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* From the Gundersen Lutheran Medical Foundation, La Crosse, WI.
Correspondence to: Kwame O. Akosah, MD, Gundersen Lutheran Medical Foundation, 1836 South Ave, La Crosse, WI 54601; e-mail: kakosah{at}gundluth.org
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionConclusionReferences |
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Design: Chart review.
Setting: An integrated health-care center serving a tristate area.
Patients: Inclusion criteria were discharge from the hospital with a primary diagnosis of CHF, outpatient follow-up within the hospital system, and the presence of left ventricular systolic dysfunction as the basis for CHF. Patients were categorized into group 1 if they were referred to the HFC after hospital discharge, and into group 2 if follow-up care was provided by their primary care physician.
Measurements and results: There were 38 patients in group 1 and 63 patients in group 2. There was a trend toward a shorter time to the first outpatient visit following discharge (11 days vs 15 days, p = 0.09), more outpatient visits within 90 days (10 visits vs 2 visits, p < 0.001), and more patient-initiated contacts (four contacts vs one contact, p = < 0.001) in group 1 compared to group 2, respectively. The combined hospital readmission and mortality rate at 90 days (10% vs 30%, p < 0.018) and 1 year (21% vs 43%, p < 0.02) was lower in group 1. There was a 77% relative risk reduction for 30-day hospital readmission in favor of group 1, and a statistically lower rate of readmissions at 90 days and 1 year. Utilization and maintenance of standardized CHF medications were significantly higher in patients who attended the HFC.
Conclusions: A comprehensive disease management program for patients discharged with a diagnosis of CHF resulted in fewer rehospitalizations and improved event-free survival compared to patients followed up by their primary care physicians.
Key Words: congestive heart failure • disease management • outcomes
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionReferences |
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Unfortunately, several challenges remain for management of CHF in the community. First, evidence suggests that it is very difficult for the average physician to keep abreast of the latest research findings. Familiarity with published guidelines remains less than ideal.8 Second, the medical management of CHF is complex. Many patients with CHF patients have multiple comorbidities and do not receive standardized CHF medications, or are not prescribed doses shown to provide benefit in clinical trials.9 10 11 Third, evidence suggests that many patients with CHF do not receive a diagnosis and treatment until advanced disease occurs.12 13
As a result of these multiple limitations in management and deficiencies in the episodic management model of care for CHF disease, heart failure clinics (HFCs) have been established in several institutions. These programs provide intensive outpatient management to improve health status, prevent clinical deterioration, and avert acute crisis. Several of these programs assess their success based on quantifying hospital readmission rates at some time frame prior to and after patient enrollment in an HFC. The advantage of this methodology is that patients serve as their own controls. However, this methodology may not be rigorous enough to exclude confounding factors such as the advent of recommendations derived from large clinical trials, including the Metoprolol CR/XL Randomized Intervention Trial,6 the Randomized Aldactone Evaluation Study,7 and the Carvedilol Prospective Randomized Cumulative Survival Study,14 as well as publication of guidelines that may in themselves have resulted in changes in practice patterns.
After reviewing the management of patients with CHF patients in this institution, we established an HFC in 1999. The purpose of the clinic was to improve outcomes of patients with CHF. We undertook this study in order to determine what difference our clinic has made. During this study, we tried to answer the following question: are there differences in outcomes between patients referred to the HFC after hospitalization compared to patients receiving follow-up care by their primary care providers?
The purpose of this study was to determine if patient participation in our short-term, intensive HFC would result in improved hard end points (morbidity and mortality) compared with patients discharged to usual follow-up care by their primary physicians. A second objective was to identify system features associated with improved outcomes.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionReferences |
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Criteria for enrollment in the HFC included New York Heart Association class III or IV, multiple hospitalizations (two hospital admissions in 2 months or three hospital admissions in 6 months), or by referral by a primary care physicians. Mean time of enrollment in the HFC is 3 months. At enrollment, a plan of care is developed. During this time, the patient’s medications are aggressively titrated, requiring frequent monitoring of laboratory values and physical examination. With intensive education, patients are taught self-care skills in the management of their disease. Timing of follow-up visits is flexible and individualized for each patient based on their response to therapy.
Our goal is to have all patients receiving ACEI (20 mg of lisinopril or equivalent) and up-titrate the ACEI to maximal dose (40 mg of lisinopril or equivalent) unless contraindicated. When an adequate dose of ACEI (20 mg of lisinopril or equivalent) is achieved, ß-blocker therapy is initiated and up-titrated. During the period of up-titration, we closely monitor diuretics, with a goal of achieving a euvolemic state. Low-dose spironolactone is considered for all patients with systolic dysfunction.
Particular attention is also placed on concurrent management of comorbidities such as ischemia, atrial fibrillation, hypertension, ventricular tachycardia, peripheral vascular disease, diabetes, and renal disease. Patients with significant ischemia and with objective evidence of viable myocardium are referred for cardiac surgery evaluation. Our HFC follows the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines in aggressive treatment of hypertension.15
In addition, patient education focuses on self-care management, including diet, exercise, emotions, weight monitoring, and recognition of exacerbation symptomatology. Patients are empowered to contact HFC staff for concerns related to their CHF diagnoses and changes in their CHF standardized medications. Once the patient is optimally managed, he or she is discharged back to the referring physician with a long-term plan of care. A follow-up visit is established for 6 months after HFC discharge unless changes in the patient’s condition occur.
Patient Population
Between April 1, 1999, and March 30, 2000, there were a total of 251 patients discharged alive with a primary diagnosis of CHF. Patients were included in this study if they met one of the following designated categories. Patients were classified as group 1 if they were referred directly to our HFC for management after hospital discharge and had left ventricular systolic dysfunction as a basis for their CHF. Patients were classified as group 2 if they were not referred to the HFC, but did receive follow-up care within our health-care system and had left ventricular systolic dysfunction as a basis for their CHF.
A chart review was conducted on all patients meeting inclusion criteria. Data were collected from electronic clinic records and included basic demographics and clinical profile. In addition, medication utilization was tracked. Outcome information including hospital readmissions and mortality, as well as combined end point of hospital readmission plus death, were determined at 30 days, 90 days, and again at 1 year. Hospital readmission was defined as a CHF-related admission to the index hospital. The index hospital is a major community referral center serving a tristate area and a 100-mile radius. Mortality was determined from the clinic record and death certificate listings. One-year outcome data were available on all patients meeting inclusion criteria.
Statistical Analysis
All continuous variables are expressed as means and SDs. Comparisons between groups were performed using the independent t test, the paired-sample t test, and a 2 x 2 factorial analysis for repeated measures. Categorical variables were analyzed with the 
2 test, the Fisher exact test, and independent samples proportional analysis. Survival data were analyzed using a Kaplan-Meier curve yielding a Breslow statistic. A two-sided p value of 0.05 was considered significant.
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionReferences |
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Patients referred to the HFC were predominantly male (71% vs 43%, respectively; p = 0.005), and relatively younger (68 ± 16 years vs 76 ± 11 years, respectively; p = < 0.002). However, group 1 patients had more severe left ventricular dysfunction with a left ventricular ejection fraction of 29% vs 39% for group 2 (p < 0.005; Table 1 ). Comorbidities were prevalent in both groups; however, patients in group 1 were more likely to have renal disease (p < 0.035), severe dysrhythmias (p < 0.039), an automatic implantable cardioverter defibrillator implant (p < 0.028), and hypotension (p < 0.002; Table 2 ).
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Medication Utilization
Discharge Medications:
At the time of hospital discharge, prescription rates for ACEI (all doses) were 82% for group 1 and 65% for group 2. There were no significant differences in the proportion of patients placed on adequate doses of standardized medications between the two groups. We defined adequate or recommended ACEI dosage as lisinopril 
20 mg or an equivalent brand of ACEI. The prescription rate for the recommended dose of ACEI was 29% in both groups, for angiotensin receptor blockers (ARBs) was 5% in group 1 and 6% in group 2, and for any dose of ß-blocker was 71% in group 1 and 62% in group 2.
Medications at Follow-up:
All group 1 patients, at the time of discharge from the HFC to follow-up care by their primary care providers, were either receiving a maximal ACEI dose (lisinopril 30 mg or equivalent) or an ARB. Mean time to discharge to primary care physician was 4 months. All patients were receiving ß-blocker therapy. One year after hospital discharge, 16% of patients in group 1 had the doses of their standardized medications reduced by the primary care provider. However, maintenance on adequate doses of standardized medications at 1 year was significantly higher for group 1 (84%) compared with group 2 (38%; p < 0.001) [Table 4
]. Multivariate analysis revealed that there were also significant increases in the standardized dosage of ACEI from hospital to follow-up by group, with the CHF patients having significant up-titration, compared to the patients followed up by their primary care providers (F = 53.0, p < 0.001). The mean ACEI dose was 36 mg of lisinopril or equivalent in group 1, compared to 20 mg in group 2. Specifically, 82% of patients in group 1 were maintained on a ß-blocker and 65% tolerated moderate-to-high doses, defined as 100 to 200 mg of metoprolol succinate or an equivalent dose of another ß-blocker. By contrast, only 56% of group 2 patients maintained ß-blocker therapy at 1 year.
Outcomes
There was a trend toward lower hospital readmission rate at 30 days in group 1 (3% vs 13%, respectively; p = 0.08), with a relative risk reduction of 77%. Both 90-day (5% vs 23%, respectively; p < 0.020) and 1-year (16% vs 31%, respectively; p < 0.030) hospital readmission rates were significantly lower for group 1. Time to hospital readmission also trended longer for group 1 (192 days) compared with group 2 (104 days) [p = 0.08]. Among patients readmitted, only two patients in group 1 had two additional hospital admissions for CHF exacerbations. In contrast, there were four patients in group 2 with two additional hospital admissions and four patients with three additional hospital admissions. In other words, multiple readmission rates were also lower for group 1.
There were no differences in mortality alone at 90 days or 1 year, although mortality trended favorably for group 1. For instance, the mortality rate at 1 year was 11% for group 1, compared to 17% in group 2. However, there were significant differences in combined end points of rehospitalization and mortality at 90 days and 1 year. Rates for mortality and readmission were 30% for group 2 at 90 days, compared to 10% in group 1 (p < 0.018). The combined end point of 1-year mortality and hospital readmission rates for group 2 was 43%, compared to 21% for group 1 (p < 0.021). Event-free survival (survival without hospital readmission) was significantly higher in group 1 at 90 days (90% vs 70%, respectively; p < 0.018) and at 1 year (79% vs 59%, respectively; p < 0.02) [Fig 1 , Kaplan-Meier curve].
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionReferences |
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Currently, the focus of CHF management is on episodic treatment and crisis intervention, strategies that are costly and suboptimal. CHF is a progressive disease that spans a spectrum from asymptomatic left ventricular dysfunction to end-stage disease. To address some of these limitations and adequately contend with the complexity of treatment for advanced heart failure, many disease management strategies have been developed.
Disease management systems operate on the supposition that heart failure is an active disease state regardless of whether or not an individual is symptomatic. In other words, instead of treating patients on a crisis basis, management is focused on treating the underlying disease process. Some of these models are designed to provide ready access to a health-care professional, whereby early signs of exacerbation can be promptly treated to avert crisis. Regardless of the model used, CHF disease management programs have consistently reported reductions in hospitalizations, emergency department visits, and probably costs.16 17 18 19
In our HFC, optimal management is viewed as a continual process of treating a progressive disease that is always active. By aggressively managing the disease and maximizing standardized medications, even when patients are in clinically stable condition, our goal is to prophylactically prevent exacerbations. Moreover, prompt attention to early signs and symptoms of decompensation, identified by the patients themselves, can lead to improved outcomes.
Current literature suggests that different models of CHF management programs have resulted in reductions in both hospitalization and emergency department visits. However, outcome variables have typically been measured before and after patient enrollment in the program. Using this methodology, the evidence supporting improved outcomes can be misleading. First, it does not tell whether or not the performance of the program is above or below national standards, because baseline data may vary in different programs. For instance, if the baseline readmission rate for an institution is 60% and is reduced by the CHF program to 30%, this reflects a 50% risk reduction for readmission. In contrast, a second program that reduced their readmission rate from 30 to 20% has a relative risk reduction for hospitalization of only 30%. Program 2 has a better performance, although it achieved a lower relative risk reduction. Analyzing program performance by this method can be misleading. Second, analysis using a before and after enrollment in a program design does not account for different confounding factors, such as improvements in general care based on the results of clinical trials, such as acceptance of use of ACEI and spironolactone, which are available to all care providers.
We wanted to determine if our comprehensive model of CHF program in the community leads to long-term improved outcomes. The results of this study show that the answer is affirmative. Compared to a group of patients discharged from the hospital in the same time frame and followed up by their primary care providers, the population of patients enrolled in the HFC had a trend toward fewer repeat hospital admissions at 30 days, and significant reductions at 90 days and at 1 year. Even though patients return to their primary care physicians after aggressive short-term management in our HFC, the improved outcome in terms of rehospitalization was retained at 1 year.
Although we did not specifically study costs, our results are consistent with other investigators16 17 19 who have demonstrated that the benefit of reduced hospitalization is associated with significant cost savings per patient per year. In our study, not only did fewer patients require hospital readmissions in group 1, but only two patients required readmissions. In contrast, four patients in group 2 required two additional hospital admissions, and four patients required three additional hospital admissions. Inpatient hospital management is expensive, and any strategy that reduces hospitalization is likely to be associated with cost savings.
Although there were no significant differences in mortality at 30 days, 90 days, or 1 year, the results at each time interval showed a trend, favoring patients managed in the HFC. For instance, mortality rates at 1 year were 11% and 17% in groups 1 and 2, respectively. Difference in mortality within such a short term of follow-up would not be expected in a one-center study. Furthermore, when analyzed as a combined end point of mortality and hospital readmission, there was a statistically significant difference between groups in favor of patients seen in the HFC at 90 days and at 1 year.
What may explain these differences in outcomes? One possible explanation may be drug utilization. At the time of hospital discharge, similar proportions of patients in each group were treated with adequate ACEI and a ß-blocker. However, at 90 days, all patients in group 1 were tolerating either high-dose ACEI or an ARB. In contrast, the proportion of patients in group 2 receiving adequate ACEI or ARB and a ß-blocker did not change. At 1 year, while group 1 patients were being followed up by their primary care providers, a few patients had medications withdrawn or doses reduced. However, the maintenance rate of ACEI or ARB was still high (84%), whereas the maintenance rate remained low and unchanged in group 2 (38%).
This suggests the importance of not only starting patients on standardized medications, but also up-titrating these medications prior to discharging the patient back to the referring physician, because the likelihood of the medications being maintained is high. In contrast, when patients are not placed on adequate doses of standardized medications, they are likely to remain on suboptimal doses at 1 year. At 1 year, the mean dose of ACEI was 36 mg in group 1, compared to 20 mg in group 2.
It is possible that differences in outcomes may be explained in part by other technical or system differences. We found that there was a trend toward a shorter time period from discharge to the first outpatient visit for group 1, and significantly more outpatient visits and telephone contacts initiated by patients. We interpret this to mean, regardless of the model of care, that minor changes in the system can derive significant improvements in outcomes. These system changes include a prompt outpatient visit following hospital discharge, more frequent outpatient evaluations with up-titration of medications, and having a mechanism in place for ready access to a health-care provider. Patient education goals included recognizing early signs of decompensation, and empowerment to call their health-care providers when these signs and symptoms develop. Each of these goals is a critical component in managing a complex disease entity such as CHF.
Limitations
Our study has limitations that must be taken into account. First, this is not a randomized study. Referral to our clinic was at the discretion of the patients’ primary physicians. However, this reflects the reality of clinical care. An alternative design is a matched-case control study, but this could not be done for practical reasons. Second, the sample size is relatively small. In 1 calendar year, there were 251 patients discharged from the index hospital with a primary diagnosis of CHF. Among these, 101 patients had follow-up care at the index institution or one of its affiliate clinics. Outcome data were available on all of the 101 patients. It is unfortunate that we did not have access to data regarding all patients. Third, although all patients were discharged from the index institution, the source of in-hospital care was not uniform. This is typical and not unexpected in a multispecialty care hospital. The extent to which differences in physician care during hospitalization may have influenced outcome is not known.
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Conclusion |
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Acknowledgements |
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Footnotes |
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Received for publication October 25, 2001. Accepted for publication February 6, 2002.
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