CHF program reduces admissions by 85%
$9,800 per patient saved
A study of heart failure patients accepted for heart transplant at University of California at Los Angeles' (UCLA) Ahmanson Cardiomyopathy Center revealed a drop in hospital readmissions by 85% during the first six months after referral and an estimated per patient savings of $9,800.1 Gregg C. Fonarow, MD, director of the center at the UCLA and lead author of the three-year study, attributes the program's success to its comprehensive approach to the management of heart failure patients.
The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost. Fonarow notes that conventional management of such patients usually centers on an individual physician who coordinates adjusting medications, stabilizing the patient, and providing education. But given physicians' time constraints and often incomplete experience with every condition or detailed knowledge regarding diet, exercise, and monitoring of fluids, there's often not enough time for a real emphasis on disease management.
Fonarow adds that under conventional management, patients leaving the hospital are often seen by different physicians for follow-up and further adjustment of medications.
The program stresses patient self-care. UCLA's comprehensive approach involves optimizing patients' medication combined with detailed education for patients and their families. "There's close communication and contact with a multidisciplinary heart failure center that's really focused on disease management and prevention," Fonarow says. Such an approach takes into account not only patients' medications and laboratory tests, but also their personal adjustment to their conditions. By addressing individual educational and dietary needs and making home nursing and social support available, clinicians are better able to involve patients actively in their own care, Fonarow says.
"We try to anticipate all of the potential needs in areas where, if therapy fails, a patient will end up back in the hospital."
Specifically, when patients begin the program, a heart failure nurse specialist sits down with them for at least 30 minutes to provide detailed instructions regarding nutrition. The nurse covers areas such as how to read sodium instructions on product labels and gives patients a five-page sheet of acceptable and unacceptable foods. Patients learn how to adapt their diets to fit within the center's guidelines and how to choose foods when eating out. Patients also receive detailed information on how to exercise, how to monitor symptoms, and when to gradually advance the exercise regimen.
"Patients get constant reinforcement every time they're seen back at the center," Fonarow says. "We review their weight chart with them and answer any questions they have about their diets."
Patients take active role in treatmentHe notes that having patients monitor their weight daily is a good way to make them realize their efforts toward self-care can have direct results. "If they ate too much salt one day, their weight would go up the next day, and it would give them immediate feedback that they had taken in too much. So it actively involves patients in their own management and lets them see that this isn't a futile, irreversible disease."
Another key factor was the use of a flexible diuretic regimen coupled with daily weight monitoring. "About 70% of heart failure hospitalizations are due to volume overload," Fonarow points out. "So this meticulous attention to the patient's volume status and having them actively involved in monitoring was very important."
Fonarow adds, however, that the most significant factor UCLA found in sharply reducing the need for rehospitalization was the increased use of angiotensin-converting enzyme (ACE) inhibitors. At the outset of the program, ACE inhibitors were given to the 78% of patients not already taking them, and doses were increased for the 22% who were.
Over a three-year period, 214 patients were accepted for heart transplant and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per minute, and an average of two hospital admissions in the previous six months. Changes in the medical regimen included a 98% increase in ACE inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling regarding diet and progressive exercise.
During the six months after referral, there were only 63 hospital readmissions - an 85% reduction. Functional status improved as assessed by functional class and peak oxygen consumption. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient. Fonarow says that the study's results highlight the potentially dramatic effects a comprehensive disease management program can have on heart failure. "It shows that there can be a real impact," he says.
Reference1. Fonarow G, Stevenson LW, Walden JA, et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol 1997; 30:725-732.
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