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Poliambulanza Hospital Brescia, Italy
Correspondence to: Renzo Rozzini, MD, Poliambulanza Hospital, Brescia Geriatric Research Group, via Romanino 1, Brescia, Italy 25122
To the Editor:
We read with interest the article by Akosah et al1 (September 2002) on the importance of a disease management program for patients with chronic heart failure. We were impressed by their results, although it is obvious that a continuous follow-up by an expert physician leads to better clinical outcomes. The critical point, at least in the health system of our country, is the real feasibility of a large-scale disease management program.
A first issue concerns the fact that not all hospital wards are able to organize follow-up systems for a large number of patients with heart failure. In fact, it is interesting to note that the group of those referred on discharge to the heart failure clinic in the article by Akosah et al1 are clinically more compromised (lower ejection fraction, higher level of comorbidity), indicating that in a "real-world" condition (such as that of the not randomized study), the sicker patients are naturally eligible for a disease management program. In this line, we suggest that such programs should be devoted to a selected population of patients with heart failure, probably those who are hospitalized in skilled hospital wards.
A second point concerns the role of primary physicians, since they are excluded from patient care if a qualified program is implemented. This fact has to be taken in consideration, particularly in health systems that are centered on family doctors; however, we have no answers to this problem.
Taking in consideration these points, we report data on 579 patients with a diagnosis of heart failure consecutively discharged from our 24-bed Acute Care for the Elderly Medical Unit, with the aim to discuss a possible third and intermediate model (Table 1 ). Patients in New York Heart Association (NYHA) class III and IV were considered separately (n = 149, 25.7%); in patients in these NYHA classes, 6-month mortality was of 33.6% (n = 50). These results were obtained with an informal follow-up program based on careful information of family physicians, on a monthly outpatient clinic control, and on the education of patients and the patient’s family to a strict compliance with drugs and dietary regimen and control of weight. We think that our program, although less beneficial than that of Akosah et al,1 is a good compromise for a large-scale management of patients with HF.
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References
* Gundersen Lutheran Heart Institute La Crosse, WI
Correspondence to: Kwame O. Akosah, MD, Gundersen Lutheran Heart Institute, 1836 South Ave, La Crosse, WI 54601
To the Editor:
On behalf of my co-authors, I thank Drs. Rozzini, Sabatini, and Trabucchi for their comments on our article. They raise important issues concerning disease management programs for heart failure. One of their questions concerns the "feasibility of a large scale disease management program" in their country. There are various models of disease management programs for heart failure. These include minimal specialty involvement, such as nurse-run or nurse practitioner-run clinics. Other models of disease management include electronic monitoring programs, whereby patients record vital signs and weights, which are then read at a central station; the information is provided to a private physician to decide what action is necessary. Some community hospitals have programs that are jointly run by physicians and nurses or nurse practitioners. These programs usually provide clinic visits for the patients. In our institution, we decided to provide a comprehensive multispecialty service that involves cardiologists, nurse practitioners, and nurses. In the case described above, I suspect the model that works best is the one that matches the peculiarities of your community.
The second point raised "concerns the role of primary physicians, since they are excluded from patient’s care if a qualified program is implemented." The role of the primary physician in the management of a patient with chronic disease such as heart failure is crucial. We, too, had to overcome barriers when we established our program. One barrier concerned the attitude of our doctors toward associate clinicians. We had to assure them that their patients would not be cared for exclusively by nonphysician associate clinicians. Next, we had to dispel the perception that the Heart Failure Program represented a threat or competition to their practice. Rather, the program is a resource available to appropriate patients and clinicians. We work with primary physicians, and our program has been well received. Working with the primary physician is important in addressing all comorbidities including diabetes mellitus, renal failure, pulmonary disease, and others that have impact on the overall morbidity and mortality of the patient.
Rozzini and colleagues present their data in the subset of 149 patients discharged from the hospital with New York Heart Association class III and IV heart failure. In this group, mortality at 6 months was 33.6%, which they call less impressive compared to our results. However, this is being modest because these results are not easily comparable for two reasons. First, their patients were much older, with mean age of 81 years, compared to 68 years for our group. One would expect a higher rate of death based on age alone. Second, most of their patients had diastolic heart failure with a mean left ventricular ejection fraction of 60.6%. I am not aware of survival rates for octogenarians with diastolic heart failure. Perhaps outcome measures other than survival may be more realistic in the very elderly, as mortality at this age is strongly linked with average life expectancy. Such measures may include quality of life and impact of program on resource utilization.
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