicated with patients andphysicians as appropriate.

Although this report does not define a specific population, it doesprovide some general outcome data for patients participating in theENH CHF program. After 18 months, telemanagement participants’compliance rate averaged 89.5%. Patient satisfaction surveys indi-cated a high level of satisfaction with the CHF Tel-Assurance pro-gram. CHF hospitalization rates with the program were 0.6 per

patient per year at ENH, compared with the national benchmark of1.7 per patient per year. The 30-day readmission rate for patientsparticipating in the program was 2.3% (compared with 23% nation-ally) and the LOS was 4 days (compared with a national average of6.2 days).

Intensive home-care surveillance prevents hospitalizationand improves morbidity rates among elderly patients withsevere congestive heart failure.Kornowski R, Zeeli D, Averbuch M, et al.American Heart Journal. 1995;129:762-766.

A nonrandomized, pre- and post-intervention comparison studyevaluated the impact of intensive home care surveillance on mor-bidity of elderly patients with severe congestive heart failure (ejec-tion fraction less than 40%, New York Heart Association functionalclass III or IV). Forty-two patients (mean age 78 years and ejectionfraction 27%) who had completed 1 year of home surveillance wereincluded in the study. All recruited patients had also been hospital-ized at least once for cardiovascular complications during the yearpreceding program enrollment. The outcomes of program partici-pants at the 12-month follow-up were compared with medical datafor these same patients collected during the year prior to the inter-vention.

The intervention consisted of weekly home visits by an internistaffiliated with the Tel Aviv Medical Center. The visits included a his-tory and physical examination, review of medications, laboratorystudies and intravenous medications (as needed), and discussionof treatment plans for the coming week (i.e., patient education andplanning). In addition, various therapies (e.g., physical therapy, oxy-gen, extra home visits) were available, and paramedical staff pro-vided extra patient support.

Evaluation at the end of the first year of home care surveillancerevealed a significant decrease in the mean total hospitalizationrate. The hospital length of stay also significantly decreased, andsimilar reductions were seen in cardiovascular admissions. The abil-ity of patients to perform daily activities (i.e., functional status) alsosignificantly improved, and drug therapy was modified at least oncein all 42 patients. The authors concluded that an intensive homecare program was associated with a marked decrease in the needfor hospitalization and improved functional status of elderly patientswith severe congestive heart failure. The authors suggested thatsuch a service might offer a cost-effective advantage and have amajor impact on health expenditures, although costs were notassessed in the study.

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Nonpharmacologic therapy improves functional and emo-tional status in congestive heart failure.Kostis JB, Rosen RC, Cosgrove NM, Shindler DM, Wilson AC.Chest. 1994;106:996-1001.

A 12-week, parallel-design randomized controlled trial was con-ducted to compare the effects of a multimodal nonpharmacologicintervention with both digoxin and placebo in patients with conges-tive heart failure (CHF) who were receiving background therapy withan angiotensin-converting enzyme (ACE) inhibitor. Twenty patientswith New York Heart Association functional class II or III CHF andan ejection fraction <40% treated at the University of Medicine andDentistry of New Jersey–Robert Wood Johnson Medical Schoolwere randomized to one of three treatment groups: nonpharmaco-logic treatment (n = 7), digoxin therapy (n = 7), or placebo (n = 6).

The 12-week nonpharmacologic treatment program included (1)graduated exercise training (e.g., walking, cycling, rowing) three tofive times per week; (2) structured cognitive therapy and stressmanagement twice weekly for 60 to 90 minutes; and (3) weeklydietary counseling and interventions aimed at salt reduction andweight reduction in overweight individuals. All three aspects of theprogram were provided in a group setting. Biomedical and behav-ioral assessments were completed before and after the program.The treatment with digoxin or matching placebo was initiated at astarting dose of 0.125 mg, and the digoxin dosage was titrated toachieve a blood level between 0.8 and 2.0 ng/mL. Placebo anddigoxin were both administered in a randomized, double-blind fash-ion.

The authors concluded that nonpharmacologic therapy improvedfunctional capacity, body weight, and mood in patients with CHF. Incontrast, digoxin improved the ejection fraction without correspon-ding changes in exercise tolerance or quality of life.

Randomized trial of an education and support intervention toprevent readmission of patients with heart failure. Krumholz HM, Amatruda J, Smith GL, et al.Journal of the American College of Cardiology. 2002;39:83-89.

The impact of a targeted education and support intervention on therate of hospital readmission or death and hospital costs wasassessed in a 1-year, randomized controlled trial of 88 patients withcongestive heart failure (CHF) who were at least 50 years old.Patients were randomized to an intervention group or a controlgroup. In the intervention group, patient knowledge of each of fivecare domains for chronic illness (knowledge of the illness, relation-ship between medications and the illness, relationship betweenhealth behaviors and the illness, knowledge of early signs andsymptoms of decompensation, and where and when to obtainassistance) was assessed to identify knowledge gaps. An experi-enced cardiac nurse provided patient education. Telephone calls

were made to patients to reinforce the care domains.Recommendations for changes in treatment were not part of thetelephone calls, although the nurse made recommendations to thepatient to contact his or her physician as needed if the health sta-tus deteriorated. The control group received usual care.

The percentage of patients who died or were readmitted to thehospital during the 1-year study was significantly lower in the inter-vention group (57%) than in the control group (82%). The totalnumber of readmissions was 49 in the intervention group and 80 inthe control group, representing a significant 39% reduction.

The total estimated cost of the intervention was $530 per patient.Average hospital readmission costs were significantly lower in theintervention group ($14,420) than in the control group ($21,935).The net cost savings associated with the intervention was $6,985per patient after taking into consideration the cost of the interven-tion.

Comparison of Health Buddy with traditional approaches toheart failure management.LaFramboise LM, Todero CM, Zimmerman L, Agrawal S.Family & Community Health. 2003 Oct-Dec;26(4):275-288.

Four strategies for delivery of the education content of a heart fail-ure (HF) disease management program were compared in a 2-month pilot study of 90 patients discharged from the hospital witha primary diagnosis of HF within the previous 6 months. Patientswere randomized to one of four strategies: (1) telephonic casemanagement, (2) five home visits for patient assessment and edu-cation (i.e., home care), (3) assessment and education by using atelehealth communication device (Health Buddy), and (4) a combi-nation of home visits and the telehealth communication device.

The telehealth communication device had a screen that displayedquestions from the health care provider and allowed patients torespond. It also provided patients with education according to ascript developed by the health care provider. Patient responseswere automatically transmitted electronically to the health careprovider for review. Follow-up phone calls were made to the patientif his or her responses suggested an exacerbation of the disease.Twenty (30%) of 66 patients assigned to use the telehealth commu-nication device were unable to use it because of poor health, tech-nical problems (e.g., lack of electrical outlets or telephone service),or poor eyesight.

Self-efficacy (i.e., level of confidence in making lifestyle and behav-ioral changes related to HF management) worsened in the tele-phonic case management group and improved in the other threegroups. There were no significant differences between the groupsin measures of functional status, mood, or quality of life. At the endof the 2-month pilot study, functional status (i.e., performance in a

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6-minute walk test) had improved from baseline to a significantextent in all four groups. More than half (52%) of patients improvedtheir walking distance by 10%, and 45% improve their walking dis-tance by 20%.

At baseline, 29% of participants were depressed. Depressionimproved from baseline in all four groups, although the improve-ment from baseline was not significant. Quality of life improved sig-nificantly from baseline in all four groups.

[See the summary of Todero CM, LaFramboise LM, ZimmermanLM. Symptom status and quality-of-life outcomes of home-baseddisease management program for heart failure patients. OutcomesManagement. 2002 Oct-Dec;6(4):161-168.]

Case management in a heterogeneous congestive heart fail-ure population: a randomized controlled trial.Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P.Archives of Internal Medicine. 2003;163:809-817.

A randomized controlled trial was conducted to evaluate the effectof a hospital-based nurse case management program on hospitalreadmission rates in 287 patients with congestive heart failure(CHF). Patients with a primary or secondary diagnosis of CHF anda left ventricular ejection fraction less than 40% or radiologic evi-dence of pulmonary edema requiring diuresis (i.e., a heterogeneouspatient population) were randomized to the intervention or a controlgroup that received usual care. The intervention consisted of earlydischarge planning and coordination of care, individualized andcomprehensive patient and family education, 12 weeks of tele-phone follow-up, and promotion of optimal CHF medications anddoses based on consensus guidelines. A care manager coordinat-ed these services.

After 90 days there was no difference between the two groups inthe hospital readmission rate (37%). Patients in the interventiongroup required fewer days of hospitalization than those in the con-trol group (6.9 days vs. 9.5 days), but the difference was not signifi-cant.

Patient adherence to the treatment plan was better in the interven-tion group than in the control group for daily weight measurements,checks for edema, and a low-salt diet, but both groups took med-ications as prescribed equally well. Patient satisfaction was signifi-cantly greater in the intervention group compared with the controlgroup.

The intervention reduced the total inpatient and outpatient mediancost and the readmission median cost by 14% and 26%, respec-tively. The differences between the intervention group and controlgroup were not significant, although the differences might be signifi-cant if the intervention was used for a larger number of patients.

The effect of a nurse-managed CHF clinic on patient read-mission and length of stay.Lasater M.Home Healthcare Nurse. 1996;14:351-356.

A 1-year pre- and post-intervention comparison study was con-ducted to examine the impact of a nurse-managed clinic on hospi-tal readmission rates for exacerbation of congestive heart failure(CHF) among 80 patients with CHF or cardiomyopathy managed athome. Beginning in July 1993, all patients from the tricounty areasurrounding the South Carolina Medical Center with such a diagno-sis were automatically enrolled in the clinic for care after hospitaldischarge. The clinic program focused on precautions to reduce ordetect the signs and symptoms of CHF, including a complete car-diopulmonary assessment, daily weights, and patient education(medications, sodium-restricted diet). The expertise of physicians,dieticians, and social workers was used in collaboration with pri-mary management by registered nurses. Follow-up care wasscheduled at the nurse’s discretion, and critical-path algorithmsdirected this care. Financial assistance was available to facilitatecare and the procurement of medication or supplies.

Prior to program implementation, the medical center observed a25.6% readmission rate within 6 months among 39 patients withCHF or cardiomyopathy. The average length of stay (LOS) was 7.3days. Reanalysis of these measures in a comparable patient popu-lation (n = 41) 6 months after program implementation showed asignificant drop in the readmission rate to 21.9%; the average LOShad also significantly decreased to 5.7 days. Comparison of hospi-talization charges preintervention ($6,898) and 1 year post-interven-tion ($6,404) further revealed a decrease in charges of almost $500per patient. The decreased costs were thought to representdecreased severity of illness upon readmission. Improved patientknowledge of medications was also observed after the intervention.

Assessment—patients, chronic heart failure, and home care.Lazarre M, Ax S.Caring. 1997;16:20-22, 24.

A study assessed the impact of a cardiac specialty program forhome care developed by a private home health care agency (TGCHome Health Care Inc of Lakeland, FL) on outcomes in patientswith heart failure (HF). In this program, nurses with a critical-carebackground provided targeted teaching to patients and familiesabout disease pathophysiology, risk factors, and management ofsymptoms, diet, weight, and medications. Critical pathways wereused to ensure clarity and consistency of information provided.Each patient was also assigned a cardiac nurse case manager whoplanned and delivered care and monitored patients for signs andsymptoms of CHF exacerbation. Other members of the multidisci-plinary treatment team included a home care aide, social worker,and physical or occupational therapist. Several types of assess-

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ment and therapy were available, including comprehensive car-diopulmonary assessment, electrocardiographic monitoring, pulseoximetry, intravenous diuretic administration, and inotropic support.

During the 7-month course of this study, 34 patients entered theprogram. Study inclusion criteria included admission to homehealth care with a primary or secondary diagnosis of HF and adiagnosis of HF as either an acute exacerbation or new onset. Staffmeasured hospital readmission rates in this population 30 and 90days following enrollment and documented rates of 2.9% and8.8%, respectively. These rates reflected 7 admissions among 6 ofthe 34 patients. The rates were significantly lower than the nationalaverage readmission rates of 16% (30 days) and 32% (90 days), asreported by the Cardiology Pre-eminenece Roundtable. No attemptwas made to convert outcomes into potential savings. The authorsconcluded that a home care program featuring targeted teaching,close monitoring by cardiac-trained nurses, and early managementof HF exacerbations may reduce hospital readmissions and trans-late into cost savings.

A study of the relationship between home care services andhospital readmission of patients with congestive heart fail-ure.Martens KH, Mellor SD.Home Healthcare Nurse. 1997;15:123-129.

A retrospective chart audit was conducted to (1) explore the rela-tionship between home care nursing services and hospital readmis-sion rates in patients with a primary diagnosis of congestive heartfailure (CHF) and (2) obtain descriptive information about homehealth care nurse interventions provided to patients with CHF by aspecific hospital-based home care agency. The care provided topatients with CHF was audited because a fiscal report identifiedCHF as the most common admission diagnosis.

By using the hospital’s computerized medical records, all patientswith CHF discharged from the hospital to the home over a 1-yearinterval were retrospectively identified and evaluated. Of the 1,176CHF discharges during 1993 and 1994, 924 patients were dis-charged to home with or without a referral for home care services.Most discharges (79%) were to the home only, with only 247patients referred to a home health agency. There were 219 read-missions to the hospital within 12 months after discharge amongthe 924 patients. This figure included admission of 162 patientswho were readmitted between one and six times. Patients receivinghome care services were readmitted to the hospital significantlyless often within 90 days after discharge than the patients notreceiving such services. This relationship approached significanceafter 35 days, but no significant relationship was found 14 or 28days after discharge. Length of stay for the patients readmittedranged from 1 to 56 days, with most staying 4-7 days.

Of the 247 discharged patients with referral to a home health careagency, 120 (48%) patients were referred to the hospital-basedhome care agency involved in the study. Most referrals involvedextended care, with an average of 10.74 registered nurse visits perreferral. Fifty-seven patients (48%) were readmitted to the hospital,with 50 (42%) readmissions occurring within 3 months. A qualityassurance–focused review of care for all patients admitted to homecare with CHF for one quarter of the year (n = 32) revealed that 9patients (28%) were readmitted to the hospital within 3 months. Allof these readmissions occurred within 26 days, leading the authorsto conclude that hospital readmission was related to the reason forinitial hospitalization.

To elicit possible variables related to hospital readmission, docu-mentation of care provided to 31 members of a 32-patient sub-group was analyzed. These data consisted of three categories ofinformation: areas of assessment (e.g., vital signs, heart and lungsounds, weight, medication compliance), assessment of findings(e.g., documentation of edema, weight gain, medical compliance),and patient teaching (i.e., documentation of instructions to patientsabout nutrition, medications, disease management). This focusedreview indicated that many areas were always assessed, with theexception of medication compliance. Most patients also receivedinstructions, but documentation suggested instructions were notprovided at each visit. Of the nine patients in this subgroup whowere readmitted, the vital signs of four (44%) were outside normallimits; vital signs were also abnormal in seven (32%) of the 22 notreadmitted. The difference between groups was not significant.Similarly, no significant difference was found between five patientsreadmitted for evidence of fluid overload and 12 patients with fluidoverload who were not readmitted.

Outcomes for patients with congestive heart failure in anursing case management model.Morrison RS, Beckworth V.Nursing Case Management. 1998;3:108-114.

A retrospective chart review was conducted to evaluate outcomesin patients with congestive heart failure (CHF) who received careaccording to a hospital-based nursing care management modeldeveloped at an acute-care hospital in the southeastern UnitedStates. The broad theoretical framework for this model was contin-uous quality improvement (CQI). Multidisciplinary CQI teams wereestablished for specific case types, including CHF. A physician wasdesignated team champion, and a case manager was named teamfacilitator. The function of each team was to identify the best prac-tice, develop a critical pathway of care, and spearhead its approvaland implementation. Once a critical pathway was implemented, thecase manager assumed the role of consultant/auditor, includingtaking responsibility for patients whose care did not follow the criti-cal pathway. Patients whose care followed the pathway were typi-cally managed by the nursing unit registered nurses. CHF was the

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diagnosis with the highest volume and costs at this institution, sothe critical pathway for CHF was developed first.

The retrospective chart review yielded data for 50 randomly select-ed CHF patients who received care under the nursing care modelapproximately 5 years after it was first introduced. Outcomesassessed in these patients included length of stay (LOS), costs,physiologic status, physical functioning, health knowledge, andfamily caregiver status.

The mean LOS in 1996 was 5.4 days compared with about 17days in similar patients hospitalized in 1991, before implementationof the model. The mean fixed costs, variable costs, and total costsfor the 50 patients were estimated as $2,491, $1,858, and $4,291,respectively. Whereas several significant correlations existed amongvarious outcome measures, the only predictor of LOS identified viaregression analysis was number of medications. Only 15 of 28patients who met the criteria for use of angiotensin-convertingenzyme inhibitor therapy in Agency for Health Care Policy andResearch (now the Agency for Healthcare Research and Quality)guidelines were taking the medication at the time of discharge fromthe hospital. The authors concluded that further attention to com-pliance with such guidelines is needed, along with collection ofmore data about physiologic status during hospitalization, closerevaluation of a patient’s health knowledge prior to discharge, andrevision and further testing of the data collection instrument.

Telemanagement of heart failure: a diuretic treatment algo-rithm for advanced practice nurses. Mueller TM, Vuckovic KM, Knox DA, Williams RE.Heart Lung. 2002 Sep-Oct;31(5):340-347.

Telemanagement (i.e., telephone contact between patients andhealth care providers) and a diuretic treatment algorithm with phar-macologic and nonpharmacologic interventions were used in aneffort to prevent decompensation in 200 patients with heart failure(HF). Advanced-practice nurses contacted patients by telephone toidentify problems and provide patient education, with the goal ofreducing morbidity, clinic visits, and hospitalization. The diuretictreatment algorithm was based on evidence-based medicine andwas designed to provide consistent care while allowing for flexibilityin clinical judgment and implementation of an individualized plan ofcare.

Patient compliance with the telephone calling program was high(90%). The 30-day hospital readmission rate decreased from 2.3%in 1997-1999 to 0.7% in 1999-2001. The hospitalization ratedecreased by 50%, and hospital costs for treating HF decreasedby 52% as a result of the intervention.

Emerging information management technologies and thefuture of disease management.Nobel JJ, Norman GK.Disease Management. 2003 Winter;6(4):219-231.

The use of emerging information management technology involvinga remote biometric measuring and monitoring device in the homesetting was studied in patients with congestive heart failure (CHF).Patient data (body weight and symptoms) were automatically trans-mitted on a daily basis to a central call station that was monitoredby cardiac nurses who analyzed trends and notified the physician ifthe data suggested a change in patient health status. Patients witha deteriorating condition were called and encouraged to seeksame-day or emergency care. The device also allowed for interac-tive communication between patients and nurses, which helpedpatients adhere to the prescribed health regimen, including medica-tions and weight management. The nurses assessed patient under-standing of the disease, treatment, self-care skills, diet, and med-ication compliance.

Two populations of health maintenance organization members (anelderly one more than 65 years of age and a younger one 65 yearsof age or younger) were compared before and 12 months afterinstallation and use of the device. Comparisons also were madewith control patients in each age group who did not participate inthe intervention. Data were obtained for 78,038 member-monthsfor the elderly group (including 66,297 member-months that servedas a control) and 7,477 member-months for the younger group(including 6,408 member-months that served as a control).

In the elderly population, the bed days per thousand members peryear were reduced by 53% in the intervention group and by 0% inthe control group; costs paid per member per month decreased by50% in the intervention group and by 0% in the control group. Inthe younger group, the bed days per thousand members per yearwere reduced by 62% in the intervention group and by 9% in thecontrol group; the costs paid per member per month were reducedby 60% in the intervention group and by 9% in the control group.

Heart failure disease management in an indigent population.O’Connell AM, Crawford MH, Abrams J.American Heart Journal. 2001;141:254-258.

The effects of a multidisciplinary disease management program foroutpatients on functional status (New York Heart Association func-tional class, which reflects severity of illness), hospitalization rate,and costs were assessed in a nonrandomized study of indigentpatients admitted to a university hospital with heart failure. Group Awas comprised of 14 patients with a hospital readmission rate of atleast two times per year and an ejection fraction of 45% or lesswho were not candidates for transplantation. Group B was com-prised of 21 patients referred by their primary care provider or the

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hospital team at the time of hospital discharge because of a highlikelihood of readmission due to financial, social, or nonadherenceissues. The ejection fraction was 45% or less in group B. Patientsenrolled in the multidisciplinary disease management program werefrequently monitored in an outpatient clinic, with weekly telephonecontact. Written information and individualized counseling aboutsymptoms, diet, exercise, and medications were provided topatients. A medication consultation, with assessment for drug inter-actions, patient education, and medication adjustment in accor-dance with Agency for Health Care Policy and Research (now theAgency for Healthcare Research and Quality) guidelines, was per-formed by a cardiovascular pharmacist. Patients were referred asneeded to a dietitian, diabetes case manager, and cardiac rehabili-tation team. The intervention was the same for patients in group Aand group B, but the two groups were analyzed separatelybecause of different characteristics (e.g., greater severity of illnessin group A). The 1-year period before program enrollment wascompared with the 1-year period after enrollment.

After 1 year, functional status improved significantly in both groups,possibly as a result of improved medication use. The need for hos-pitalization decreased from 33 and 9 admissions in group A andgroup B, respectively, in the year before program enrollment to 3and 0 admissions, respectively, in the year after enrollment. Thesavings in hospital charges associated with the program for groupA and group B were $167,000 and $50,000, respectively. The netsavings when hospital and clinic charges were considered for bothgroups combined amounted to $4,600 per patient.

Enhanced access to primary care for patients with conges-tive heart failure: Veterans Affairs Cooperative Study Groupon Primary Care and Hospital Readmission.Oddone EZ, Weinberger M, Giobbie-Hurder A, Landsman P,Henderson W.Effective Clinical Practice. 1999;2:201-209.

A multisite, randomized controlled trial evaluated whether enhancedaccess to primary care affects the diagnostic evaluation, pharma-cologic management, and health outcomes of patients hospitalizedwith congestive heart failure (CHF). Eligible patients included veter-ans hospitalized at one of nine Veterans Affairs medical centerswith a diagnosis of CHF, among other conditions. These patientswere randomly assigned to receive enhanced access to care (n =222) or usual care (n = 221) and were followed for 6 months.

The intervention (enhanced care) was delivered by a primary carephysician/registered nurse team. Prior to discharge, the nurse edu-cated each patient in obtaining daily weights and appropriate useof diuretics. Educational materials from the American HeartAssociation about living with heart failure also were reviewed. Thephysician and nurse visited the patient to review medications,establish a treatment plan, and provide contact information for fol-

low-up outpatient care. Following discharge, the nurse telephonedthe patient within 2 days to assess any problems and arranged fol-low-up appointments with the nurse and doctor within 1 week. Thefrequency of other visits and telephone calls was discretionary.Control patients received the usual care offered at their facility,which did not include access to a primary care nurse, supplementaleducation, or needs assessment.

Of the 504 patients who entered the study, complete data wereavailable for 443 patients. About 80% of patients in both groupsunderwent recommended evaluation of left ventricular ejection frac-tion. Among patients for whom an angiotensin-converting enzyme(ACE) inhibitor was recommended in accordance with Agency forHealth Care Policy and Research (now the Agency for HealthcareResearch and Quality) guidelines (i.e., those with an ejection frac-tion <40%), three quarters in both the enhanced-access and usual-care groups received the drug (75% and 73%, respectively).Enhanced access to primary care did not improve quality of life(assessed via survey). Patients with enhanced access to care aver-aged 1.5 readmissions in 6 months of follow-up compared with 1.1readmissions for patients who received usual care, a difference thatis significant. The authors concluded that compliance with recom-mended CHF testing and treatment was equally high in both studygroups. They also observed that enhanced access to primary caredid not improve patients’ self-reported health status and was asso-ciated with more frequent hospitalizations.

Impact of a nurse-managed heart failure clinic: a pilot study.Paul S.American Journal of Critical Care. 2000;9:140-146.

The clinical and economic effects of a nurse practitioner-managed,multidisciplinary outpatient heart failure clinic were evaluated in a12-month nonrandomized study in which patients served as theirown controls. The clinic was developed in 1995 at a southeasternuniversity hospital to enhance the follow-up and management ofpatients with chronic congestive heart failure (CHF). After initial eval-uation by a cardiologist at the clinic, patients and their familiesreceived additional evaluation and education from a nurse practi-tioner (about diet, exercise, body weight, and symptom manage-ment) and clinical pharmacist (about medications). The nurse prac-titioner then followed a protocol to determine the frequency andneed for follow-up telephone calls and clinic visits. These calls andvisits were used to reinforce education, assess patient needs,arrange tests, and adjust medication. At each clinic visit, the patientsaw the physician, the nurse practitioner, and a clinical pharmacist,and had access to a dietitian and social worker as needed. Theclinic offered flexibility in allowing the nurse practitioner to seepatients on demand for evaluation and treatment that could reducethe risk for hospital readmission.

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The “convenience” study sample consisted of 15 patients with CHFwho were referred to the clinic after admission to an affiliated univer-sity hospital. Data were retrieved from a computerized medicalrecord system for the 6 months prior to and the 6 months followingclinic enrollment (i.e., patients served as their own controls). Thepatients had a total of 38 hospital admissions (151 hospital days) inthe 6 months before joining the clinic compared with 19 admissions(72 hospital days) in the 6 months afterward. These decreases intotal number of hospital admissions and hospital days were signifi-cant. There were also nonsignificant decreases in mean length ofstay (4.3 days vs. 3.8 days) and the number of emergency depart-ment visits (10 vs. 8). The mean inpatient hospital charges perpatient admission decreased from $10,624 to $5,893, and reim-bursements were $7,751 (a 73% collection rate) and $5,138 (a 87%collection rate), respectively. Mean charges for emergency depart-ment visits decreased from $390 before clinic enrollment to $284afterward. The authors concluded that participation in the heart fail-ure clinic appeared beneficial and that early management of CHFexacerbation may decrease readmissions and improve outcomes.

The results of a randomized trial of a quality improvementintervention in the care of patients with heart failure.Philbin EF, Rocco TA, Lindenmuth NW, Ulrich K, McCall M, JenkinsPL. The MISCHF Study Investigators.American Journal of Medicine. 2000;109:443-449.

The impact of a multifaceted quality improvement intervention onquality of care, hospital length of stay and charges, in-hospital and6-month mortality, hospital readmissions, and quality of life ofpatients with heart failure was compared with that of usual care in arandomized controlled trial. Ten acute-care community hospitalswere randomized to the intervention or usual care, and data werecollected for a 9-month baseline period and a 9-month period afterthe intervention, including 6 months after hospital discharge foreach patient. The intervention comprised use of inpatient, emer-gency department, and home care critical pathways, with diagnos-tic tests and treatments based on published clinical trial results,expert guidelines, and widely accepted practices. The emergencydepartment pathway emphasized rapid diagnosis and initiation oftreatment. Videotaped presentations to the hospital staff andteaching aids for patients and families were used to improve staffand patient knowledge. The intervention was managed by physi-cians, nurse leaders, and administrators responsible for qualitymanagement. Markers of quality of care included measurement ofleft ventricular systolic function, documentation of the primarycause of heart failure, proper dietary counseling, and prescribing ofangiotensin-converting enzyme inhibitors.

The changes from baseline in markers of quality of care were mixedand not significantly different for the intervention compared withusual care. Average hospital length of stay decreased from baselineby 1.8 days in the intervention group and by 0.7 days in the control

group, a difference that is not significant. Hospital chargesdecreased slightly in the intervention group and increased slightly inthe control group. The intervention produced small changes in mor-tality, hospital readmission, and quality of life that were not signifi-cantly different from those associated with usual care.

A community hospital-based congestive heart failure pro-gram: impact on length of stay, admission and readmissionrates, and cost.Rauh RA, Schwabauer NJ, Enger EL, Moran JF.American Journal of Managed Care. 1999;5:37-43.

The impact of a multidisciplinary inpatient and outpatient conges-tive heart failure (CHF) program was evaluated in a retrospectiveanalysis of patients hospitalized at a community-based hospitalwith a primary diagnosis of CHF. The control group comprised 407patients treated during the year prior to program initiation. Theintervention group consisted of 347 patients treated in the programfor 1 year. A subset of the intervention group (n = 81) received out-patient inotropic therapy designed to address signs of CHF decom-pensation and avoid the need for hospital readmission.

The program (intervention) used a multidisciplinary team approachbased on Agency for Health Care Policy and Research (now theAgency for Healthcare Research and Quality) guidelines. Patientswere managed in accordance with inpatient and outpatient treat-ment protocols established and implemented by team members. A4-day inpatient heart failure clinical path addressed necessary con-sultations/tests, treatment, diet, activity, patient education, and dis-charge planning. Patients at high risk for decompensation upondischarge were referred to an outpatient, hospital-based CHF clinicfor follow-up management, including the intermittent administrationof intravenous inotropes. Team members were educated about theprotocols, clinical paths, services for CHF patients, and patienteducation materials at the individual and group level. Patients andtheir families learned how to manage CHF via a nurse-directededucational program focusing on diet, compliance, and symptomrecognition. After hospital discharge, patients received regular fol-low-up telephone calls to address problems and encourage com-pliance with the home CHF management regimen.

The primary endpoint for the analysis was length of stay (LOS) forall CHF-related hospital admissions. Secondary endpoints were theprimary admission rate for CHF management, the readmission ratewithin 90 days after discharge, and the per-case cost to the patientand provider for all CHF admissions. Compared with the controlgroup, patients in the intervention group had a significantly reducedLOS (5.7 days vs. 7.3 days), significantly fewer admissions for CHFmanagement (404 vs. 503), and a lower 90-day readmission rate(13% vs. 18%). The mean cost per admission was $6,719 in thecontrol group and $5,601 in the program group, representing a17% reduction in cost per admission. A 77% net reduction in non-

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reimbursed (lost) hospital revenue ($718,468) was also noted afterprogram implementation. The cost of operating the outpatient heartclinic was approximately $104,000, and revenue generated fromthe program was about $211,000. Data regarding the effectivenessof the outpatient inotropic therapy in avoiding readmission were notincluded in the report.

Prevention of readmission in elderly patients with congestiveheart failure: results of a prospective, randomized pilotstudy.Rich MW, Vinson JM, Sperry JC, et al.Journal of General Internal Medicine. 1993;8:585-590.

The impact of a nurse-directed, nonpharmacologic, multidiscipli-nary intervention on hospital readmissions in elderly patients withcongestive heart failure (CHF) was evaluated in a prospective, ran-domized controlled trial. Patients at least 70 years of age who wereadmitted to a secondary and tertiary teaching hospital over a 1-year interval were screened for CHF. Ninety-eight patients (meanage 79 years) who were considered at moderate-to-high risk forearly hospital readmission were enrolled. The patients were strati-fied by risk and randomly assigned to receive conventional physi-cian-directed care supplemented by a nurse-directed multidiscipli-nary team (n = 63) or conventional care by their usual physician (n= 35).

The intervention consisted of (1) comprehensive education by anexperienced geriatric cardiovascular nurse, (2) a detailed medica-tion review with specific recommendations designed to improvecompliance and reduce side effects, (3) social service consultationsto facilitate discharge planning and the transition back to home, (4)individualized dietary teaching by a registered dietitian, and (5)enhanced follow-up care through home care and telephone con-tacts. The follow-up care consisted of regular home visits, in accor-dance with federal home care guidelines, and nurse-initiated tele-phone calls. Patients also received educational materials (includinga patient guide to CHF), charts, and medication cards to facilitateappropriate dietary modification, medication compliance, and dailyself-monitoring of weight. Patients in the control group receivedconventional care that could include social service evaluation,dietary and medication teaching, and home care; but this care wasconsidered lower in intensity than the care provided to the interven-tion group.

All patients were followed for 90 days after initial hospital discharge.The primary endpoints were rehospitalization within 90 days andthe cumulative number of days hospitalized during follow-up. The90-day readmission rate was 33% for the patients in the interven-tion group compared with 46% for the patients in the controlgroup, a difference that is not significant. The mean number of hos-pital days was not significantly different in the two groups; it was4.3 for the intervention group versus 5.7 for the control group. In a

subgroup of 61 patients at intermediate risk for readmission, theintervention reduced readmissions by 42% (from 48% to 28%), andthere was a trend toward reduction in the average number of hos-pital days (a change from 6.7 days to 3.2 days). The authors con-cluded that a comprehensive, multidisciplinary approach to reduc-ing repetitive hospitalizations in elderly patients with CHF might leadto a reduction in readmissions and hospital days, particularly inpatients at moderate risk for early rehospitalization. They felt thatfurther evaluation of this treatment strategy in a larger trial, includ-ing an assessment of the cost-effectiveness, was warranted.Extrapolation of these data to all CHF patients discharged aftershort-stay hospitalization suggests a potential cost savings of$262.5 million per year, although no cost data were analyzed in thestudy.

A multidisciplinary intervention to prevent the readmission ofelderly patients with congestive heart failure.Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE,Carney RM.New England Journal of Medicine. 1995;333:1190-1195.

The effects of a nurse-directed, multidisciplinary intervention onrates of readmission, quality of life, and costs of care for high-riskelderly patients with congestive heart failure (CHF) were evaluatedin a prospective, randomized controlled trial. Patients at least 70years of age who were admitted to the Washington UniversityMedical Center because of CHF were eligible to participate if theyhad at least one risk factor for early readmission. Of 282 eligiblepatients, 142 were randomly assigned to an intervention group and140 were assigned to a control group. The intervention consistedof nurse-directed education about CHF for the patient and family,individualized dietary assessment and instruction, social-serviceconsultation for discharge planning, medication review by a geri-atric cardiologist, and intensive follow-up. The follow-up consistedof home care services supplemented by individualized home visitsand telephone contact with members of the multidisciplinary treat-ment team. The goal of this follow-up was to reinforce education,ensure dietary and medication compliance, and identify CHF symp-toms amenable to outpatient treatment. Patients in the controlgroup received standard treatment and services ordered by theirphysicians.

All patients were followed for 1 year, although the primary studyendpoint was readmission-free survival after 90 days. That statuswas achieved in 91 patients (64%) in the intervention group com-pared with 75 patients (55%) in the control group, a difference thatis not significant. However, when the analysis was limited to sur-vivors of the first hospitalization, the difference between the twogroups was significant. There were significantly fewer readmissionswithin 90 days for any reason in the intervention group (53 vs. 94readmissions, which is a 44% reduction). Readmission for CHFwas less frequent in the intervention group (24 vs. 54 readmissions,

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which is a 56% reduction). The total hospital days per patient alsowas reduced in the intervention group (3.9 vs. 6.2 days, which is a37% reduction). The proportion of patients readmitted more thanonce in the 90-day follow-up interval was also significantly less (6%vs. 16%).

In a subgroup of 126 patients who completed the Chronic HeartFailure Questionnaire, quality-of-life scores after 90 days wereimproved from baseline to a significantly greater extent in patientsin the intervention group than in patients in the control group. Theaverage cost of the intervention was $216 per patient. Caregivercosts and nonhospital costs did not differ significantly between thetwo groups, although the cost of hospital readmission was signifi-cantly higher in the control group ($3,236 vs. $2,178). The overallcost of care was estimated to be $460 less per patient in the inter-vention group because of the reduction in hospital admissions.

Effect of a multidisciplinary intervention on medication com-pliance in elderly with congestive heart failure.Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P.American Journal of Medicine. 1996;101:270-276.

Medication compliance was evaluated in elderly patients with con-gestive heart failure (CHF) to identify factors associated withreduced compliance and to assess the effect of a multidisciplinarytreatment approach on medication adherence. Patients in thisprospective randomized controlled trial were a subset of patients atleast 70 years old enrolled in a previous trial conducted at theWashington University Medical Center. The patients had beenadmitted to the hospital with CHF and satisfied study entry criteria.Prior to discharge, 156 eligible patients were randomly assigned tothe intervention (n = 80) or conventional care (n = 76).

The intervention began while the patients were still hospitalized.Patient education about CHF management was provided using a15-page teaching guide prepared by the study team. A study nursevisited each patient daily to emphasize the importance of compli-ance with medications and diet. Each patient also received dietaryinstruction from a dietitian and discharge planning from a socialservice representative. Shortly prior to discharge, a geriatric cardiol-ogist made specific recommendations regarding each patient’smedication regimen. Following discharge, patients were visited bythe hospital’s home care department and were contacted regularlyby the study nurse. Patients in the control group received conven-tional medical care including standard hospital services (i.e., dietaryteaching, medication instructions).

Detailed data on all prescribed medications were collected at thetime of hospital discharge, and medication compliance wasassessed by pill counts performed at the patient’s home roughly 30days later. The overall compliance rate during the first 30 days afterdischarge was 85%. Compliance was 88% for patients in the inter-

vention group compared with 81% for patients in the control group,a difference that is significant. Eighty-five percent of patients in theintervention group achieved a compliance rate of 80% or greaterversus 70% of patients in the control group. The difference is signif-icant. Multivariate analysis showed that assignment to the interven-tion group was the strongest independent predictor of compliance,although Caucasian race and not living alone were also predictiveof compliance.

Hospital readmission rates were determined for the first 90 daysfollowing hospital discharge. During this interval, 22 control-grouppatients (29%) and 18 intervention-group patients (23%) were read-mitted to the hospital 31 and 22 times, respectively. Total days ofrehospitalization were 258 days for the control group and 188 daysfor the intervention group. Thus, readmissions per patient werereduced by 33% and hospital days were reduced by 31% inpatients randomized to the intervention group. Independent predic-tors of readmission were low systolic blood pressure and highblood urea nitrogen concentration. There was a trend toward fewerreadmissions in patients who were more than 90% compliant. Theauthors concluded that such a multidisciplinary treatment strategyappears to improve medication compliance in elderly CHF patientsand may improve outcomes.

Effect of a standardized nurse case-management telephoneintervention on resource use in patients with chronic heartfailure.Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A.Archives of Internal Medicine. 2002;162:705-712.

A randomized controlled trial was conducted to assess the effectsof a telephone congestive heart failure (CHF) case managementintervention on resource use. Physicians were randomized to anintervention group or a usual-care control group so that the sameapproach was used for all patients treated by a particular physician.Patients were identified at the time of hospitalization and were fol-lowed for 6 months after discharge from the hospital. The interven-tion was based on a decision support software program designedto emphasize factors known to predict hospitalization in patientswith CHF (i.e., patient nonadherence to medications and diet, lackof knowledge of the signs and symptoms of worsening illness).Printed education materials were mailed to patients in the interven-tion group monthly. Physicians in the intervention group receivedpatient progress reports produced automatically by the software,using data collected by telephone. Physicians also received phonecalls from case managers (registered nurses) about specific patientconcerns as needed. Care for patients in the usual-care group wasnot standardized and presumably involved patient education beforehospital discharge.

After 6 months, the heart failure hospitalization rate in the interven-tion group was 48% lower than that in the usual-care group. The

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average number of hospital days for CHF was 46% lower and thepercentage of patients with multiple admissions was 43% lower inthe intervention group compared with the usual-care group.Inpatient heart failure costs were 46% lower in the interventiongroup. All of these differences were significant. The interventionyielded cost savings even after the costs of the intervention weretaken into consideration. There was no evidence of cost shiftingfrom the inpatient setting to the outpatient setting. Patient satisfac-tion was greater in the intervention group than in the usual-caregroup.

Disease management interventions to improve outcomes incongestive heart failure.Roglieri JL, Futterman R, McDonough KL, et al.American Journal of Managed Care. 1997;3:1831-1839.

The impact of selected disease management interventions (e.g.,post-hospitalization follow-up) on outcomes in patients with con-gestive heart failure (CHF) or a CHF-related diagnosis were studiedin a managed care setting. The analysis was part of a 24-month,multicenter, longitudinal comparison study of a comprehensive CHFdisease management program. Study subjects consisted of 149patients enrolled in the CHF disease management program and allmembers of a managed care plan. The program participants wereenrolled in the CHF program following physician or social workerreferral or identification by review of medical claims. The larger pop-ulation of health plan members corresponded to plan membershipfor the third quarters of 1995 (n = 139,922) and 1996 (n =161,267).

The program consisted of patient education, nurse-initiated tele-phone calls to patients (telemonitoring), a home visit by a nurse(post-hospitalization discharge intervention), and physician educa-tion (mailings and telephone calls to raise program awareness.) Thetelemonitoring and education-oriented interventions were availableonly to patients enrolled in the program, although all members ofthe health plan were eligible for the guideline-based clinical inter-ventions. Guidelines directing treatment for patients with CHF andCHF-related diagnoses included those from the American HeartAssociation, the Agency for Health Care Policy and Research (nowthe Agency for Healthcare Research and Quality), and NYLCareHealth Plans.

Review of hospital and emergency department utilization data pro-vided information about utilization events, which were categorizedas attributable to pure CHF or a CHF-related diagnosis. The effectsof the program were then analyzed for pure CHF and CHF-relateddiagnoses, with outcomes for the third quarter of 1996 (post-inter-vention follow-up) compared with those for the third quarter of1995 (pre-intervention baseline).

Overall, the data demonstrated significantly reduced admission andreadmission rates for patients with a pure CHF diagnosis. Amongthe entire CHF patient population, the third quarter admission ratedeclined 63%, and the 30-day and 90-day readmission ratesdeclined 75% and 74%, respectively. Among program participantswith a pure CHF diagnosis, the 30-day readmission rate wasreduced to 0, and an 83% reduction occurred for both the third-quarter admission and 90-day readmission rates. In addition, theaverage length of stay for patients with CHF-related diagnoses wassignificantly reduced among both plan participants and programparticipants. Reductions were seen in total hospital days and emer-gency department utilization. The authors concluded that a com-prehensive disease management program can reduce health careutilization not only among CHF patients in the program, but alsoamong an entire managed care plan population.

A medication discharge planning program: measuring theeffect on readmissions.Schneider JK, Hornberger S, Booker J, Davis A, Kralicek R.Clinical Nursing Research. 1993;2:41-53.

The effect of a medication discharge-planning program on hospitalreadmissions among patients with congestive heart failure (CHF) ina quasi-experimental, after-only, randomized controlled study. Fivenurses implemented the program for 54 patients with CHF whowere admitted to a 600-bed nonprofit, Midwestern medical facilityover a 5-month interval. All enrolled patients had the cognitivecapability to self-administer medications and were taking one ormore medications at the time of discharge from the hospital. Thesepatients were randomly assigned to a control (n = 28) or an experi-mental group (n = 26). The experimental group participated in themedication discharge-planning program, and the control groupreceived the usual informal discharge planning provided on thenursing unit.

Five nurse investigators were trained by the principal investigator tofollow a specific format for medical discharge planning based onOrem’s theory of self-care. Training involved a review and practiceof the discharge-planning format. Discharge planning was conduct-ed prior to hospital discharge. It involved oral presentation of infor-mation about the prescribed medication by the nurse investigator.This information was consistent with printed medical informationcards provided to the patient. The cards listed the purpose of eachmedication, side effects, whom and when to call with questions,and any medication-specific instructions. The nurse investigatoralso reinforced information and corrected any patient misunder-standings about medications. Family members, if present, wereincluded in the program.

The nurse investigator next inquired about the patient’s daily routineand assisted him or her in scheduling medication administrationtimes. Patients were then queried about problems with taking med-

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ications at home. If the patient identified no problems, the nurseinvestigator posed two potential problems (forgetfulness and limitedbudget) and discussed solutions to these problems. Finally, thenurse briefly reviewed the medication schedule and purpose ofeach medication. Subsequent reinforcement and instruction wereprovided as appropriate. Patients also were given a physician tele-phone number for any questions once they had left the medicalcenter. The entire interaction took about 20 minutes.

The two groups were similar with respect to all demographic data.The total number of medications at the time of hospital dischargeranged from 1 to 11. Eight (29%) of the 28 patients in the controlgroup were readmitted within 31 days after discharge comparedwith 2 (8%) of the 26 patients in the experimental group. The differ-ence is significant. The authors concluded that these findings con-firm the importance of a medication discharge-planning program.

Congestive Heart Failure Disease Management Study: apatient education intervention.Serxner S, Miyaji M, Jeffords J.Congestive Heart Failure. 1998;4:23-28.

The effects of educational mailings and compliance aides on hospi-tal readmissions, quality of life, and compliance were evaluated in a6-month randomized controlled trial of 109 elderly patients hospi-talized with congestive heart failure (CHF). The subjects were identi-fied by selecting all patients with a diagnosis of CHF dischargedfrom Columbia Good Samaritan Hospital and Columbia San JoseMedical Center within a 1-year interval. Study exclusion criteriaconsisted of CHF of noncardiac origin, inability to speak English, notelephone or residence, and discharge to a skilled nursing facilityoutside of the Columbia Hospital system.

Patients were randomized to an education intervention (n = 55) orstandard care (n = 54). The intervention consisted of mailings at 3-to 4-week intervals of a personalized letter and a wide range ofeducational materials (booklets, brochures, fact sheets, resourceguide, video). These materials were accompanied by complianceaides (medication sheets and a weight chart). Patients in the con-trol group received the customary hospital education but no specialinformation after discharge. Trained nurse interviewers conductedtelephone surveys before and after the intervention for all patients.The survey used was a unique instrument designed by a multidisci-plinary CHF patient education task force that assessed CHF knowl-edge, attitudes, self-efficacy, and key outcome behaviors. Themedical staff was informed about the study by mail to raise pro-gram awareness. Hospital records were used to monitor patienthealth care utilization related to CHF admissions and costs. Nodata were collected on admissions or emergency department visitsto hospitals not within the system.

Compliance, quality of life, and hospital readmissions were moni-tored for 6 months. In the control group, 27 (50%) of the patientswere admitted at least once during this interval compared with 15(27%) of the patients in the intervention group. The 44% reductionin readmissions was significant. Multiple readmissions were morecommon among patients in the control group than in the interven-tion group. Compared with the control group, the interventiongroup had a significantly lower (by 51%) total number of readmis-sions (21 vs. 43 in the control group). Post-test analysis revealedsignificant differences between the control and intervention groupson key behavioral and attitudinal measures (reduction in salt intake,change in cooking habits, weight monitoring). There also were sig-nificant differences between the two groups on frequency of forget-ting medications (i.e., medication compliance), self-efficacy scores,and ratings of personal health. Compared with the control group,the intervention group reported better overall health status, greaterconfidence in self-management, and enhanced compliance withdiet, medications, and weight monitoring. The cost of the educa-tional program was $50 for patients, and the average cost of aCHF admission to the study medical facility at that time was$6,000. Based on the reduced readmission rate, the investigatorsestimated that the intervention reduced overall costs. A net returnon the investment of $8:$1 for the hospital and $19:$1 for third-party payers was projected.

Prevention of hospitalizations for heart failure with an inter-active home monitoring program.Shah NB, Der E, Ruggerio C, Heidenreich PA, Massie BM.American Heart Journal. 1998;135:373-378.

A 1-year observational pre- and post-intervention comparison studywas conducted to determine whether a program less rigorous thansome intensive multidisciplinary interventions could reduce hospital-izations in patients with moderate or severe congestive heart failure(CHF). A secondary aim of the study was to ascertain whether ben-efits associated with some inpatient programs directed at elderlypatients with CHF would extend to younger individuals with the dis-ease treated as outpatients. Twenty-seven patients (mean age 62years) with class II–IV CHF satisfied enrollment criteria and enteredthe study. These patients included patients referred to the HeartFailure Clinic at the San Francisco Veteran Affairs Medical Centerafter a recent hospitalization or while treated as stable outpatients.

The intervention featured patient education and self-monitoring,automated reminders to improve compliance, and telephone com-munication with a nurse monitor. Educational materials relating tosymptoms, medications, and management of CHF were mailed toparticipants weekly for the first 8 weeks of the study. Patients alsoreceived devices and instruction in obtaining daily weights and vitalsigns, and were given a pager through which they receivedreminders regarding medications and measurements. Patient clini-cal status was assessed and physiologic data were collected in

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weekly telemonitoring phone calls by study nurses. Patients werealso provided with 24-hour telephone access to a nurse to reportchanges in their condition, weight gain, or medical emergencies.Cardiologists reviewed physiologic data weekly and received imme-diate notification of patient changes in status. Nurses followed upany such notifications with the patient, and physicians reported anyactions taken to the nurse.

The primary endpoints were numbers of hospitalizations and hospi-tal days during the mean follow-up period of 8.5 months comparedwith values during an equivalent period before the intervention.Overall, the number of hospitalizations per patient-year of follow-upafter enrollment (0.4) did not differ significantly from the numberprior to enrollment (0.8). However, cardiovascular hospitalizationsignificantly decreased from 0.6 per patient-year to 0.2 per patient-year. All-cause and cardiovascular hospital days also decreasedsignificantly from 9.5 to 0.8 per patient-year and 7.8 to 0.7 perpatient-year, respectively. During the study, there were 52 physiciannotifications by the monitoring system for 65 reported problems(e.g., weight gain, shortness of breath, edema). This notificationresulted in 19 physician interventions, 50% of which were toincrease the dosage of diuretics or change other cardiac medica-tions. Patient acceptance of the program was high, with 82% ratingthe program as useful or very useful. The treating physicians alsofound the program helpful in permitting medication adjustments byphone. No associated economic effects were reported.

Effects of a home-based intervention among patients withcongestive heart failure discharged from acute hospital care.Stewart S, Pearson S, Horowitz JD.Archives of Internal Medicine. 1998;158:1067-1072.

The effect of a home-based intervention (HBI) on readmission anddeath among “high-risk” patients with congestive heart failure (CHF)was evaluated in a randomized controlled trial conducted at a terti-ary referral hospital in Australia. Hospitalized patients with CHF/sys-tolic dysfunction, exercise intolerance, and recurrent hospitaladmissions for acute CHF were eligible to participate. Ninety-sevenpatients were randomized to receive usual care (n = 48) or the HBI(n = 49).

Before hospital discharge, HBI patients were visited by the studynurse and counseled about compliance with the treatment regimenand the need to report any signs of clinical deterioration. One weekafter discharge, these patients received a home visit by a nurse andpharmacist. The pharmacist assessed patient medication knowl-edge by questionnaire and medication compliance by pill count.Patients who demonstrated poor medication knowledge or non-compliance received remedial counseling, a daily medicationreminder, a weekly medication container, incremental monitoring bycaregivers, medical information/reminder cards, and referral to acommunity pharmacist. The nurse also evaluated patients for evi-

dence of clinical deterioration or adverse effects from medications;patients were referred to their primary care physician as appropri-ate. The nurse also contacted patients’ primary care physicians todiscuss the visit and arrange more intensive follow-up, as appropri-ate. Patients in the usual-care group received normal levels of post-discharge care, including follow-up physician appointments within 2weeks after hospital discharge and home support in some cases(27%).

Seven patients (14%) assigned to the HBI group received no homevisit because of early readmission or study withdrawal. The homevisit to the remaining patients revealed that 22 (52%) patients werenoncompliant with medications and 38 (90%) patients had inade-quate knowledge of the treatment regimen. Therefore, most HBIpatients required remedial measures, including referral of ninepatients to community pharmacists. In addition, 14 patientsshowed signs of clinical deterioration, prompting referral to the pri-mary care physician. Patients were followed for 6 months after theintervention to evaluate the primary composite study endpoint(unplanned readmissions plus out-of-hospital deaths) and second-ary endpoints (time until first endpoint, rate of unplanned readmis-sion, total hospital days, emergency department visits, overall mor-tality, and costs).

During follow-up, HBI patients had significantly fewer unplannedreadmissions (36 vs. 63) and a trend toward fewer out-of-hospitaldeaths (1 vs. 5) than control patients. The composite primary end-point was 0.8 vs. 1.4 events per patient assigned to HBI and usualcare, respectively. The difference is significant. There were no signif-icant differences between the two groups in time until primary end-point, percentage of patients with unplanned admissions, or overallmortality. However, HBI patients had fewer days of hospitalization(261 vs. 452) and significantly fewer visits to the emergency depart-ment (48 vs. 87) than the control group. The mean cost of hospital-based care for the HBI group averaged $3,200 versus $5,400 forthe usual-care group. The estimated cost of the intervention was$190 (Australian dollars) per patient; outpatient costs for the twogroups did not differ.

Effects of a multidisciplinary, home-based intervention onunplanned readmissions and survival among patients withchronic congestive heart failure: a randomised controlledstudy.Stewart S, Marley JE, Horowitz JD.The Lancet. 1999;354:1077-1083.

In a 6-month randomized controlled trial, 200 patients with chroniccongestive heart failure (CHF) who were discharged home afteracute hospital admission were randomly assigned to usual care (n= 100) or a multidisciplinary, home-based intervention (n = 100).Eligible patients included those who had been admitted to a tertiaryreferral hospital in Australia and (1) were 55 years old or older, (2)

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had New York Heart Association functional class II, III, or IV CHF, (3)had at least one prior hospital admission for acute CHF, and (4)met no study exclusion criteria.

The study began with assessment of all patients immediately priorto discharge to obtain baseline demographic, clinical, and psy-chosocial data. Patients were then randomized to the interventiongroup or usual-care group, and existing norms for discharge plan-ning were applied to all patients (including follow-up appointmentswithin 2 weeks after discharge at an outpatient cardiac clinic).Patients assigned to the home-based intervention group thenreceived a structured home visit by a cardiac nurse within 7 to 14days after discharge. Nurse assessments included a physicalexamination, review of medication compliance, and evaluation ofthe patient’s understanding of appropriate treatment for CHF (e.g.,appropriate diet, exercise, symptom recognition). Based on thisassessment, patients and their families (if appropriate) received acombination of remedial counseling, introduction of strategies toimprove treatment compliance and response, incremental monitor-ing by caregivers, and referral to a primary care physician for urgentcare, if appropriate. The nurse then sent a report to the patient’sprimary care physician and cardiologist detailing results of theassessment and any remedial actions. The nurse then arrangedany changes in pharmacologic therapy and additional home visits,as appropriate, as well as follow-up telephone contacts after 3 and6 months.

The patients were followed for 6 months (the effective interventionduration). The primary composite study endpoint was frequency ofunplanned readmissions plus out-of-hospital deaths within 6months. Secondary endpoints included time to first endpoint(event-free survival), frequency of unplanned admissions alone, fre-quency of out-of-hospital deaths alone, days of unplanned read-missions, functional status and quality of life, and hospital andcommunity-based health care costs. During 6 months of follow-up,there were 129 primary-endpoint events in the usual-care groupand 77 events in the intervention group, a difference that is signifi-cant. Significantly more intervention-group patients than usual-carepatients remained event free (51 vs. 38). There were also signifi-cantly fewer unplanned readmissions (68 vs. 118) and associateddays in the hospital (460 vs. 1,173) among intervention-grouppatients. Whereas intervention-group patients had superior quality-of-life scores after 3 months of follow-up, scores did not differ sig-nificantly between the two groups after 6 months. Hospital-basedcosts amounted to $490,300 (Australian) for the intervention groupand $922,600 for the usual-care group. Community-based healthcare costs were similar for the two groups. The mean cost of theintervention was $350 per patient.

Home-based intervention in congestive heart failure: long-term implications on readmission and survival.Stewart S, Horowitz JD.Circulation. 2002;105:2861-2866.

The long-term effects of a multidisciplinary, post-discharge, home-based intervention were evaluated in participants in two previouslypublished studies (see the summaries of Stewart S, Pearson S, etal. Archives of Internal Medicine. 1998;158:1067-1072 and StewartS, Marley JE, et al. Lancet. 1999;354:1077-1083), involving a totalof 297 patients with congestive heart failure (CHF). The interventioninvolved home visits by nurses to optimize medication manage-ment, provide patient education, identify early signs of clinical dete-rioration, and intensify medical follow-up as appropriate. Patientswere randomized to the intervention or usual care.

After a median follow-up time of 4.2 years, there were significantlyfewer unplanned hospital readmissions and deaths in the interven-tion group (0.21 events per patient per month) than in the usual-care group (0.37 events per patient per month). The median event-free survival time was significantly longer in the intervention group(7 months) than in the usual-care group (3 months). The mediancost (in Australian dollars) of unplanned readmissions was signifi-cantly lower in the intervention group ($325 per month per patient)than in the usual-care group ($660 per month per patient).

Nurse-led heart failure clinics improve survival and self-carebehaviour in patients with heart failure: results from aprospective, randomised trial.Stromberg A, Martensson J, Fridlund B, Levin LA, Karlsson JE,Dahlstrom U.European Heart Journal. 2003;24:1014-1023.

The impact of a nurse-led heart failure (HF) clinic on morbidity, mor-tality, and self-care behavior was studied in a 12-month, random-ized controlled study of 106 patients who were admitted to thehospital for HF. The intervention involved follow-up after hospitaliza-tion by trained cardiac nurses who made changes in medicationsaccording to protocol and provided education and social supportto the patient and his or her family. The control group receivedusual care.

The intervention group had significantly fewer deaths and hospitaladmissions and days, and scored significantly higher on a ques-tionnaire about self-care behaviors (a high score reflects betterbehavior) than the control group. A 55% decrease in admissionsper patient per month was associated with the intervention.

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Symptom status and quality-of-life outcomes of home-baseddisease management program for heart failure patients. Todero CM, LaFramboise LM, Zimmerman LM.Outcomes Management. 2002 Oct-Dec;6(4):161-168.

Changes in CHF symptom occurrence and characteristics andquality of life were evaluated over a 2-month period in 93 patientswith CHF who had recently been discharged from the hospital andwere referred by their physician to a home disease managementprogram. Nurses visited the patients at home at baseline (approxi-mately 1 month after hospital discharge) and again 2 months laterto assess symptoms and collect data. The program included rou-tine reminders to monitor symptoms and suggestions for symptommanagement. A patient education videotape explaining the diseaseand its management was shown, and patients were given an edu-cational manual for reference.

Patients were randomized to one of four strategies for delivery ofthe educational component of the program: (1) telephonic casemanagement, (2) five home visits for patient assessment and edu-cation (i.e., home care), (3) assessment and education by using atelehealth communication device (Health Buddy), and (4) a combi-nation of home visits and the telehealth communication device.However, because a preliminary analysis revealed that symptomstatus did not differ at baseline or the end of the study based onwhich group the patient was assigned to, the data for the fourgroups were combined.

The most common symptoms at baseline were fatigue (86%) andshortness of breath (78%). The percentage of patients experiencingthese and each of nine other symptoms was decreased from base-line at the end of the study. Shortness of breath was the mostcommon symptom at the end of the study, affecting 75% ofpatients. Fatigue was the second most common symptom at theend of the study, affecting 70% of patients.

The frequency, severity, amount of interference with physical activi-ty, and the interference with enjoyment of life from shortness ofbreath improved over the 2-month study. Similarly, the frequency,severity, amount of interference with physical activity, and the inter-ference with enjoyment of life from fatigue improved during thisperiod. Improvements in quality of life also were reported.

[See the summary of LaFramboise LM, Todero CM, Zimmerman L,Agrawal S. Comparison of Health Buddy with traditional approach-es to heart failure management. Family & Community Health. 2003Oct-Dec;26(4):275-288.]

Heart failure collaborative care: an integrated partnership tomanage quality and outcomes.Urden LD.Outcomes Management for Nursing Practice. 1998;2:64-70.

Preliminary outcome information is reported about an integrateddisease case management program for heart failure (HF) that wasestablished at a hospital in response to the complexity and difficultyof treating patients with HF. First, an interdisciplinary team createdan inpatient HF clinical pathway with the goals of decreasing lengthof stay (LOS) of hospitalized HF patients and eliminating or minimiz-ing unnecessary readmissions and emergency department visits.Work was then begun to integrate this inpatient HF pathway with ahome care HF pathway. The net result was the development of aHF service consisting of five overlapping components: (1) inpatientconsultation with a nurse practitioner (NP) and cardiologist, path-way care, and comprehensive discharge planning and teaching; (2)regular outpatient follow up at a HF clinic with an NP, cardiologist,and nurse clinician; (3) intermittent outpatient intravenous infusiontherapy, managed by a nurse clinician who was supervised by anNP and cardiologist; (4) ongoing outpatient telemanagement by anurse clinician; and (5) linkage with appropriate community, homehealth, and referral services.

Preliminary outcome data gathered for 108 patients seen on theservice indicate that patients have been satisfied with the service,accessibility, timely response, and personalized care. However,because no baseline data about satisfaction with care wereobtained, no conclusions about changes in satisfaction with carecan be drawn. Early assessment also showed an increase in con-sultations (e.g., dietician and social service referrals) by more than20%. Patient education (about HF medication, diet, and symptommanagement) was thought to be considerably improved. Significantimprovements were noted in overall quality of life, emotional func-tioning, and physical functioning after 3 months of follow-up. TheLOS for hospitalized HF patients decreased by 1.1 days sinceimplementation of the HF inpatient pathway. Readmissions within30 days after discharge decreased from 17% to 4%. The decreasein overall LOS resulted in $2,700 in cost savings per patient hospi-talization. These emerging trends suggest that the HF service inter-ventions will have additional positive fiscal outcomes.

Pharmaceutical care of patients with congestive heart fail-ure: interventions and outcomes.Varma S, McElnay JC, Hughes CM, Passmore AP, Varma M.Pharmacotherapy. 1999;19:860-869.

The effects of a structured pharmaceutical care program forpatients with congestive heart failure (CHF) on disease control,quality of life, and health care facility utilization were evaluated in alongitudinal, prospective, randomized controlled trial. Elderlypatients who were hospitalized or attended an outpatient clinic in

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one of three study sites in Northern Ireland were recruited. Eighty-three patients with a confirmed diagnosis of CHF who (1) weremore than 65 years old, (2) had an adequate cognitive status, and(3) met no exclusion criteria were restrictively randomized to anintervention group (n = 42) or a control group (n = 41). Groupswere matched as well as possible for CHF severity, renal function,concomitant illness, and cognitive status.

The intervention group received algorithm-based education from aresearch pharmacist about CHF, its treatment, and lifestyle changesfor symptom control. Educational material was provided in writtenand oral form. Patients were also encouraged to monitor theirsymptoms and comply with prescribed drug therapy. This was rein-forced by providing patients with monitoring diary cards that theywere to show to their physicians and community pharmacists.Instructions for an extra dose of diuretic were provided in the eventof a defined weight gain or symptoms. If necessary, dosage regi-mens were simplified in liaison with hospital physicians. Theresearch pharmacist discussed the project with physicians andcommunity pharmacists, and obtained information from communitypharmacists about dispensed medications for evaluating medica-tion compliance. The 41 patients in the control group receivedstandard care, excluding education and counseling by the pharma-cist, self-monitoring, or liaison among physicians and communitypharmacists. The following outcome measures were assessed in allpatients at baseline as well as after 3, 6, 9, and 12 months: 2-minute walk test, blood pressure, body weight, pulse, forced vitalcapacity (FVC), quality of life, knowledge of symptoms and drugs,compliance with therapy, and health care utilization.

Body weight, pulse, and FVC did not differ between the two groupsafter the intervention. Patients in the intervention group tended tohave higher blood pressures, with a significant difference betweenthe two groups in diastolic pressures noted after 12 months.Patients in the intervention group showed improved compliancewith drug therapy on some measures (drug use profile data but notself-reported data), which in turn improved aspects of their exercisecapacity (distance walked) compared with patients in the controlgroup. Education on management of symptoms, lifestyle changes,and dietary recommendations also benefited patients in the inter-vention group, as suggested by superior scores on quality-of-life,physical functioning, and emotional health assessments. Drug ther-apy knowledge improved significantly in the intervention group dur-ing the 12-month study compared with the control group. Therewere significantly fewer hospital admissions in the interventiongroup (14 vs. 27 in the control group). Although intervention-grouppatients tended to have more emergency department visits (15 vs.7) and doctor emergency visits (38 vs. 35), there were no signifi-cant differences between the two groups in these measures.Specific costs were not determined.

Does increased access to primary care reduce hospitalreadmissions? Veterans Affairs Cooperative Study Group onPrimary Care and Hospital Readmission.Weinberger M, Oddone EZ, Henderson WG.New England Journal of Medicine. 1996;334:1441-1447.

In a multicenter, randomized controlled trial conducted at nineVeterans Affairs (VA) Medical Centers, 1,396 veterans hospitalizedwith diabetes (n = 751), chronic obstructive pulmonary disease (n =583), or congestive heart failure (n = 504) were randomized to acustomary post-discharge care group or an intensive, primary careintervention group. Exclusion criteria included certain concomitantillnesses, plans for care from a skilled nursing facility, inability tospeak English, lack of a telephone, and poor cognitive status.Baseline assessment showed that the patients were severely ill;two thirds were considered at medium or high risk for readmission.Half of those with congestive heart failure had New York HeartAssociation functional class III or IV disease. Baseline quality-of-lifescores were poor.

The intervention was delivered by a team consisting of a registerednurse and a primary care physician. The intervention was designedto increase access to primary care after hospital discharge, withthe goals of reducing readmissions and emergency department vis-its and increasing patients’ quality of life and satisfaction with care.It involved close follow-up by the team, beginning before dischargeand continuing for 6 months. Prior to discharge, patients in theintervention group were assessed by a primary care nurse andwere given educational materials and a card with team membernames and beeper numbers. The primary care physician also visit-ed patients to review the hospital course, discharge plans, andmedication regimens. The nurse then scheduled a follow-up clinicappointment within 1 week after discharge. The nurse telephonedpatients within 2 days after discharge to assess potential problemsand remind patients about their appointments. Additional remindersand protocols for missed appointments were implemented as nec-essary. Patients in the control group received customary post-dis-charge care, without primary care nurse access, supplemental edu-cation, or needs assessment.

Patients were followed for 180 days after hospital discharge usinga national database of VA hospitalization information and computersystems at local hospitals. Although patients in the interventiongroup received more intensive care, they had a significantly highermonthly readmission rate (0.19 vs 0.14) and more days of rehospi-talization (10.2 vs. 8.8) than patients in the control group. Patientsin the intervention group were more likely to be readmitted thanpatients in the control group (49% vs. 44%, respectively), and thereadmission tended to occur sooner in intervention-group patientsthan in control-group patients. Intervention-group patients were sig-nificantly more satisfied with their care than were control-grouppatients, although quality-of-life scores did not differ between thetwo groups. The study lacked adequate power to permit subgroup

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analysis, but no significant differences in outcomes were notedbetween the three disease strata. The authors concluded that theprimary care intervention increased rather than decreased the rateof rehospitalization among patients discharged from VA hospitals,although the intervention was associated with greater patient satis-faction with care.

A comprehensive management system for heart failureimproves clinical outcomes and reduces medical resourceutilization.West JA, Miller NH, Parker KM, et al.American Journal of Cardiology. 1997;79:58-63.

The feasibility and safety of a physician-supervised, nurse-mediat-ed, home-based system for heart failure (HF) management wasevaluated in an observational study involving 51 patients with HF.This MULTIFIT system was designed to effectively implement con-sensus guidelines for pharmacologic and dietary therapy using anurse manager to enhance compliance and monitor patient clinicalstatus by telemonitoring. Patients recently hospitalized with HF at aKaiser-Permanente medical center and outpatients referred byphysicians with a diagnosis of HF were recruited for the study.

Nurse case managers, who worked in conjunction with primaryphysicians, were primarily responsible for implementing the MULTI-FIT intervention. It consisted of an initial comprehensive nurse visitto the patient’s home followed by regularly scheduled, nurse-initiat-ed telephone calls. The frequency of these calls was predeterminedbut could be increased if symptoms progressed or after a recentevent (e.g., emergency department visit, hospitalization). Nursemanagers also educated patients about HF-related issues, includ-ing sodium restriction, pharmacotherapy, and symptom recognition.Behavioral techniques were introduced to improve compliance andfoster self-monitoring skills. Physician consultation was available onan as-needed basis, and a primary physician retained overallresponsibility for patient management.

Patient management was directed by locally adapted guidelinesconsistent with the American College of Cardiology/American HeartAssociation consensus report, as well as Agency for Health CarePolicy and Research (now the Agency for Healthcare Research andQuality) clinical practice guidelines. One specific goal of implement-ing the guidelines was to optimize use of vasodilator therapy (i.e.,angiotensin-converting enzyme [ACE] inhibitors, hydralazine). Localcardiologists assisted with developing guideline implementationgoals consistent with the local environment. Monitoring of care bythe nurse manager provided information about guideline compli-ance.

Fifty-one patients with the clinical diagnosis of HF were followed fora mean of 138 days after program enrollment. Compared with the6 months before program enrollment, medical resource utilization

declined significantly after enrollment. For example, utilization ratesfor general medical visits, cardiology visits, HF-related emergencydepartment visits, and total emergency department visitsdecreased by 23%, 31%, 67%, and 53%, respectively. Comparedwith the 12 months before enrollment, hospitalizations for HFdecreased significantly (by 87% from 1.12 to 0.15 per year) and thetotal hospitalization rate decreased significantly (by 74% from 1.61to 0.42 per year). Functional status, symptomatic status, andhealth-related quality of life also improved during the intervention asdetermined by the Duke Activity Status Index, New York HeartAssociation functional class, and the Short Form-36. The programalso achieved pre-established pharmacologic and dietary goals,with significant increases in dosages of ACE inhibitors andhydralazine. For example, the percentage of patients taking targetdosages of the ACE inhibitor lisinopril increased from 45% to 83%.For hydralazine, the percentage of patients taking target dosagesincreased from 10% to 70%. Self-reported use of dietary sodiumsignificantly decreased. The total contact time between nurse man-agers and patients (including the initial 2-hour visit) averaged 7.0hours. The authors concluded that the MULTIFIT system enhancedthe effectiveness of pharmacologic and dietary therapy for HF inclinical practice, improving outcomes and compliance and reducingmedical resource utilization.

The benefit of implementing a heart failure disease manage-ment program.Whellan DJ, Gaulden L, Gattis WA, et al.Archives of Internal Medicine. 2001;161:2223-2228.

The effects of a congestive heart failure (CHF) disease managementprogram on medication use, hospitalization rate, number of clinicvisits, and costs were evaluated in a randomized, prospective studyof 117 patients with a recent hospitalization for CHF, an ejectionfraction less than 20%, or symptoms consistent with New YorkHeart Association functional class III or IV. The program involvedthe use of treatment protocols, follow-up clinic visits and telephonecalls, and a patient education manual.

The mean enrollment time was 4.7 months. The use of angiotensinconverting-enzyme inhibitors was high at baseline (78%) and didnot change significantly as a result of the intervention (79%). Theuse of beta-blockers increased significantly from baseline (52%) tothe end of enrollment (76%).

As a result of the intervention, the hospitalization rate decreasedsignificantly from 1.5 hospitalizations per patient-year to none, andthe number of clinic visits increased significantly from 4.3 clinic vis-its per patient-year to 9.8 clinic visits per patient-year. The outpa-tient cost per patient-year increased by $659, and the inpatientcost per patient-year decreased by $6,963. The cost per dischargealso decreased. A total cost savings of $8,571 per patient-yearwas associated with the intervention.

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Uptake of self-management strategies in a heart failuremanagement programme.Wright SP, Walsh H, Ingley KM, et al.The European Journal of Heart Failure. 2003 Jun;5(3):371-380.

The effectiveness of an integrated outpatient heart failure (HF) man-agement program was evaluated in a 12-month, randomized con-trolled trial involving 197 patients with a first diagnosis or exacerba-tion of HF who were admitted to a New Zealand hospital. The inter-vention entailed HF clinic visits every 6 weeks, with counseling by anurse specialist and optimization of drug therapy; patient educationsessions; telephone follow-up as required; provision of diaries forrecording daily weights; and instructions on performing daily weightmeasurements. A control group received usual care without struc-tured patient education, provision of a diary, or advice on self-man-agement. Patients were encouraged to purchase scales for homeuse; the clinic did not purchase scales for use by patients.

The intervention had no effect on deaths or hospital readmissions,but it decreased total bed days and multiple readmissions, andimproved quality of life. Seventy-six of the 100 patients randomizedto the intervention group used the diaries, and these patients tend-ed to receive more medications, were more likely to attend patienteducation sessions and make clinic visits, and were less likely todie during the study than patients who did not use the diaries. Ofthe 76 patients who used the diaries, 51 patients weighed them-selves regularly; these patients tended to own scales at home,attend education sessions, and experience fewer hospital admis-sions than patients who did not weigh themselves regularly. At theend of the study, knowledge of self-management was greater in theintervention group than in the control group.

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Appendix C.

Method of Identifying Population for

Size of Whom Data Are Intervention Guideline Audience for Primary Manager Author(s) Population Evaluated Strategy Based? Intervention of Intervention

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

Anon, 1998 Nearly 5,000 Not specified Home visit by Yes, Agency for Patients Cardiac nursespatients with home health Health Care PolicyCHF agency nurse to and Research

assess patient (now the Agency status, diet, for Healthcare medication Research and compliance; Quality), Americanpatient workbook Heart Associationfor assistance guidelineswith disease management;nurse visits and telephone contact

Anon, 2000 95 patients Not specified Telephone case Not specified Patients Cardiac care with CHF management nurses

system (patient education)

Anon, 2001 69 elderly Claims data and Computer-based Not specified Patients Nurse(Disease patients with physician referrals (Internet) or Management moderate to telephone Advisor. 2001; severe CHF (interactive voice 7[7]:103-106) response)

reporting by patients of self-measured blood pressure, pulse, weight, and CHF symptoms

Anon, 2001 159 patients Monthly automated Patient education Not specified Patients Program (Disease with CHF review of claims primarily by coordinatorManagement data using an telephoneAdvisor. 2001; algorithm7[6]:92-96)

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Economic Outcomes Time Period Study/Evaluation Effects Measured Studied Design Assessed Setting Key Results

Hospital admissions, 2 years Not specified, but no Inpatient health Health plan The intervention reducedinpatient costs, control group identified care costs members both hospital admissionshospital days, decreased 61% receiving home and hospital days by 58%ED visits care from and ED visits by 49%.

contracted homehealth care agency

New York Heart 6 months before Controlled pre-and Hospital and total Patient homes Functional class Association and after post-intervention costs decreased by quality of life improved.functional class, comparison 64% and 68%, The hospitalizationquality of life, respectively rate decreased by 49%.hospital and ED ED use did not change.use, costs

Hospitalizations, 1 year RCT Cardiac costs per Patient homes There were 20 hospital days, cardiac patient per month hospitalizations for a total costs decreased by $247 of 149 days in the

in the computer computer group and 39 group and $265 in hospitalizations for 258 the interactive voice days in the interactive response group, voice response group.and increased by$135 in the usual-care (control) group

Self-reported 18 months Pre- and post- Overall costs Patient homes Disease knowledge and disease knowledge intervention decreased by ~35% functional status and functional health; comparison due to decreases improved in 93% and 56%ACE inhibitor use; in ED use and of patients, respectively.ED use; hospital hospital admissions ACE inhibitor use increasedadmissions and LOS and LOS by more than 20% to 65%.

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Appendix C. (continued)




Anon, 2001 117 patients Hospitalization for Planning before Not specified Patients Attending physicians,(Clinical Resource with CHF CHF within past 6 hospital discharge; nurse practitioners,Management) months, New York clinic and nurse specialist,

Heart Association telephone pharmacist, socialfunctional class III follow-up; and worker, and or IV, and ejection patient education nutritionistfraction <20% about medications,

diet, and care plan

Anon, 2001 Not specified Not specified Software program Not specified Patients with CHF Nurse case managers(Data Strategies & and appliance for Benchmarks) use at home by

patients to transmit health data to nurse case managers

Anon, 2002 10 patients Inpatients judged Use of a home- Not specified Patients Nurse practitionerwith CHF in need of extra based device to

support and measure and reinforcement and electronically outpatients with transmit weight, poor understanding blood pressure, of disease and heart rate, oxygenfrequent physician saturation, andor ED visits temperature to

a central location on a daily basis

Bertel O, 25 patients with Consecutive Special CHF Not specified Patients and Not specifiedConen D, 1987 severe CHF patients referred to program focused physicians

institution because on:of severe CHF (1) individualized refractory to medical therapytreatment for CHF,

(2) antiarrhythmic treatment and close follow-up visits, and (3) continuous education of patients and physicians to improve treatment compliance and early management of complications

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Use of target Not specified Pre- and post- Outpatient costs University Use of target dosages of dosages of ACE intervention increased by 27%, medical center ACE inhibitors and beta-inhibitors and comparison inpatient costs blockers increased.beta-blockers, clinic decreased by 38%, Hospitalization rate visits, hospitalization and total cost of decreased from 1.86 to rate and LOS care decreased by 1.21 times per patient per

37% year. Average LOS decreased from 7.67 to 6.07 days. Rate of clinic visits increased from 7.8 to 12.9 visits per patient year.

Hospitalizations, Not specified Pre- and post- The savings in Patient homes Hospitalizations and ED ED visits, bed days intervention direct costs was visits decreased by 23%.

comparison $1,266 per patient Total number of bed days per year decreased by 50%.

Hospitalizations, 3 months Pilot study None Inpatient and Hospitalizations and ED ED visits, patient outpatient visits were eliminated andsense of well-being patient well-being and and understanding of understanding of the the disease disease were significantly

improved.

Survival, outcomes Not specified, but Nonrandomized None University-based The 1-year survival in the of medical treatment 1-year and 2-year observational with hospital in intervention group (92%) for CHF, outcomes survival rates were comparison with Switzerland was significantly higher of medical treatment provided for the pre-existing “control” than that in the control for arrhythmias intervention group group group (43%). The 2-year

survival rate for theintervention group (83%) compares favorably with previously reported survival rates.

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Bouvy ML, 152 patients Patients admitted Patient interviews Not specified Patients PharmacistHeerdink ER, with CHF to the hospital or about medication et al., 2003 attending a compliance with

specialist monthly follow-upoutpatient CHF contactclinic

Capomolla S, 234 patients Referral through an Cardiovascular Yes, American Patients MultidisciplinaryFebo O, et al., 2002 with HF unspecified risk stratification, College of

process creation of an Cardiology/Americanindividualized Heart Associationplan of care, and health care education and counseling

Cardozo L, 290 elderly Random selection Implementation of Yes, internally Health care Clinical nurse Aherns S, 1999 patients with of patients (age internally developed clinical providers manager

CHF >65 years) developed clinical pathway for CHF monitoring presenting to a pathway for CHF management processes of care;tertiary-care intended to variances in care teaching hospital improve care for reported to for CHF elderly patients attending physicianmanagement over and improve for corrective a 1-year interval resource utilization action

Chapman DB, 67 patients Not specified Comprehensive Yes, internal Patients (education, Registered nurseTorpy J, 1997 with CHF outpatient protocols support, home with CHF

program offering established by the health care); training (nursestandardized care, Heart Failure physicians coordinator) inpatient education, Center based on (education about conjunction withoutpatient infusion both the 1994 program and physician medical of inotropic agents, Cardiology protocols used) director and electronic linkages Preeminence administratorbetween clinic Report on CHFand ED, and and a 2-day home health care cardiology nurse visits roundtable meeting

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Medication 6 months RCT None Outpatient clinic, Medication compliance compliance, hospital, and was greater in therehospitalization, home intervention group than in mortality, and qualify the control (usual-care) of life group. There were no

significant differences between the two groups in rehospitalization, mortality, or quality of life.

Cardiac deaths, 12 months RCT There was a cost Day hospital and Cardiac deaths and hospital readmissions, savings of $1,068 community readmissions were New York Heart for each quality- significantly lower and Association functional adjusted life-year New York Heart Associationclass gained by using the functional class was more

intervention instead likely to improve in the of usual care intervention group than in

the control (usual-care) group.

LOS, cost of care, 12 months Randomized Significant reduction Tertiary-care LOS decreased from 6.36mortality, readmission retrospective pilot in variable cost of teaching hospital days (for controls) to 5.25statistics, and study $776 per patient in metropolitan days (with pathway).performance rates of attributed to Detroit Performance of three of processes of care shorter LOS six processes of care

improved. However, rate of readmission increasedfrom 9.25% (in controls) to13.5% (with pathway).

Hospital admissions, 12 months before Observational pre- and Potential for Hospital at Hospital admissions, number of hospital and 16 months post-intervention decreased costs tertiary-care hospital days, and averagedays, average LOS after enrollment comparison due to less medical center LOS decreased by 30%,

frequent followed by 42%, and 17%, hospitalization outpatient clinic respectively.(estimated cost of and home care1 year of clinic treatment was$2,000 vs. $9,000 for average cost ofsingle admission)

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Civitarese LA, 20 physicians All patients of a Internally Yes, internally Physicians; PhysiciansDeGregorio N, in private private community developed clinical developed clinical patients as 1999 community medical group practice guideline practice guideline secondary

medical group; admitted to the integrated with for treatment recipients275 patients hospital during the monthly quality of CHFwith CHF study interval with improvement

a confirmed meetingsdischarge diagnosis of CHF (ICD-9 code 428)

Cline CM, 190 adults Recruited from Education None for evaluation Patients and Registered nurses Israelsson BY, with HF patients admitted about HF or treatment families with experienceet al., 1998 to university (pathophysiology, specific to the treating patients

hospital for HF over treatment); study; patients with HF2-year interval guidelines for received self-

self-management management of diuretic therapy; guidelines for follow-up at diuretic therapynurse-directed outpatient clinic

Costantini O, 582 inpatients Hospital Care management, Care Patients Nurse care Huck K, et al., 2001 with CHF inpatients with daily use of recommendations manager, faculty

new care were based on cardiologist, and guidelines national guidelines physician

representative from part-time faculty

Dennis LI, 24 Medicare “Convenience” Assessment and Use of agency Patients who were Home health Blue CL, et al., patients with sample drawn from patient teaching nursing care plans Medicare care nurses1996 CHF and pool of Medicare interventions and Medicare beneficiaries

18 Medicare beneficiaries administered to regulations patients with receiving home patients by home appropriate forCOPD health care for health care nurses patients with CHF

CHF or COPD or COPD

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Rates of classifying 21 months Prospective None Patients Rates of classifying systolicsystolic and diastolic hospitalized at and diastolic dysfunctiondysfunction, use of Pittsburgh medical remained unchanged.ACE inhibitors, groups’ primary ACE inhibitor usehospitalization rates, community-based increased by 39%.documentation of hospital Quarterly admissions for discharge instructions systolic dysfunction-based

CHF decreased by 49%.Documentation of patient discharge instructions was suboptimal.

1-year survival rates, 1 year Prospective, Mean cost of Swedish university The intervention did not time until randomized trial intervention: $208 hospital clinic and affect 1-year survival rate, readmission, days in per patient (US); patient homes but it increased the numberhospital, health care Mean annual of days until readmissioncosts reduction in overall (141 vs. 106 in control

cost: $1,300 per group), and decreased thepatient number of days in

hospital (4.2 vs. 8.2).

Quality of care 1 year Controlled pre- and Care management Large university Care management (use of inhibitors, post-intervention was associated with medical center improved quality of care documentation of comparison a $2,204 reduction and reduced median echocardiography, in hospital costs hospital LOS from 5 days daily weight to 3 days.measurement) and hospital LOS and costs

Hospital readmission 12 months Retrospective chart None Patient homes A significant relationship rates review (nonexperimental was found between certain

research design) interventions implemented by home health care nurses and hospital readmission rates amongMedicare patients with CHFor COPD. Hospitalization readmission rates significantly decreased as the number of nurse visits and assessment-based interventions increased.

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Dimmick SL, Not specified Recruited from Telehealth disease Not specified Patients Registered nursesBurgiss SG, et al., county residents management 2003 (videoconferencing,

telephone conversations, and remote monitoring of blood pressure, blood oxygen saturation, and pulse)

Discher CL, 593 patients Patients admitted Treatment Yes, Agency for Patients and health Nurse case Klein D, et al., 2003 with CHF to the hospital who algorithm/clinical Health Care Policy care professionals manager

had physician pathway and and Research (nowsupport, and education of the Agency for adequate cognitive health care Healthcare ability and living professionals and Research and conditions for patients Quality)program participation

Doughty RN, 197 patients Patients admitted Clinical review at Yes, Agency for Patients NurseWright SP, et al., with HF to a hospital with a clinic, individual Health Care Policy2002 a primary diagnosis and group and Research

of HF education (now the Agency sessions, a for Healthcare personal diary to Research and record medication Quality)administration and body weight measurements, information booklets, and regular clinical follow-up

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Weight control (a 13 months Not randomized or A reduction in cost Homes and Weight control was measure of controlled of care for CHF clinics achieved by more than 50%medication and hospitalizations of patients as a result of dietary compliance), from $8 billion the intervention. Sleepmood (sleep problems, to $4.2 billion was problems improved, fatigue, depression, projected annually although feelings of and appetite), and on a national basis fatigue, depression, and hospitalization rate loss of appetite increased.and costs The hospitalization rate

decreased from 1.7 times per patient per year to 0.6 per patient per year, and the hospital LOS decreasedfrom a national benchmark of 6.2 days to 4 days.

Average hospital 1 year Pre- and post- There was a Community The intervention led to aLOS and costs, intervention significant reduction hospital significant reduction in documentation of left comparison in cost per patient average LOS from 6.1 ventricular ejection from $6,828 to days to 3.9 days, fraction and ACE $4,404 improvement in inhibitor use, and documentation of leftnurse satisfaction ventricular ejection

fraction and ACE inhibitoruse, and high nurse satisfaction.

Number of patients 12 months RCT None Hospital-based There was no significant who died or were clinic difference between the readmitted to the intervention group and the hospital, number of control (usual-care) group bed days, and quality in the number of patients of life who died or were

readmitted to the hospital.The intervention was associated with fewer multiple readmissions and bed days, and greater improvement in the physical-functioning component of quality of life than usual care.

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Duncan K, 16 patients Recruited from an Exercise plus Not specified Patients Research nursePozehl B, 2003 with HF HF clinic adherence

involving individualized goal setting, graphic feedback on goals, and problem-solving support

Fonarow GC, 214 heart Patients with HF Comprehensive Patients educated Patients and their Education by HFStevenson LW, transplant presenting for heart management in accordance with families clinical nurse et al., 1997 candidates transplantation program by HF Heart Failure specialist; follow-up

evaluation who met transplant team Practice Guidelines; care provided by eligibility featuring a systematic HF cardiologistsrequirements (i.e., systematic adjustment of stable for hospital approach to drug medications discharge; no therapy; patient described, but nocontraindications; education (diet, specific guidelinesnot “too well”) exercise, self- identified

monitoring); and regular telephone and clinic follow-upwith HF team after discharge

Gattis WA, 181 adults with Patients with HF Evaluation by a Target dosages of Patients Clinical pharmacist Hasselblad V, et al., HF and left and left ventricular clinical pharmacist, ACE inhibitors 1999 ventricular dysfunction including used were in

dysfunction (ejection fraction medication accordance with<45%) undergoing evaluation, those establishedevaluation at therapeutic by randomizeduniversity-affiliated recommendations controlled trial clinic to physician,

patient education, and follow-up telemonitoring

Gilbert JA, 1998 Unidentified Not specified Telephone-based Not specified Patients Not specified, but number of disease multidisciplinarypatients with management team mentionedCHF system, designed

to monitor patients after hospital visits and provide education and support

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Maximum oxygen 24 weeks RCT None Cardiac All outcomes were betteruptake (a measure of (12 weeks rehabilitation than at baseline in the exercise capacity), supervised and facility and home intervention group.dyspnea, fatigue, 12 weeks Adherence to the exercisewalk-test unsupervised) regimen during the performance, unsupervised weeks wasquality of life significantly better in the

intervention group than in the control group.

Functional status, 6 months before Nonrandomized, Estimated savings in Heart Functional status improved hospital readmissions, and at least observational (pre- hospital readmission transplantation and hospital readmissionmanagement costs 6 months after and post-intervention costs of $9,800 per center rate decreased by 85%

intervention comparison) patient; estimated with the intervention.(3-year interval) cost of intervention:

$200-$400 per patient

Primary endpoints: 6 months (median Double-blind None Duke University, All-cause mortality and HFall-cause mortality patient follow-up randomized general cardiology clinical events decreased and nonfatal HF interval) controlled trial faculty clinic and ACE inhibitor use andclinical events (ED dosage improved with the visits or hospitalization intervention.for HF); secondary endpoints: ACE inhibitor use and dosage

Hospital readmission 9 weeks Observational (pilot) None Patient homes Hospital readmission ratesrates study (telemanagement decreased from 76% to

through Crozer- 18% with the intervention.Keystone HealthSystem, a Springfield, PA-based integrated delivery system)

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Goodyer LI, 100 elderly All elderly patients 3 months of Patient instruction Patients PharmacistMiskelly F, et al., patients with at a London clinic intensive based on protocol, 1995 chronic, stable who met inclusion medication but no specific

HF criteria counseling by a guidelines werepharmacist identified

Gorski LA, 51 patients Claims analysis, Education (regular Yes, American Patients NurseJohnson K, 2003 with HF health risk telephone calls, College of

assessment, and mailings) and Cardiology/Americanreferrals from coordination and Heart Associationutilization managers, promotion of case managers, interdisciplinaryphysicians, and patient care patients using community

resources, newsletters, and referrals to a home health care program

Hanumanthu S, 134 patients All patients Comprehensive Not specified Patients and Physicians who Butler J, et al., 1997 with HF referred to Heart management by providers (providers work exclusively

Failure and Heart HF specialists/ participated in with HF and heart Transplantation transplant team, periodic meetings transplant patients;Program (by including medical with affiliated home assisted by nurse cardiologists) management, health agency and coordinators andduring a 1-year cardiovascular hospice to home health careinterval testing, and integrate patient agencies

medication care)adjustments

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Medication knowledge, 3 months Prospective RCT None Outpatient clinic Medication compliance medication compliance, for the elderly at increased by 32% and results on submaximal Charing Cross knowledge improved with6-minute exercise Hospital, London the intervention. Results test, visual analogue for the 6-minute exercisescores of test improved by 20 breathlessness, meters for the interventionNottingham Health group and worsened byProfile scores, 22 meters for the controlclinical signs of HF patients. Nottingham(e.g., edema) Health Profile scores did

not change for either group.Distance to breathlessnessand peripheral and pul-monary edema scoresimproved only in the inter-vention group.

Hospitalization rate, 9 months Pre- and post- A cost savings of Home The intervention led to a self-care behaviors, intervention $165,000 was substantial decrease inand patient satisfaction comparison projected hospitalization rate and an

increase in self-carebehavior, and patient satisfaction was good, very good, or excellent.

Annual hospitalization Follow-up intervals Nonrandomized, None Vanderbilt Heart The intervention reduced rates, peak exercise ranging from observational pre- and Failure and Heart cardiovascular- and HF-capacity, and 30 days to 1 year post-intervention Transplantation related admissions by 53%medication use compared with comparison Program and 69%, respectively, and

similar period improved functional statusbefore intervention compared with earlier

care.

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Harrison MB, 200 patients Patients screened Transitional care Yes, Agency for Patients NursesBrowne GB, with CHF during (telephone Health Care Policyet al., 2002 hospitalization outreach within and Research

24 hours after (now the Agency discharge, for Healthcare consultations Research and between hospital Quality) guidelinesand home care nurses, patient education, and supportive care for self-management)

Heidenreich PA, 68 patients Use of medical Multidisciplinary Patient educational Patients NursesRuggerio CM, with HF claims database program consisting materials based (education, self-et al., 1999 to identify patients of patient on Agency for monitoring

with an HF claim education, daily Health Care techniques);>$50, a self-monitoring and Policy and physicians hospitalization for telephone Research (now (notification of HF, or recent ED transmission of the Agency for problems based visit for HF, with data, and Healthcare on results of subsequent contact physician Research and patient self-of patient’s notification of Quality) monitoring)physician abnormal weight guidelines for

gain, vital signs, patients with HFand symptoms

Hershberger RE, 108 outpatients Referred because Use of current Yes, Agency for Patients Cardiologists, Ni H, et al., 2001 with CHF of chronic, practice guidelines Health Care Policy specially trained,

symptomatic CHF for treating CHF, and Research experienced frequent telephone (now the Agency nurses, and a contact between for Healthcare social workernurses and patients, Research and pre-emptive Quality) and hospitalization, American Heart patient education Association/

American College of Cardiology guidelines

Hinkle AJ, 2000 Not specified Electronically Internet-based Not specified Patients Not specifiedidentified from disease claims data management

(assesses willingness to change, educates about CHF, promotes positive behavioral change)

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Disease Managem



Health-related quality 12 weeks RCT None Hospital and Health-related qualityof life, rates of hospital patient homes of life was significantly readmission and better in the transitional-ED visits care group than in the

usual-care group. The hospital readmission rate did not differ significantly (23% vs. 31%). ED visits were significantly lower in the transitional-care group(29% vs. 46%).

Primary endpoints: Approximately Nonrandomized, Estimated cost of Community setting Hospital days per year total claims (costs) 1 year (mean matched-control study program was $200 (patient homes) significantly decreased per year, admissions follow-up 7.4 per patient per from 8.6 (in previous year)per year, hospital months) month; estimated to 4.8 in intervention days; secondary mean savings per patients, while increasing endpoints: patient year was $9,000 from 8.9 to 17 in control compliance with (difference in cost patients. Number of self-monitoring, between groups) admissions per year did number of physician not differ significantly notifications, between the two groups.quality of life

Patient self-care 6 months before Pre- and post- Average estimated Outpatient setting Patient self-care knowledge and daily and 6 months intervention cost savings knowledge, daily weight weight measurement, after referral comparison associated with measurement, and quality severity of illness, ED reduced of life increased, and use, hospitalization, hospitalization was severity of illness and quality of life $4,307 per patient decreased. Hospitalization

rate and ED use decreased from 56% and 54%, respectively, before referralto 27% and 15%, respectively, after the program.

Frustration with CHF, Not specified Not applicable None Third-party Decreased frustration knowledge of CHF, insurer with CHF in >90% ofquality of life patients, increased

knowledge of CHF in >82% of patients, improvedquality of life in >50% ofpatients.

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Jerant AF, Azari R, 37 patients Patients admitted In-person nurse Yes, Visiting Patients Nurseet al., 2003 with CHF to a university visits shortly after Nurses

hospital with a hospital discharge Association and primary diagnosis and after 60 days, Advisory Council of CHF plus telenursing to Improve

(video-based Outcomes home telecare or Nationwide in telephone calls) Heart Failure

Kasper EK, 200 patients Patients Outpatient Not specified Patients MultidisciplinaryGerstenblith G, with CHF hospitalized with program with et al., 2002 CHF who were periodic follow-up

at increased risk telephone callsfor readmission and visits, an

individualized treatment plan, a treatment algorithm, and provision of a scale, low-sodium meals, telephone, and transportation if needed

Knox D, Not specified Not specified Integrated Clinical pathway Patients and MultidisciplinaryMischke L, 1999 multidisciplinary for LOS based on providers team, with

program of Agency for Health advanced inpatient Care Policy and practical nurse consultation and Research (now coordinating andeducation, patient the Agency for supervising outpatient clinic Healthcare compliance visits, cardiac Research and monitoringhome care, and Quality) guidelinesmonitoring of compliance through automated telemanagement program


[57]

Disease Managem



CHF-related hospital 180 days Pre- and post- CHF-related Home The number of ED visitsreadmissions and intervention readmission was significantly lower withED visits comparison charges were telenursing than with

>80% lower with usual care.telenursing than withusual care

Hospital 6 months RCT The cost per patient Home There were significantlyreadmissions, was similar with the fewer hospital mortality, symptoms, intervention and readmissions and deaths,and quality of life usual-care groups patients were less

symptomatic, and qualityof life improved to agreater extent in the intervention group compared with theusual-care group.

Patient satisfaction, 18 months for Outcome data None Evanston Satisfaction was high andcompliance with compliance; other presented, but not a Northwestern compliance rate averagedautomated periods of tracking defined study Healthcare 89.5%. CHF telemanagement not indicated hospital and clinic, hospitalization rate wasprogram, and patient 0.6 per patient per year hospitalization homes vs. national benchmark rate, 30-day of 1.7 per patient per readmission rate, year. The 30-day LOS readmission rate was

2.3% (vs. 23% nationally). LOS was 4 days (vs. national average of 6.2 days).

[58]

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Kornowski R, 42 elderly Individuals Home Not specified Patients Internal medicine Zeeli D, et al., 1995 patients with participating in surveillance physicians;

severe CHF home surveillance program collaboration with program for ≥1 year involving paramedical personnelwho met other home visits byinclusion criteria internists and (history of paramedical hospitalization in personnel for preceding year, evaluation,ejection fraction recommendations<40%) to patient (i.e.,

education), and treatment

Kostis JB, 20 patients Not specified Nonpharmacologic Not specified Patients Treatment team, Rosen RC, et al., with CHF treatment program, including physicians,1994 consisting of psychotherapist,

exercise, dietary dietician, and staffcounseling, at cardiovascularcognitive therapy, rehabilitation facilityand stress management

Krumholz HM, 88 patients Patients at least Targeted education Not specified Patients Experienced Amatruda J, et al., with HF 50 years old who and support cardiac nurse2002 were hospitalized intervention with

with HF telephone follow-up

LaFramboise LM, 90 patients Patients discharged Home visits, Yes, Agency for Patients Research nurseTodero CM, et al., with HF from the hospital telehealth Health Care Policy2003 within the previous communication and Research

6 months with a device, or both (now the Agencyprimary diagnosis compared with for Healthcareof HF telephonic case Research and

management Quality)

[59]

Disease Managem



Total and 12 months before Nonrandomized, pre- None Home care A home surveillance cardiovascular-related and after and post-intervention surveillance program significantlyhospital admissions, intervention comparison program in decreased total and hospital LOS, Tel Aviv cardiovascular-relatedfunctional status, hospital admissions andmedication use hospital LOS in elderly

patients with severe CHF,and significantly improved self-reported functional status.

Ejection fraction, 12 weeks Randomized, None University of Compared with digoxinexercise tolerance, controlled, Medicine and therapy and placebo, the anxiety and parallel design Dentistry of nonpharmacologic depression scores New Jersey— intervention resulted in(mood), weight loss Robert Wood significant improvements

Johnson Medical in exercise tolerance,School weight control, and

mood. In contrast, digoxin significantly improved ejec-tion fraction but not exer-cise capacity or quality oflife.

Rate of hospital 1 year RCT The intervention Home The percentage of patientsreadmission or death reduced hospital who died or were

readmission costs by readmitted to the hospital $6,985 per patient was significantly lower in

the intervention group (57%) than in the controlgroup (82%). The interven-tion reduced the total num-ber of readmissions by39%.

Self-efficacy (i.e., 2 months Pilot RCT None Home Self-efficacy worsened inlevel of confidence in the telephonic case making lifestyle and management group andbehavioral changes increased in the other related to HF three groups. Functional management), status, mood, and qualityfunctional status, of life improved from mood, and quality baseline in all four groups;of life there were no significant

differences between thegroups in these measures.

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Laramee AS, 287 patients Patients admitted Early discharge Yes, Agency for Patients NursesLevinsky SK, with CHF to the hospital planning, patient Health Care Policyet al., 2003 with a primary or and family and Research

secondary education, (now the Agencydiagnosis of CHF 12 weeks for Healthcareand a left of telephone Research andventricular ejection follow-up, and Quality), fraction <40% or promotion of American radiologic evidence optimal CHF College of of pulmonary medications Cardiology/Americanedema requiring Heart Association,diuresis Heart Failure

Society of America

Lasater M, 1996 80 patients All patients Program at Unidentified Patients Registered nurses;with CHF or hospitalized at nurse-managed critical-path collaboration bycardiomyopathy local medical CHF clinic algorithms directed physicians

center for CHF emphasizing nurse-provided care (cardiologists), or cardiomyopathy precautions to dieticians, social were automatically reduce risk of workersenrolled in CHF hospital precautions clinic readmissionfor follow-up after (patient education,hospital discharge cardiopulmonary

assessment, daily weights, assessment of medication compliance)

Lazarre M, 34 patients All patients who Cardiac care Unidentified Patients and Nurses with a Ax S, 1997 with HF entered cardiac program for home critical pathways families critical-care

care program care featuring used to guide background during 7-month targeted teaching, targeted teaching contracted bycourse of study close monitoring home health who also met by cardiac-trained care agency;inclusion criteria nurses, collaboration

cardiovascular with assessment, and multidisciplinaryearly teammanagement of HF exacerbations


[61]

Disease Managem



90-day hospital 90 days RCT The total inpatient Hospital and The 90-day readmissionreadmission rate, and outpatient home rate was the same (37%)costs, and patient median cost and for both groups.adherence the readmission Adherence to the

median cost were treatment plan was reduced by 14% and significantly better in the26%, respectively intervention group than in

the control group.

Patient knowledge 1 year (6 months Nonrandomized, Comparison of Nurse-managed The intervention decreasedof medications, before and after observational hospitalization CHF precautions hospital readmissionshospital readmission intervention) (pre- and post- charges after clinic associated (22% vs. 26%) and LOS rates, hospitalization intervention intervention ($6,404) with South (5.7 days vs. 7.3 days), costs comparison) vs. before Carolina Medical and improved patient

intervention ($6,898) Center knowledge of medications.revealed a savingsof almost $500 perpatient

Hospital readmission 7 months Nonrandomized, None Patients 30-day and 90-day rates 30 and 90 days partially controlled receiving home readmission rates after program (results compared with care according (2.9% and 8.8%, enrollment national averages) to a home health respectively) were lower

care agency- than national averages sponsored (16% for 30 days and 32% cardiac program for 90 days).

[62]

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Martens KH, 924 patients Use of Home health care Not specified Patients Home health Mellor SD, 1997 with CHF computerized nursing care nurses

discharged to medical records to interventions home (study identify all CHF focused on patient aim #1); 120 patients in hospital assessment andpatients with system who were teachingCHF and discharged to home,referral to with or without specific home referral to homehealth care health care, overagency (study a given intervalaim #2)

Morrison RS, 50 patients Random selection Hospital-based, Yes, institutional Care providers Nurse case Beckworth V, 1998 with CHF from patients nursing care critical pathways manager

hospitalized within management developed by a a 6-month interval model involving continuous qualitywith a primary the development improvement teamdiagnosis of CHF and implementation(ICD-9 code 428) of a critical

pathway for CHF care

Mueller TM, 200 patients Not specified Telemanagement Yes, Heart Failure Patients Advanced-practice Vuckovic KM, with HF and a diuretic Society of America nurseset al., 2002 treatment and others

algorithm

Nobel JJ, 78,038 member Members of a Remote biometric Not specified Patients Cardiac nursesNorman GK, 2003 months with health maintenance measuring and

age >65 years organization monitoring device,and 7,477 and interactive member months communication with age between nurses<65 years and patients

[63]

Disease Managem



Hospital readmissions 3 months (follow-up Retrospective chart None Patient homes Patients who receivedwithin various 90 days after audit home health care nursingintervals, compliance intervention) services were readmittedwith intervention to the hospital implementation significantly less often

(28% vs. 42%) within 90 days after hospitaldischarge than patientsnot receiving suchservices.

Hospital LOS, costs Calendar year Retrospective chart The estimated Acute-care Mean LOS in 1996 with(fixed, variable, 1996 review mean fixed, variable, hospital in the implementation of thetotal), physiologic and total costs for southeastern nursing care management status, physical 50 patients treated United States model was 5.4 days vs.functioning, health according to this ~17 days in 1991 before knowledge, and model were $2,491, implementation.family caregiver $1,858, and $4,291, Regression analysisstatus respectively identified number of

medications as the onlypredictor of LOS. Guidelinecompliance was suboptimal.

Patient compliance 2 years Not randomized or Hospital costs for Home Patient compliance waswith telephone calling controlled treating HF high (90%). The 30-dayprogram, 30-day decreased by 52% readmission ratehospital readmission decreased from 2.3% inrate, hospitalization 1997-1999 to 0.7% in rate, and costs 1999-2001. The

hospitalization rate decreased by 50%.

Hospital days per 12 months Controlled but not The intervention Home The intervention reducedthousand members randomized reduced the costs hospital days per thousandper year paid per member members per year by 53%

per month by 50% in patients >65 years oldin patients >65 and by 62% in patientsyears old and by <65 years old.60% in patients <65 years old

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O’Connell AM, 35 indigent Patients admitted Multidisciplinary Yes, Agency for Patients Cardiologists, Crawford MH, patients with to university disease Health Care Policy nurse practitioneret al., 2001 CHF not hospital with high management and Research with specialized

eligible for hospitalization rate program (monitoring (now the Agency training and transplantation or referred by at clinic, telephone for Healthcare experience caring

primary care contact, patient Research and for cardiacphysician because education, Quality) guidelines patients, socialof high risk of medication for medications worker, pharmacist,hospitalization consultation, dietitian, cardiacdue to financial, referral to rehabilitation teamsocial, or dietitians and nonadherence other specialists)issues

Oddone EZ, 443 patients Random invitation Enhanced access Appropriate Patients Primary care Weinberger M, with CHF of CHF patients to primary care, utilization of ACE physician/registeredet al., 1999 treated at one of including inhibitors assessed nurse team

nine Veterans assignment to using Agency forAffairs medical primary care Health Care center study sites nurse and Policy and

physician team, Research (now patient education, the Agency forincreased Healthcare telephone contact, Research andand additional Quality) guidelinesoutpatient visits (guideline

implementation not described);American Heart Association materials used for patient education

Paul S, 2000 15 patients A “convenience” Nurse practitioner- Nurse practitioner Patients and their Nurse practitionerwith CHF sample of patients managed, provided care in families in collaboration

who were admitted multidisciplinary accordance with with multidisciplinary to a university- outpatient clinic unidentified clinic teamaffiliated clinic offering patient protocols

education, assessment and treatment by a multidisciplinary team, frequent monitoring via nurse telephone calls and visits, and on-demand clinic visits for worsening signs of CHF


[65]

Disease Managem



Functional status 1 year before and Nonrandomized, There was a net Clinic Functional status improved(severity of illness), year after pre- and post- savings of $4,600 and the need for hospitalization rate, 1enrollment intervention per patient hospitalization decreased.and hospital and comparisonclinic costs

Diagnostic evaluation, 6 months of Multisite RCT None Nine Veterans Compliance with pharmacologic follow-up after Affairs medical recommended CHFmanagement, randomization centers (inpatient testing and treatment washealth-related and clinic care) similar among the quality of life, and patient homes intervention and control hospital readmission groups. Enhanced accessrates to primary care did not

improve patients’self-reported health status and was associated with morefrequent hospitalizations (1.5 readmissions in6 months vs. 1.1 in thecontrol group).

Total hospital 6 months before Nonrandomized Mean inpatient Nurse practitioner- Clinic enrollment readmissions, total and after selection with hospital charges managed, decreased hospital hospital days, mean intervention subjects serving as decreased from multidisciplinary admissions (and days)LOS, ED visits, (clinic enrollment) own controls $10,624 per patient outpatient clinic from 38 (151 hospitalcharges, and admission to $5,893; affiliated with days) to 19 (72 hospitalreimbursement mean ED visit university hospital days). It also decreased

charges decreased mean LOS (4.3 days vs.from $390 to $284 3.8 days) and number of

ED visits (10 vs. 8).

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Philbin EF, 1,504 patients Selected based on Multifaceted quality Critical pathways Patients and health Physicians, nurseRocco TA, et al., with HF at diagnosis-related improvement were based on care staff leaders, 2000 acute-care grouping (inpatient, ED, and expert guidelines administrators

community home care critical responsible forhospitals pathways with quality

recommended managementdiagnostic tests and treatments;staff and patient education)

Rauh RA, 754 patients Patients at a Physician-directed, Yes, Agency for Patients and Nurses in Schwabauer NJ, with CHF community-based nurse-managed Health Care Policy families received collaborationset al., 1999 hospital with a inpatient and and Research patient education; with physicians,

discharge diagnosis outpatient CHF (now the Agency members of dieticians, and of CHF (diagnosis- program, featuring for Healthcare multidisciplinary social workersrelated grouping intensive patient Research and treatment team127) education, Quality) guidelines were educated

treatment in for CHF about CHFaccordance with management and protocols, and protocols at theaggressive individual and outpatient group levelpharmacologic management

Rich MW, 98 elderly Patients at least Comprehensive, Home visits were Patients Nurses workingVinson JM, et al., patients with 70 years of age nurse-directed in accordance with with a 1993 CHF admitted to a multidisciplinary federal home-care multidisciplinary

secondary and approach to guidelines treatment teamtertiary teaching reducing repeatedhospital over a hospitalizations1-year interval were including teaching,screened for CHF; medication andCHF patients at dietary intervention,moderate-to-high discharge planning,risk for early and enhanced hospital readmission, follow-up carewho met no study exclusion criteria,were enrolled


[67]

Disease Managem



Quality of care 9-month baseline RCT A slight reduction Hospital and The intervention had small(e.g., measurement and post- in hospital patient homes effects on outcomes thatof left ventricular intervention periods, charges was were not significantly systolic function), including 6 months observed different from the effectshospital LOS and after hospital of usual care. Averagecharges, mortality, discharge hospital LOS decreasedhospital readmissions, from baseline by 1.8 daysquality of life in the intervention

group and by 0.7 daysin the control group.

Primary endpoint: 1 year prior to Retrospective chart 17% ($1,118) Community-based Compared with control LOS for all CHF- program review reduction in cost per Illinois hospital group, intervention grouprelated hospital implementation for admission; 77% (inpatient setting) had a significantly reducedadmissions; controls; 1 year ($718,468) net and associated LOS (5.7 days vs. 7.3 secondary after program reduction in physician-directed, days), fewer admissionsendpoints: primary implementation nonreimbursed nurse-managed for CHF management CHF admission for intervention hospital revenue; outpatient CHF (404 vs. 503), and a rate, readmission group cost of operating clinic (outpatient lower 90-day rate within 90 days outpatient heart setting) readmission rate (13%of discharge, per- clinic was about vs. 18%).case cost (to $104,000, and patient and program revenueprovider) for all generated wasCHF admissions $211,000

All-cause admissions 90-day Prospective RCT No actual cost data 550-bed The intervention did not and cumulative post-intervention were provided; secondary and significantly reduce number of hospital follow-up however, potential tertiary care readmissions or hospital days during 90-day annual savings university teaching days. The 90-day follow-up interval were estimated at hospital followed readmission rate was 33%

$262.5 million if by patient homes for the intervention groupdata were vs. 46% for the control extrapolated to all group. The mean number patients with CHF of hospital days was 4.3 discharged from for the intervention groupshort-stay hospitals vs. 5.7 for the control

group.

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Rich MW, 282 elderly Patients A nurse-directed Not specified Patients and Nurses Beckman V, et al., patients with hospitalized at multidisciplinary their families collaborating with1995 CHF treatment site intervention, multidisciplinary

were invited to offering teamparticipate if they comprehensive had risk factors for education, a readmission and prescribed diet, met no exclusion medication review, criteria social service

support, and intensive follow-up(telephone contactand home visits)

Rich MW, 156 elderly Subset of Comprehensive Not specified Patients Study nurse inGray DB, et al., patients with patients in previous patient education, collaboration with1996 CHF trial who had a dietary and social multidisciplinary

diagnosis of CHF service team (physician,and who did not consultations, pharmacist, meet any exclusion medication review, dietician, socialcriteria and intensive worker, home

postdischarge care workers)follow-up

Riegel B, 358 patients Patients screened Telephone case Yes, Agency for Patients Case managersCarlson B, with CHF for eligibility when management to Health Care (registered nurses)et al., 2002 hospitalized provide patient Policy and

education and Research (nowcollect and the Agency fordocument patient Healthcare progress data after Research and discharge Quality) and others


[69]

Disease Managem



Primary outcome 4-year study with Prospective RCT Average cost of Hospital at Elderly patients with CHFmeasure: survival 1-year follow-up intervention was university medical participating in a for 90 days without (90 days during $216 per patient; center followed by nurse-directed hospital readmission; intervention and the cost of hospital patient homes multidisciplinary secondary endpoints: 9 months after readmission was intervention experiencedall-cause readmissions, intervention $2,178 in the improved quality of life, CHF-related discontinuation) intervention group 44% fewer readmissions readmissions, vs. $3,236 in the within 90 days, 56% fewercumulative days of control group hospital admissions for hospitalization after (P = .03); CHF, 37% fewer hospital follow-up, quality of estimated savings days, and lower medical life, medical costs of $460 per costs compared with

patient control patients receivingstandard care.

Medication Medication Prospective RCT None Washington Compared with controls,compliance (by pill compliance University Medical overall compliance count), hospital assessed for Center improved and readmission rates 30 days, hospital (hospitalization) readmissions and hospital

readmission rates followed by days decreased by 33% assessed for patient homes and 31%, respectively, in 90 days elderly patients with CHF

who underwent a multidisciplinary treatmentintervention aimed atimproving medication compliance.

HF hospitalization 6 months RCT Inpatient HF costs Hospital and The HF hospitalization rate,rate, number of HF were 46% lower in patient homes number of HF hospital hospital days, and the intervention days, and percentage of percentage of patients group patients with multiple with multiple readmissions were 48%,readmissions 46%, and 43% lower

in the intervention groupthan in the usual-care control group.

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Roglieri JL, All participants Referral by Patient education, Yes, American Patients Nurse forFutterman R, in a managed attending physician telemonitoring, Heart Association, (educational and telemonitoring et al., 1997 care plan, or hospital case post-hospitalization Agency for Health clinical interventions and patient

including a manager, or discharge Care Policy and and telemonitoring) education; not subset of identified in review intervention Research (now and physicians specified who149 patients of medical claims (home visit by the Agency for (education about managed who participated (ICD-9 codes) nurse), and Healthcare program, including physician in a CHF physician Research and review of CHF educationdisease education (practice Quality), and treatment management guidelines) NYLCare guidelines)program HealthPlans

Schneider JK, 54 patients with Patients admitted Nurse-directed The medication Patients and Nurse Hornberger S, et al., CHF to medical facility medication discharge- families (when investigators1993 over 5-month discharge planning planning program present)

interval for CHF was basedwho met other on Orem’s theoryinclusion criteria of self-care; no (ability to specific guidelinesself-administer were identifiedmedications, takingone or more medications at discharge)

Serxner S, 109 elderly CHF patients Low-cost Not specified Patients; providers Trained nurseMiyaji M, et al., patients with discharged from a educational also received interviewers1998 CHF hospital system materials and mailed information

over the course of compliance aids to raise programa year who had a mailed to awarenesstelephone, spoke patients at English, and had regular intervalsCHF of cardiac (home-based origin educational

intervention)


[71]

Disease Managem



Third-quarter 24 months Longitudinal None Managed care Third-quarter admissionadmission rates, (12 months before comparison study health plan and rate and 30- and 90-day 30- and 90-day and after patient homes readmission rates declinedreadmission rates, intervention) 63%, 75%, and 74%,LOS, total hospital respectively, in patients days, and ED with any CHF-related utilization among diagnosis. In patients withpatients with (1) a a pure CHF diagnosis, pure CHF 30-day readmission rate diagnosis and (2) decreased to 0, and any CHF-related third-quarter admission diagnosis and 90-day readmission

rates both decreased 83%.Health care utilization(admissions, readmissions,LOS) also decreased inentire managed care planpopulation.

Hospital readmission 1 month of Quasi-experimental, None A 600-bed, Participants in therate 31 days after follow-up after after-only, randomized nonprofit medication discharge-discharge intervention controlled study Midwestern planning program had

medical facility significantly lower readmission rates 31 daysafter discharge than patients who underwent standard discharge planning (8% vs. 29%).

Quality of life, 6 months (3-month RCT Cost of program Patient homes The intervention reducedhospital intervention, with was $50 per patient; (recipients of hospital readmissions byreadmissions, 6-month follow-up estimated net return home-based 51% and improved overallassociated costs, after enrollment) on the investment program offered patient health status, compliance with of $8:$1 for the by Columbia confidence in medications, diet, hospital and $19: hospital system) self-management, andand daily weights $1 for third-party compliance with diet,

payers medications, and weight monitoring among patients with CHF.

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Shah NB, Der E, 27 patients with Patients referred to Mailed patient Not specified Patients; Nurses with et al., 1998 moderate or CHF clinic at education materials, physicians notified access to

severe CHF Veterans Affairs automated of problems cardiologistsmedical center reminders for detected by patientduring 6-month medication self-monitoringenrollment period compliance, self-who met inclusion monitoring of criteria weights and vital

signs, and facilitated telephonecommunication with a nurse monitor

Stewart S, 97 patients Patients at tertiary Home visit by a Not specified Patients Home-based, Pearson S, et al., with CHF referral hospital nurse and nurse-pharmacist1998 who had pharmacist to team

CHF/systolic optimize medicationdysfunction, management, exercise provide educationintolerance, and (and remedial recurrent hospital counseling) aboutadmissions for medications andacute CHF; who medication met no exclusion compliance, criteria; and who identify early agreed to clinical participate deterioration, and

intensify medical follow-up, as appropriate

Stewart S, 200 patients Patients Home visit and Not specified Patients and Home-based Marley JE, et al., with chronic discharged from telemonitoring by families cardiac nurse1999 CHF a tertiary referral a cardiac nurse

hospital in to optimizeAustralia with medication and(1) age ≥55 years, disease (2) New York Heart management, Association identify early functional class II, clinical deterioration,III, or IV CHF, and intensify medical(3) at least one follow-up, andprior hospital provide remedialadmission for counselingacute CHF (patient teaching),

as appropriate


[73]

Disease Managem



Hospitalizations (all 1 year (mean Observational (pre- and None Patient homes No significant differencecause and follow-up interval post-intervention in number of cardiovascular), was 8.5 months comparison) hospitalizations per hospital days after intervention) patient-year before and (all cause and after the intervention (0.8cardiovascular), and 0.4, respectively).physician notifications, Cardiovascular patient acceptance hospitalizations decreased

from 0.6 per patient-yearto 0.2 per patient-year.All-cause and cardiovascular hospital days decreased from 9.5 to0.8 per patient-year andfrom 7.8 to 0.7 per patient-year, respectively.

Primary endpoint: 6 months of RCT The mean cost Tertiary referral The intervention reducedfrequency of follow-up after of hospital-based hospital in southern primary-endpoint eventsunplanned enrollment care for the Australia followed (0.8 vs. 1.4 per patient),readmissions plus (duration of intervention group by patient homes unplanned readmissionsout-of-hospital intervention) averaged $3,200 (36 vs. 63), out-of-hospitaldeaths; secondary vs. $5,400 for the deaths (1 vs. 5), days of endpoints: event-free usual-care group hospitalization survival, percentage (not significant); (261 vs. 452), and visitsof patients with the estimated to the ED (48 vs. 87).unplanned cost of thereadmissions, total intervention washospital days, number $190 (Australian)of ED visits, overall per patient;mortality, cost of outpatient costshospital-based did not differcare between groups

Primary endpoint: 6 months of RCT Hospital-based Tertiary referral The intervention reducedfrequency of follow-up after costs were hospital in primary endpoint eventsunplanned enrollment Australian $490,300 Australia followed from 129 to 77, readmissions (duration of for the intervention by patient homes unplanned readmissionsplus out-of-hospital intervention) group and Australian (118 vs. 68), and deaths; secondary $922,600 for the associated hospital daysendpoints: event-free usual-care group (1,173 vs. 460) andsurvival, days of (P = 0.16); increased the numberunplanned community-based of patients remainingreadmissions, health care costs event-free (51 vs. 38).functional status were similar for both Quality-of-life scores did and quality of life, groups; mean cost not differ significantlyhospital and of the intervention between the two groupscommunity-based was Australian $350 after 6 months.health care costs per patient

[74]

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Stewart S, 297 patients Screening of Postdischarge Not specified Patients and MultidisciplinaryHorowitz JD, 2002 with CHF patients admitted home-based families

to the cardiology intervention unit of a hospital (see theand active summaries ofconsultation with Stewart S, the admitting Pearson S, et al.physician Archives of

Internal Medicine.1998;158:1067-1072 and Stewart S, Marley JE, et al. Lancet.1999;354:1077-1083)

Stromberg A, 106 patients Patients Follow-up HF Not specified Patients Cardiac nursesMartensson J, with HF hospitalized for HF clinic where et al., 2003 medication

changes were made by protocol, and patients and family members received education and social support

Todero CM, 93 patients Referred by CHF disease Yes, Agency for Patients NursesLaFramboise LM, with CHF physician to home management Health Care Policyet al., 2002 disease program with and Research

management routine reminders (now the Agencyprogram after to monitor for Healthcarehospital discharge symptoms, Research andfor acute suggestions for Quality)exacerbation of symptom CHF management, and

patient education


[75]

Disease Managem



Unplanned hospital Median of 4.2 RCT The median cost of Tertiary referral There were significantlyreadmissions, years unplanned hospital in fewer unplanned deaths, and event- readmissions was Australia followed readmissions and deaths, free survival significantly lower by patient homes and the median event-free

in the intervention survival was significantlygroup than in a longer in the interventioncontrol group group than in the control receiving usual care group.

Mortality, hospital 12 months RCT None Clinic The intervention group hadadmissions and significantly fewer deathsdays, and self-care and hospital admissionsbehavior and days, and exhibited

better self-care behaviorthan the control group.

The percentage of 2 months Not randomized or None Home The percentage of patientspatients with specific controlled with each CHF symptomHF symptoms; the decreased as a result offrequency, severity, the intervention. Theand amount of frequency, severity,interference with amount of interferencephysical activity with physical activity, from the symptoms; and interference with and the interference enjoyment of life fromwith enjoyment of shortness of breathlife from the and fatigue (the twosymptoms most common symptoms)

improved.

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Urden LD, 1998 108 patients Not specified Integrated disease Inpatient CHF Patients and Team consistingwith CHF case management clinical pathway providers (clinical of a cardiologist

program (service) developed pathway) medical director,for CHF featuring internally by team nurse practitioner,inpatient and and nurse clinicianoutpatient consultation, comprehensive education,outpatient treatment, andintensive hometelephone contact, including monitoringand home intervention

Varma S, 83 elderly Patients hospitalized Structured Use of previously Patients Research McElnay JC, et al., patients with or attending an pharmaceutical published pharmacist in1999 CHF outpatient clinic in care program algorithm for liaison with

one of three study for elderly CHF pharmaceutical community sites with: patients education, but no physicians and(1) confirmed specific practice community diagnosis of CHF, guidelines identified pharmacists(2) age >65 years, and (3) adequate cognitive score

Weinberger M, 1,396 patients Patients Intensive Not specified Patients Primary care Oddone EZ, et al., with diabetes hospitalized at outpatient teams, consisting1996 (n = 751), one of nine primary care by of one primary

COPD (n = 583), Veterans Affairs a dedicated care nurse andor CHF (n = 504) hospitals with physician-nurse one primary

CHF, COPD, or team following care physiciandiabetes inpatient

assessment and provision of patienteducational materials


[77]

Disease Managem



Hospital LOS, Not specified, but Observational Decreased LOS Inpatient LOS decreased by30-day readmission <1 year after resulted in $2,700 (community 1.1 days and 30-day rate, costs, program in savings per hospital in readmissions decreasedpatient satisfaction, implementation patient Michigan); from 17% to 4% after consultations, quality hospitalization outpatient (patient program implementation.of life, emotional and homes) Consultations increasedphysical functioning by >20%. Patient

education, overall qualityof life, emotional functioning, and physical functioningimproved.

2-minute walk test, 12 months Longitudinal, Average cost of Three study sites Compared with controls,blood pressure, body prospective RCT medical ward (hospitals, clinics) program participants hadweight, pulse, forced admission was in Northern Ireland better quality of life, vital capacity, £175.4 vs. £35.2 for physical functioning, quality of life, ED visit and emotional health;knowledge of medication compliance;symptoms and and medication medications, knowledge; and fewercompliance with hospital admissions therapy, and use of (14 vs. 27).health care facilities

Hospital 6 months after Multicenter RCT None Hospitals and Patients in the interventionreadmissions, intervention clinics at nine group had a higher days of Veterans Affairs monthly readmission ratehospitalization, Medical Centers (0.19 vs. 0.14) and morequality of life, days of rehospitalizationsatisfaction with (10.2 vs. 8.8) despitecare greater satisfaction

than patients in thecontrol group.

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West JA, 51 patients Recruitment of Physician- Management Patients and Nurse caseMiller NH, et al., with HF patients hospitalized supervised, nurse- guidelines providers managers with1997 at managed care mediated, home- adapted from and access to

medical center for based HF consistent with supervisingHF within past management American College physician12 months, as well system (MULTIFIT) of Cardiology/as referral of that implements American Heartoutpatients by consensus practice Association physicians guidelines for consensus

pharmacologic report and theand dietary Agency for Healththerapy, and uses Care Policy anda nurse manager Research (nowto promote the Agency for adherence and Healthcare carry out patient Research andtelemonitoring Quality) clinical

practice guidelines for CHF

Whellan DJ, 117 patients Patients with a Disease Not specified Patients Nurse practitionerGaulden L, et al., with CHF hospitalization for management or nurse specialist2001 CHF, an ejection program with and pharmacist

fraction <20%, or treatment symptoms protocols,consistent with follow-up clinicNew York Heart visits andAssociation class telephone calls,III or IV and a patient

education manual

Wright SP, 197 patients Patients with first Clinic visits, Not specified Patients Nurse specialistWalsh H, et al., with HF diagnosis or patient education2003 exacerbation of sessions, telephone

HF admitted to the follow-up, and usehospital of diaries for

recording daily weight measurements


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Death, 10 months (mean Nonrandomized, pre- None Patient Quality of life, functional hospitalizations, patient follow-up and post-intervention homes (home- status, and compliance ED visits, clinic interval of 138 ± comparison based care with guidelines improved.visits, functional 44 days) system sponsored Medical visits, cardiologystatus, exercise by managed visits, HF-related ED capacity, self- care organization) visits, and total ED visitsreported data decreased by 23%, 31%,(weights, dietary 67%, and 53%, compliance), respectively.functional status, Hospitalizations for HFhealth-related decreased by 87% fromquality of life, 1.12 to 0.15/year, andcompliance with total hospitalization rateguidelines decreased by 74%

from 1.61 to 0.42/year.

Medication use, Mean enrollment Randomized Outpatient costs Clinic Beta-blocker use and clinichospitalization rate, time of 4.7 months prospective pre- and increased, but the visits increased and number of clinic postintervention cost per discharge significantly. The visits comparison and inpatient and hospitalization rate

total costs per decreased significantly.patient-year decreased, resultingin a net savings of $8,571 per patient-year.

Mortality, hospital 12 months RCT None Hospital, clinic, The intervention had noreadmissions, bed and home effect on deaths or hospital days, quality of life, readmissions, but it and knowledge of decreased total bed daysself-management and multiple

readmissions, and improved quality of life.Knowledge of self-management was greaterin the intervention groupthan in a control group.

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