Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission

Heart failure (HF) is a complex clinical syndrome in which the heart is unable to deliver adequate cardiac output at normal filling pressures. There are proven pharmacological and clinical management strategies that can improve care and reduce associated health care costs, but these are underutilized. The Advanced Heart Failure Program (AHFP) was developed at the Dorn Veterans Administration Medical Center to provide a comprehensive multidisciplinary management approach to persons with advanced HF. Before enrollment in the AHFP, the average annual all-cause hospital admission rate was 3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, the mean all-cause hospital admission rate was 1.2. HF patients had an average annual hospitalization cost of $28,936.32 before enrollment in the AHFP. After enrollment, average hospitalization cost dropped to $10,851.12 per patient. Taking into account the 50-week cost of $3036.14 for a patient enrolled in the clinic, participation in the AHFP was associated with a significant decrease in the number of HF-related admissions, saving an average of $15,049.06 per patient. (Drug Benefit Trends. 2008;20:54-59)

Heart failure (HF) is a complex clinical syndrome characterized by dyspnea and fatigue and caused by structural or functional abnormalities of ventricular function.^1,2 These abnormalities manifest as an inability of the heart to deliver adequate cardiac output at normal filling pressures at rest and during exercise. There are proven treatments for HF that can decrease mortality and morbidity for persons with left ventricular systolic dysfunction and dramatically reduce associated health care expenditures.^1,2 These include pharmacological treatments (eg, angiotensin-converting enzyme [ACE] inhibitors and β-blockers) and nonpharmacological therapy (eg, use of multidisciplinary teams and/or a clinical pharmacist).^3-6

Despite this body of evidence, management of HF remains suboptimal. In a study of more than 11,000 patients hospitalized with acute symptoms of HF, an echocardiogram was obtained on admission in only two-thirds of them.⁷ ACE inhibitors and β-blockers were prescribed for 62% and 37% of patients, respectively, and only 17% received all 3 recommended therapies: ACE inhibitor, β-blocker, and diuretic.⁷ Suboptimal treatment of HF leads to increased mortality and health care expenditures.^1,2,8 Current models of health care delivery are reactive and focus exclusively on the patient and his or her doctor.⁸ A patient perceives a problem and then makes an appointment to see a physician. This typically leads to treatment of a medical problem that could have been prevented.

Current HF treatment annually accounts for 12 million to 15 million office visits, 6.5 million hospital bed days, more Medicare dollars spent than for any other single diagnosis, and $27.9 billion in direct and indirect costs.^1,2,9 The current model of care for HF patients is not achieving the outcomes desired and needs to be evaluated to optimize patient outcomes. Patients need to be an integral part of the health care delivery model and become partners in their care.¹⁰ The ideal health care model provides continuous care coordination and support.

An example of the ideal health care delivery model is the use of multi disciplinary treatment teams. Multidisciplinary interventions can decrease mortality rates, reduce hospital admission and readmission rates, and decrease use of health care resources.^5,10-14 A meta-analysis of the HF literature shows that use of multidisciplinary teams decreases mortality rates by 20%, all-cause hospital admission by 13%, and HF hospital admissions by 30%.¹⁰ The mortality reduction in HF with multidisciplinary teams is similar to that reported with the use of ACE inhibitors.^10,15 The model of health care delivery is an important part of the effectiveness of multidisciplinary teams in HF patients. Home-based HF interventions successfully decreased the number of all-cause admissions, HF admissions, and mean days in the hospital.¹⁰ However, the decrease in HF mortality was not significant. Use of telephone-based interventions decreased HF admission and mortality rates but led to a nonsignificant decrease in all-cause admissions.¹⁰ Some of these studies included home monitoring with self-reported or electronically transmitted daily measurements of vital signs, including body weight, blood pressure, and respiratory rates.

Randomized clinical trials based on the self-care paradigm in which the ambulatory monitoring of symptoms and vital signs combined with medication adjustment protocols have shown improved outcomes.^5,10 These trials demonstrated decreases in readmission rates, hospitalization days, and overall cost of care, combined with an increase in the time to hospital readmission. Interventions delivered solely in a clinic, hospital, or general practice have not shown positive outcomes.^5,10 Clinical trials of multidisciplinary teams with positive outcomes shared 2 key components: (1) 1-to-1 patient education on HF; medication, diet, and exercise counseling; and symptom monitoring; and (2) self-management recommendations.^5,10 Effects of multidisciplinary teams on HF patients have remained constant over time, despite the growing body of evidence supporting the use of ACE inhibitors and β-blockers.¹⁰ This suggests that multidisciplinary teams have a positive impact on the outcomes of HF patients, in addition to the use of pharmacological agents.

As the burden of chronic illnesses continues to grow in the United States, health care providers and payers struggle to find ways to maintain high-quality care while controlling spiraling costs. The high readmission rates for HF patients are a particularly appropriate target for intervention because the population at risk can be identified and the factors that contribute to this phenomenon are well known. This article describes an intervention strategy to improve outcomes of patients with chronic HF at the Dorn Veterans Administration (VA) Medical Center in Columbia, SC. This initiative was analyzed using a multivariate framework that evaluates the cost and consequences of this HF intervention.

Methods

Intervention description. The Advanced Heart Failure Program (AHFP) was developed at the Dorn VA Medical Center to provide a comprehensive multidisciplinary management approach to persons with advanced HF. The AHFP targeted patients with (1) American College of Cardiology (ACC)/American Heart Association (AHA) stage C/D or New York Heart Association(NYHA) class III/IV HF; (2) HF hospitalized 2 or more times in a 1-year period; and (3) HF with an irreversible cause. Persons with HF with terminal cancer in hospice care or who are receiving dialysis were not enrolled in the program.

The goals of the AHFP were to decrease hospital admission/readmission rates, decrease health care expenditures, and improve the quality of life (QOL) for persons with advanced HF. Health care professionals participating in the AHFP included a cardiologist, internal medicine specialist, nurse practitioner, nurse, case managers, physician assistant, pharmacist, and clinical researchers. The pharmacist involved in the AHFP had clinical and research responsibilities. Clinical responsibilities included discussion with the HF treatment team about appropriate medications and doses, monitoring and patient counseling of medications, and evaluation of patient adherence. Research responsibilities included preparation of clinical protocol, database development, analysis of data, and manuscript preparation.

Once enrolled in the AHFP, patients visited the clinic every 2 weeks for the first 2 months, then monthly thereafter. Patients initially reported every 2 weeks so that their condition could be “stabilized.” Stabilization was considered achieved when HF patients were able to tolerate their maximum dose of β-blockers for 14 days.

During the initial visit, patients received an extensive physical, diagnostic, laboratory, medication, and QOL evaluation (Table 1). The diagnostic evaluation at enrollment included a Multiple Gated Acquisition Scan, chest radiograph, echocardiogram, pulmonary function test (PFT), myocardial perfusion stress test, ECG, and an impedance cardiography (ICG) test. The laboratory evaluation at enrollment consisted of a basic metabolic panel, uric acid level, brain natriuretic peptide (BNP) level, complete blood cell (CBC) count, digoxin level, thyroid-stimulating hormone level, and free thyroxine level.

The medication evaluation at enrollment included a review of medication history and evaluation for indication/appropriateness, drug interactions, and dosing. For patients enrolled in the AHFP, treatment with lisinopril, furosemide, carvedilol, and spironolactone (pending evaluation of their pre-enrollment medications, current stage of HF, and hemodynamics) was started. Other HF medications utilized on a case-by-case basis were digoxin, valsartan, and potassium chloride. The Kansas City Cardiomyopathy Questionnaire was administered at enrollment and at each subsequent visit. The initial visit/evaluation cost of the AHFP was $1051.92 (Table 1).

In subsequent visits to the clinic, patients were evaluated using physical, diagnostic, laboratory, medication, and QOL measurements (Table 1). Laboratory evaluations included basic metabolic panel, uric acid level, BNP level, CBC count, ICG test, ECG, and digoxin level. Medications were evaluated for indication/appropriateness, drug interactions, and dose. Changes to medication regimens were made when indicated. Subsequent visit evaluation totaled $141.73 per patient. The AHFP cost for 50 weeks was $3036.14.

Patients were responsible for certain aspects of their own care and were educated on symptom management. Patients monitored their own weight, blood pressure, and  peak flow measurements daily (Table 1). If patients observed abnormalities in their measurements or did not feel well, they were instructed to call the clinic or report to the emergency department, depending on the severity of their condition. Patients determined to have a fluid overload were seen in the AHFP infusion clinic and given intravenous diuresis. The AHFP infusion clinic monitored patients to return them to a euvolemic state. If patients responded positively to intravenous furosemide, they were discharged and seen later at the clinic (thereby avoiding a hospital admission). Episodic management was available to evaluate and treat patients without hypervolemia as well.

Clinic visits and hospitalizations. Routine clinical and hemodynamic end points are monitored as part of the process of care for HF patients enrolled in the AHFP program at Dorn VA Medical Center. Since the clinic’s inception in 2004, more than 200 patients have been treated and monitored. Basic demographic information and clinical laboratory values were obtained from VA electronic records. Each time a patient was treated in the clinic or the hospital, the results and outcomes were documented. To capture hospitalization information before enrollment in the clinic, a retrospective electronic chart review was conducted for one year preceding enrollment in the HF clinic. Because the primary focus of this study was to evaluate hospitalizations of HF patients, a comparison of the number of all-cause hospitalizations was conducted for the pre-enrollment period and the post-enrollment period.

Cost calculations. The cost of a HF hospitalization was obtained through VA electronic records. Calculations for each clinic visit were based on laboratory and procedure costs.

Results

Descriptive results. The baseline characteristics of HF patients who enrolled in the program are shown in Table 2. The mean age of the 217 patients enrolled was 65.3 ± 11.6 years. All patients were classified as having NYHA class III/IV or ACC/AHA stage C/D HF. The average number of comorbidities was 4.5 per patient; the majority of patients had hypertension and hyperlipidemia in addition to HF. Other common comorbidities included diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease. Many patients also had a history of smoking.

Before enrollment in the AHFP, the average all-cause hospital admission rate was 3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, the mean all-cause hospital admission rate was 1.2. The average cost of medical service HF hospitalization cost at our institution during the study period was $9042.60. HF patients had an average annual hospitalization cost of $28,936.32 before enrollment in the AHFP. After enrollment in the AHFP, HF patients had an average hospitalization cost of $10,851.12. Taking into account the 50-week cost for a patient enrolled in the clinic of $3036.14, participation in the AHFP was associated with a decrease in the number of  HF-related admissions, saving an average of $15,049.06 per patient (Figure).

Figure. Post-enrollment hospitalization costs for heart failure patients who participated in the Advanced Heart Failure Program (AHFP) were less than half of pre-enrollment hospitalization costs plus AHFP-related costs for annual savings of $15,049.06 per patient.

Discussion

Current data suggest that multidisciplinary HF treatment teams confer a significant benefit to patients, particularly those who received 1-to-1 patient education and self-management recommendations.^5,10-14 Clinical studies of HF multidisciplinary teams have demonstrated a survival advantage (similar to that of pharmacological treatment), a decrease in number of hospital admissions and read missions, a decrease in length of hospital stay, and a reduction in health care costs and utilization.^5,10-14 Collectively, these findings across different patient populations support the likelihood of a significant association between the use of multidisciplinary treatment teams and improved outcomes for HF patients.

This study revealed that both all-cause hospital admissions and health care costs can be decreased in a HF patient population that was utilizing significant VA health care resources. HF is a chronic clinical syndrome that typically is irreversible. Our inclusion criteria selected patients that had an irreversible cause of HF, ACC/AHA stage C/D or NYHA class III/IV HF, and 2 previous hospitalizations for HF. We therefore were able to evaluate the effects of a multidisciplinary treatment team on HF patients with advanced disease who were using significant resources and not have our results biased by a selection of patients who were not as clinically ill. Given the nature of the patient population in the study, we were able to demonstrate that advanced stages of HF disease can be impacted positively by the use of non pharmacological treatment and by altering the standard reactive treatment model; HF outcomes can be improved by proactive multidisciplinary treatment teams.

Implementation of a multidisciplinary HF clinic was associated with a decrease in hospital readmission rates and health care costs. Such an intervention may be useful in decreasing resource utilization and cost for other HF patients and should be evaluated in other settings to assess the magnitude and generalizability of the effect.

References:

References

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