heart failure disease management: impact on hospital care, length of stay, and reimbursement

7
Congestive heart failure (CHF) is a major medical prob- lem with significant hospital costs. The authors developed an inpatient disease management program for CHF in a community hospital setting to determine if it is possible to: 1) increase implementation of Agency for Health Care Policy and Research criteria for CHF; 2) improve the quality of patient care, while lowering length of stay and treatment cost for CHF; and 3) maintain nursing staff satisfaction. The program encompassed a clinical pathway incorporating Agency for Health Care Policy and Re- search criteria for CHF, CHF education, and patient edu- cational materials. When compared to “unmanaged” pa- tients (n=197) not participating in the algorithm due to physician choice, “managed” patients (n=396) had sig- nificantly increased documentation of left ventricular dys- function and of angiotensin-converting enzyme inhibitor use. In contrast to unmanaged patients, managed patients had a significantly lower length of stay (3.9±2.2 vs. 6.1±2.8 days; p<0.0001) with a significant reduction in cost per patient ($4404±$1989 vs. $6828±$3347; p<0.0001). These changes were sustained in follow-up over 1 year and were associated with an improvement in nursing staff education and nursing care. Thus, a disease management program for CHF can be successfully imple- mented in a general community hospital setting, achieving improved compliance with Agency for Health Care Policy and Research treatment criteria and enhancing patient care, while reducing length of stay and cost. (CHF. 2003; 9:77–83) © 2003 CHF, Inc. Cheryl L. Discher, RN, BSN; Dahlia Klein, RN, MSN, CCM; Lisa Pierce, RN, MSN, CNP; Arlene B. Levine, MD; T. Barry Levine, MD From the Michigan Institute for Heart Failure and Trans- plant Care, Botsford General Hospital, Farmington Hills, MI Address for correspondence: T. Barry Levine, MD, Director of Cardiology, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212 E-mail: [email protected] Manuscript received December 10, 2001; accepted February 21, 2002 Congestive heart failure (CHF) continues to be a grow- ing health care concern worldwide. In the United States alone, more than 4 million persons carry the di- agnosis, and more than 550,000 new cases are report- ed annually. Disease prevalence is expected to reach 10 million in the United States alone by 2007. 1–3 Although numerous studies have demonstrated therapies that impact favorably on patient symptoms, hospitalization, and survival, 4–9 the therapy of heart failure requires ever-increasing resource utiliza- tion. 10,11 The increased prevalence and chronicity of heart failure have resulted in increasing hospitaliza- tions. In 1995, CHF was the leading diagnosis group among hospital discharges. 12 Although hospital length of stay (LOS) has decreased over the last decade, pa- tients with the diagnosis of CHF were hospitalized an average of 5.6–8.0 days. 12–14 Lack of effective CHF di- agnosis and therapy and underutilization of effective therapy contribute to CHF hospitalizations. 15–18 With growing hospital costs, CHF is the costliest cardiovas- cular illness in the United States. 10,11 CHF guidelines have been proposed during the last decade to streamline the diagnosis of CHF and im- prove the efficacy of treatment and the quality of care. 19–22 However, application of CHF guidelines re- mains limited in practice. 15,23 We have previously shown improved patient outcomes, with decreased costs and hospitalizations, with outpatient manage- ment in a specialty heart failure clinic staffed by dedi- cated CHF physician and nurse specialists. 24–26 Such outpatient endeavors have repeatedly been shown to impact favorably on CHF hospitalization frequency and health care costs. 27–33 More recently, a number of inpatient CHF disease management programs have also sought to implement CHF practice guidelines in the inpatient setting. 34–36 Our institution, a small community hospital, rec- ognized the opportunity to impact on this high-risk population. We consequently developed a collabora- tive inpatient disease management program for CHF. Our aim was not to create a dedicated inpatient CHF service, but rather a nurse case management heart failure program to maintain the usual private practi- tioner-patient care relationship. The aim of the pro- gram was to determine 1) if a disease management CHF MARCH/APRIL 2003 HF DISEASE MANAGEMENT 77 Heart Failure Disease Management: Impact on Hospital Care, Length of Stay, and Reimbursement

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Congestive heart failure (CHF) is a major medical prob-lem with significant hospital costs. The authors developedan inpatient disease management program for CHF in acommunity hospital setting to determine if it is possible to:1) increase implementation of Agency for Health CarePolicy and Research criteria for CHF; 2) improve thequality of patient care, while lowering length of stay andtreatment cost for CHF; and 3) maintain nursing staffsatisfaction. The program encompassed a clinical pathwayincorporating Agency for Health Care Policy and Re-search criteria for CHF, CHF education, and patient edu-cational materials. When compared to “unmanaged” pa-tients (n=197) not participating in the algorithm due tophysician choice, “managed” patients (n=396) had sig-nificantly increased documentation of left ventricular dys-function and of angiotensin-converting enzyme inhibitoruse. In contrast to unmanaged patients, managed patientshad a significantly lower length of stay (3.9±2.2 vs.6.1±2.8 days; p<0.0001) with a significant reduction incost per patient ($4404±$1989 vs. $6828±$3347;p<0.0001). These changes were sustained in follow-upover 1 year and were associated with an improvement innursing staff education and nursing care. Thus, a diseasemanagement program for CHF can be successfully imple-mented in a general community hospital setting, achievingimproved compliance with Agency for Health Care Policyand Research treatment criteria and enhancing patientcare, while reducing length of stay and cost. (CHF. 2003;9:77–83) ©2003 CHF, Inc.

Cheryl L. Discher, RN, BSN; Dahlia Klein,RN,MSN,CCM;Lisa Pierce,RN,MSN,CNP;Arlene B. Levine, MD; T. Barry Levine, MDFrom the Michigan Institute for Heart Failure and Trans-plant Care, Botsford General Hospital, Farmington Hills, MI

Address for correspondence: T. Barry Levine, MD, Director of Cardiology, AlleghenyGeneral Hospital, 320 East North Avenue, Pittsburgh, PA 15212E-mail: [email protected] received December 10, 2001;accepted February 21, 2002

Congestive heart failure (CHF) continues to be a grow-ing health care concern worldwide. In the UnitedStates alone, more than 4 million persons carry the di-agnosis, and more than 550,000 new cases are report-ed annually. Disease prevalence is expected to reach10 million in the United States alone by 2007.1–3

Although numerous studies have demonstratedtherapies that impact favorably on patient symptoms,hospitalization, and survival,4–9 the therapy of heartfailure requires ever-increasing resource utiliza-tion.10,11 The increased prevalence and chronicity ofheart failure have resulted in increasing hospitaliza-tions. In 1995, CHF was the leading diagnosis groupamong hospital discharges.12 Although hospital lengthof stay (LOS) has decreased over the last decade, pa-tients with the diagnosis of CHF were hospitalized anaverage of 5.6–8.0 days.12–14 Lack of effective CHF di-agnosis and therapy and underutilization of effectivetherapy contribute to CHF hospitalizations.15–18 Withgrowing hospital costs, CHF is the costliest cardiovas-cular illness in the United States.10,11

CHF guidelines have been proposed during the lastdecade to streamline the diagnosis of CHF and im-prove the efficacy of treatment and the quality ofcare.19–22 However, application of CHF guidelines re-mains limited in practice.15,23 We have previouslyshown improved patient outcomes, with decreasedcosts and hospitalizations, with outpatient manage-ment in a specialty heart failure clinic staffed by dedi-cated CHF physician and nurse specialists.24–26 Suchoutpatient endeavors have repeatedly been shown toimpact favorably on CHF hospitalization frequencyand health care costs.27–33 More recently, a number ofinpatient CHF disease management programs havealso sought to implement CHF practice guidelines inthe inpatient setting.34–36

Our institution, a small community hospital, rec-ognized the opportunity to impact on this high-riskpopulation. We consequently developed a collabora-tive inpatient disease management program for CHF.Our aim was not to create a dedicated inpatient CHFservice, but rather a nurse case management heartfailure program to maintain the usual private practi-tioner-patient care relationship. The aim of the pro-gram was to determine 1) if a disease management

CHF MARCH/APRIL 2003HF DISEASE MANAGEMENT 77

Heart Failure Disease Management: Impact on Hospital Care, Length of Stay,

and Reimbursement

program could be implemented in this hospital set-ting to increase application of selected Agency forHealth Care Policy and Research (AHCPR) CHF cri-teria37–39; 2) if improvement in the quality of patientcare might be achieved together with a lowering ofthe LOS and the treatment cost for CHF; and 3) ifnursing staff satisfaction could be enhanced with adisease case management program.

Methods Several interventions were undertaken: a heart fail-ure algorithm and clinical pathway were developed,with the aim of incorporating AHCPR clinical crite-ria for CHF. Programs for physician CHF educa-tion and for nursing competency in CHF care weredeveloped and implemented. Additionally, patienteducational materials were developed to enhancethe understanding of CHF and improve patient in-volvement in their care.1

The Clinical Pathway. The clinical pathway covered apatient’s CHF admission from the Emergency Depart-ment until discharge. The LOS goal targeted was 4days, from the prior average of 6.5 days per patient in1998. The algorithm packet included CHF floor admis-sion criteria; detailed physician CHF orders; a patientcode status record; and a nursing clinical pathway andCHF teaching record. A patient pathway, informingpatients of CHF pathophysiology, therapies, and dailyexpectations; and a 2-gram sodium meal plan and re-ferral information for cardiac rehabilitation, lifestyleclasses, support groups, and the heart failure clinic.

The heart failure algorithm is shown in Figure 1.Incorporated in the pathway packet were triggerpoints to assist with clinical decision-making to movethe heart failure patient along the health care contin-uum from the inpatient to the outpatient setting.

AHCPR Criteria for Evaluation. The catalyst for theprogram centered on enhancing the implementationof selected AHCPR clinical standards for CHF inpa-tient care,37,38 specifically: 1) left ventricular ejectionfraction (LVEF) determination or documentation ofthe results of a prior study within 6 months of the ad-mission; 2) use of angiotensin-converting enzyme(ACE) inhibitor therapy, and/or documentation of ACEinhibitor intolerance; 3) admission and daily assess-ment of fluid status via weight as well as input and out-put determinations; and 4) the use of discharge infor-mation that includes instructions regarding weightmonitoring, dietary observance, and medication usage.

Education. CHF inservices were provided for physi-cians, the nursing staff, and the ancillary departments,

such as pharmacy, nutrition, cardiac rehabilitation,and continuing care. In collaboration with a CHFphysician champion, a team approach to therapy wasdeveloped and practice changes promoted.

Nursing education encompassed the following as-pects: 1) a multidisciplinary seminar; 2) daily inpatientrounds with the physician champion on the heart fail-ure patients; 3) a 1-day observation in the outpatientheart failure clinic; 4) exposure to pertinent heart fail-ure literature, with review of the patient education ma-terials; and 5) enhancement of cardiopulmonary physi-cal examination and assessment skills.

Study Patients. All patients admitted to the hospitalwith the primary admitting diagnosis of CHF, forwhom CHF also constituted the primary or secondarydischarge diagnosis, were sequentially and prospec-tively entered into a database for retrospective analy-sis. There were two patient groups: “managed” and“unmanaged.” For the managed cohort, admittingphysicians had to agree to enroll the patient in theclinical pathway, and patients and/or their familieshad to be able to understand care instructions. Un-managed patients were patients not entered in theclinical pathway for two reasons: 1) the admittingphysician’s choice not to have their patients partici-pate in the program; or 2) patients’ inability to active-ly participate in the clinical pathway due to cognitiveimpairment or inadequate living conditions.

Case Management. The patients’ care remainedunder the supervision of their private physicians.Cardiologists were involved in patient care only ifconsulted by the admitting physician, or if directlyadmitting the patient. Working closely with thephysicians, nurses, and the ancillary departments,the nursing case manager rounded daily to reviewpatient charts and documentation. The case managerpromoted implementation of AHCPR clinical crite-ria and collected data, encouraged patient education,and facilitated patient progression from the inpatientto the outpatient setting. Prospective data collectioncomparing managed and unmanaged cohorts for1999 was divided into four quarters for serial com-parison and was also compared to the cumulative un-managed clinical end points for 1998, the year pre-ceding institution of the clinical pathway.

Statistical Analysis. The data were prospectively col-lected with retrospective analysis. They are presentedas means±standard deviation. Differences betweengroup mean values were assessed using analysis ofvariance (Statview 5, SAS Institute Inc., Cary, NC).For dichotomous data, the chi-square test was used.Statistical significance was defined as p<0.05.

CHF MARCH/APRIL 200378 HF DISEASE MANAGEMENT

CHF MARCH/APRIL 2003HF DISEASE MANAGEMENT 79

EMERGENCY ROOMPHYSICIAN OFFICE

PRIMARY DIAGNOSIS: CHF

TELEMETRY STEP-DOWN UNIT

• CHF patients requiring telemetrymonitoring

• Vasoactive drips/IV arrhythmiacontrol

• Aggressive diuresis• Abnormal electrolytes

CRITICAL CARE UNIT

• Life threatening arrhythmia• Hemodynamic monitoring• Need for balloon assist device• Cardiovascular collapse• Cardiogenic shock• Intubation need• Acute myocardial infarction• Frequent titration of vasoactive drugs

Stabilized

GENERAL MEDICAL FLOOR

• Limited code status• Electrolytes normal• Arrythmia controlled – no need for

telemetry• Vasoactive drips weaned• Need for nonaggressive diuresis

Stabilized

Discharge

Heart Failure Clinic Primary Care Physician

Outpatient Follow-Up

• Home health care• Telemanagement• Cardiac rehabilitation• Heart failure support group

Figure 1. Congestive heart failure (CHF) algorithm. CHF patients were enrolled in the CHF pathway at admission, with follow-up monitored by the case manager until discharge.

Results Patient Characteristics. Of the 593 patients in thestudy, 396 were managed patients, 197 were unman-aged (135 patients due to cognitive impairment or ad-verse living conditions and 62 patients due to physicianpreference). Data were collected for the duration offour quarters in 1999. For all patients, mean LOS was4.7±2.6 days and mean costs were $4654±$2882 perCHF admission. LVEF was equivalent for managed andunmanaged at 39%±15% and 40%±15%, respectively(p=NS). Diastolic dysfunction was present in 54% and49% of patients (p=NS). A cardiologist was the consult-ing physician for 303 of 396 managed patients and in122 of 197 unmanaged patients.

Documentation of LVEF. In 1998, prior to clinicalpathway institution, chart documentation of LVEFduring hospital admissions was 64%. Comparedwith 1998, there was a significant improvement inLVEF documentation for managed patients duringthe first quarter of 1999 (79%; p<0.0002), with sub-sequent further improvement to 84%–88% for theentire year, only for the managed cohort (Figure 2).

Medical Regimen. Documentation of ACE inhibitor useor its intolerance was 42% for CHF hospitalizations in1998. Compared with 1998, within 3 months of pathwayimplementation, ACE inhibitor use and documentationsignificantly increased for managed patients, to 80%(p=0.001) vs. 65% for unmanaged patients (p=0.01).Subsequent further improvement occurred in all quar-ters of 1999, only for the managed group (Figure 3).

Other Health Care Issues. The 1998 code statusclarification by the Emergency Department, as wellas an update on pneumococcal vaccination status,increased from 10% to 60% compliance in 1999.

Patient Care. Physician-independent patient careimproved significantly from 1998 to 1999, with nodifferentiation between managed and unmanagedpatients with regard to inpatient nursing and sup-portive services. For both patient cohorts, there wasan improvement in nursing documentation of dailyweights (60% to >91%), daily input and output(60% to >74%), CHF instruction for patients (35%to >96%), and dietary instruction (0% to >78%).Furthermore, the improvement in quality of carewas maintained throughout the follow-up period.

Length of Stay. In 1998, the average LOS was 6.5 daysper patient per CHF hospitalization. Within 3 monthsof implementation of the program, LOS for the man-aged cohort fell to 5.4±2.1 days (p<0.0001). There was

a trend to further improvement over the ensuing quar-ters, reaching the goal of LOS <4 days in the third andfourth quarters. No significant change occurred for theunmanaged group (Figure 4).

Economic Impact of the CHF Clinical Pathway. De-spite intensified involvement of the nursing staff andancillary services, the average cost per managed pa-tient was lower than that for unmanaged patients($4403.87±$1989.23 vs. $6827.77±$3346.90, respec-tively); p<0.0001. When adjusted relative to reimburse-ment per patient, the managed cohort collected on av-erage (+) $738.10 per patient (Table I), for a total posi-tive balance of (+) $292,287.60 in 1999. In contrast,unmanaged patients lost a total of (–) $1080.91 per pa-tient (p<0.0001), with a total loss for 1999 of (–)$212,939.27. Potential cost savings, had all 593 patientsbeen enrolled in the CHF clinical pathway, would havetotaled (+) $437,693.30 (593 patients × $738.10).

CHF MARCH/APRIL 200380 HF DISEASE MANAGEMENT

Figure 2. Ejection fraction documentation for managed vs.unmanaged patients in 1998 and four quarters of 1999

Figure 3. Angiotensin-converting enzyme (ACE) inhibitoruse documentation for managed vs. unmanaged patientsin 1998 and four quarters of 1999

In contrast, the potential loss, had all patients re-mained unmanaged, would have been $640,979.63(593 patients × (–) $1080.91), yielding a potentialtotal hospital saving of $1,078,672.93 for 1999.

Nursing Satisfaction. Despite an increase in time com-mitment to nursing education and increased patientcare requirements, the CHF clinical pathway was wellreceived by the nursing staff, as indicated by the resultsof the nursing survey in Table II. Nurses felt clinicallymore competent, expressed greater satisfaction withdelivered patient care, and maintained the improve-ment in quality of care throughout the follow-up.

Discussion Within 3 months of implementation, two thirds ofCHF admissions were successfully transitioned to ourheart failure disease management program, with sig-nificantly increased application of AHCPR criteria forthese managed patients.37–39 Compared to the find-ings of the preceding year, by the fourth quarterthere was improved documentation of left ventriculardysfunction, from 64% to 87%. Use of ACE inhibitionrose from 42% to 95%, while patient education on

diet and heart failure lifestyle modification rose from35% to 96%. Measurement of daily weight and 24-hour input and output of fluids increased to 91% and74%, respectively. For managed patients, these im-provements in quality of care occurred despite ashortened inpatient LOS, from 6.5 days to 3.9 days,and a decrease in average hospital costs per patient,with reimbursement per patient actually showing asurplus for the diagnosis of CHF.

The improvements noted with managed patientswere sustained, when compared with the hospital’spractice outcomes of 1998 and with the concurrent co-hort of unmanaged patients. Despite benefiting fromidentical improvements of inpatient nursing and ancil-lary services, unmanaged care was less compliant withAHCPR criteria with respect to documentation of car-diac function and medical therapy. Without implemen-tation of the entire program, unmanaged patients con-tinued to have longer, unchanged LOS, their hospitalcosts remained excessive, and reimbursements contin-ued to show a deficit.

We have previously shown improved patient out-comes with outpatient management in a dedicatedheart failure clinic—specifically, in patient sympto-matic status, functional capacity, left ventricularfunction, transplant requirements, and CHF-relatedhospitalizations.24–26 Such improvements wereachieved in a setting of dedicated CHF physicianand nurse specialists. Similar improvements havebeen noted in a number of other dedicated outpa-tient CHF therapy clinical settings.27–33

Implementation of practice guidelines is conve-nient in the specialty practice setting. To extendpractice guidelines to diverse practitioners in theinpatient setting is more challenging, due to thelarge practice variation among practitioners andthe reluctance to adhere to guidelines.15,39 More re-cently, inpatient case management programs havesuccessfully sought to implement clinical pathwaysin a number of disease states, including CHF.34–36

In this program, we attempted to adapt the in-sights of our specialty outpatient experience to a very

CHF MARCH/APRIL 2003HF DISEASE MANAGEMENT 81

Figure 4. Congestive heart failure length of hospital stayfor managed vs. unmanaged patients in 1998 and fourquarters of 1999

Table I. Economic Impact of Management Program per Patient

UNMANAGED (N=197) MANAGED (N=396)

QUARTER COST ($) PAYMENT ($) NET ($) COST ($) PAYMENT ($) NET ($)

1st 5966.50 5548.23 (–) 418.27 5457.36 5910.80 (+) 453.442nd 5491.19 5346.93 (–) 144.26 4338.98 5434.57 (+) 1095.593rd 9540.29 6419.17 (–) 3121.12 3853.48 4937.54 (+) 1084.064th 6313.11 5673.13 (–) 639.98 3965.65 4284.93 (+) 319.28

Average per patient (–) 1080.91 (+) 738.10

different inpatient setting. Specifically, our aim was notto create a dedicated inpatient CHF service, but rathera nurse case management heart failure program tomaintain the usual private practitioner-patient care re-lationship. The patients were cared for by a diversegroup of private physicians, principally internists andfamily practitioners. The common denominators of themanagement program were the clinical pathway algo-rithm, staff education, and inpatient follow-up by thenursing case manager in a consulting role. Thus, de-spite the diversity of health care providers, our CHFalgorithm achieved significant improvements in thequality of patient evaluation and care.

Staffing was not increased to accommodate thesignificantly increased demands on nursing for pa-tient assessment, record keeping, education, anddischarge planning. Although a temporary im-provement in nursing and ancillary care might beexpected during the first quarter, this enhanced en-gagement was sustained for the duration of our 1-year follow-up. Furthermore, the improvement incare actually coincided with heightened job satisfac-tion by the nursing staff.

There are several limitations to this study. Thisis a retrospective study. The groups were not ran-domized, and there may have been potential differ-ences in severity of illness. Follow-up data are notavailable regarding rehospitalization.

In summary, we demonstrated the feasibility of adisease management program in a general community

hospital setting. Case management significantly in-creased implementation of AHCPR criteria. Not onlywas there resultant improvement in the quality of inpa-tient CHF care; the goals of lowering LOS to 4 daysand significant cost savings for the treatment of CHFwere achieved. Furthermore, nursing staff satisfactionwas actually enhanced with the disease case manage-ment program in place, and the improvements in inpa-tient quality of care were sustained throughout the du-ration of follow-up. Disease management and clinicalpathways may thus provide an acceptable and effectivevehicle for both implementing and further updatingthe continually evolving diagnostic and therapeuticmodalities for CHF, in service of further enhancing thequality and efficacy of patient care.

Acknowledgment: The authors wish to thank Marge Hasler, RN,MSN, Nursing Administrator, for her dedicated support and direction;Patricia Bohn, RN, BSN and Sandy Perez, RN, BSN for their gener-ous assistance and “sharing of ideas.”

REFERENCES1 American Heart Association. 2000 Heart and Stroke Statistical

Update. Dallas, TX: American Heart Association; 1999.2 Rich MW. Epidemiology, pathophysiology, and epidemiology

of congestive heart failure in older adults. J Am Geriatr Soc.1997;45:968–974.

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4 Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilatortherapy on mortality in chronic congestive heart failure: re-sult of a Veterans Administration Cooperative Study. N Engl JMed. 1986;314:1547–1552.

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CHF MARCH/APRIL 200382 HF DISEASE MANAGEMENT

Table II. Nursing Survey Results

INDICATOR

%PERCEPTION

Program has increased practice skills 93

Program has increased clinicalthinking skills

93

Increased confidence in CHF patientcare

93

Enhanced satisfaction as a CHF nurse 93

Increased collaboration with physicians 56

Enhanced quality of patient care 93

Higher confidence in nursing role ingeneral

87

Higher likelihood of staying at currenthospital

62

Recommendation of this program toother nurses

93

CHF=congestive heart failure

demic that has reached its peak? Eur Heart J. 2001;22(3):209–217.

15 Stafford RS, Saglam D, Blumenthal D. National patterns ofACE inhibitor use in congestive heart failure. Arch Intern Med.1997;157:2460–2464.

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17 Roe CM, Motheral BR, Teitelbaum F, et al. Angiotensin-con-verting enzyme inhibitor compliance and dosing among pa-tients with heart failure. Am Heart J. 1999;138:818–825.

18 Roe CM, Motheral BR, Teitelbaum F, et al. Compliance withand dosing of angiotensin-converting enzyme inhibitors be-fore and after hospitalization. Am J Health System Pharm.2000;57(2):139–145.

19 Fonarow GC, Warner-Stevenson L, Walden JA, et al. Impactof a comprehensive management program on the hospital-ization rate for patients with advanced heart failure. J Am CollCardiol. 1995;25(suppl):264A–265A.

20 Fonarow GC, Warner-Stevenson L, Walden JA, et al. Impactof a comprehensive heart failure management program onhospital readmission and functional status of patients withadvanced heart failure. J Am Coll Cardiol. 1997;30:725–732.

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22 Packer M, Cohn JN. Consensus recommendations for themanagement of chronic heart failure. Am J Cardiol. 1999;83(suppl 2A):IA–38A.

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32 Grady KL, Dracup K, Kennedy G, et al. Team manage-ment of patients with heart failure. Circulation. 2000;102:2443–2456.

33 Whellan DJ, Gaulen L, Gattis WA, et al. The benefit of imple-menting a heart failure disease management program. ArchIntern Med. 2001;161:2223–2228.

34 Topp R, Tucker D, Weber C. Effect of a clinical case manag-er/clinical nurse specialist on patients hospitalized with con-gestive heart failure. Nurs Case Manag. 1998;3(4):140–145.

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37 Agency for Health Care Policy and Research, Public HealthService. Heart Failure: Evaluation and Care of Patients With LeftVentricular Systolic Dysfunction. Clinical Practice Guideline No.11. Rockville, MD: US Department of Health and HumanServices; June 1994. AHCPR Publication No. 94-0612.

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39 The Large State Peer Review Organization Consortium.Heart failure treatment with angiotensin-converting enzymeinhibitors in hospitalized Medicare patients in 10 large states.Arch Intern Med. 1997;157:1103–1108.

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