Internet improves CHF outcomes, study shows
Costs come down as compliance rises
More than four million Americans suffer from congestive heart failure (CHF). This costly and debilitating disease most often affects the elderly, and the fatigue and shortness of breath associated with CHF keep its victims isolated and inactive without the energy to participate in social activities. CHF is not only a costly disease, leading to multiple hospitalizations and emergency department visits; the isolation it causes often leads to depression.
One California disease management company launched a pilot program to see if it could successfully integrate its proven disease management approach with high technology. It found that good things happen when seniors with CHF go on-line. "We weren’t sure seniors would embrace the Internet. More than 90% of the seniors we enrolled in the one-year pilot had never used a computer before," explains Christine M. Ruggerio, RN, MSN, manager of clinical Web programs for LifeMasters Supported SelfCare in Newport Beach, CA. "Not only did the technology engage the patients, but compliance with daily data entry was greater than 80%."
The perfect blend
The study population was a group of 69 patients with moderate to severe CHF who were randomly placed into either an Internet group or an interactive voice response (IVR) group. The Internet group used a personal computer to enter their vital signs and symptoms into the LifeMasters database via the Internet. The Internet group also was able to access disease-specific content, community chat, and e-mail correspondence with a LifeMasters nurse. In addition to entering their vital signs, patients were asked a series of questions to determine their health status. If their answers or vital signs indicated a potential problem, patients received a call from their LifeMasters nurse.
The IVR group used a touch-tone phone to enter similar measurements into the LifeMasters database and answer the same series of questions. Like the Internet group, if the vital signs or answers indicated a potential problem, patients received a telephone call from their LifeMasters nurse. IVR users had access to printed disease-specific patient education materials and telephonic interaction with a LifeMasters nurse.
Both the Internet and the IVR groups received CHF management education from a LifeMasters nurse during scheduled telephone calls. Topics covered during the eight-week education module include:
- diet;
- exercise;
- medications;
- psychosocial/coping;
- pathophysiology;
- symptom management;
- risk factor reduction and behavior change.
Patients in both groups were patients of Physicians Medical Group of Santa Cruz County, CA. A third group did not participate in either the Internet or IVR groups but received traditional CHF care as offered by the medical group. Ruggerio notes that both intervention groups did much better than the traditional care group. LifeMasters also found that the Internet group had a slight edge over the IVR group in every area measured.
Findings include:
- The Internet group had 20 hospitalizations, compared to 39 for the IVR group.
- The Internet group had a total of 149 hospital days, compared to 258 days for the IVR group.
- The Internet group had a reporting compliance rate of just below 88%, compared to roughly 76% for the IVR group.
- The Internet group had an overall per member per month savings of $6.78, compared to a $15.63 increase in per member per month costs for the IVR group. However, these figures do not accurately reflect the overall cost savings for each group, cautions Ruggerio.
"When we looked more closely at claims costs, most of the increases in claims costs were due to diabetes and end stage renal disease — not cardiac or CHF-related claims," she says. "Both groups had a decrease in cardiac costs. The decrease in cardiac costs for the IVR group was $164.93 per member per month compared to $246.52 for the Internet group." Cardiac claims for the unenrolled population increased by $134.87 per member per month.
Both groups reported satisfaction with the program, says Ruggerio. "The overall patient satisfaction rate was 83% for both groups, and 73% of patients in both groups reported that the program made a difference’ in their care," she notes.
Learning curve
Computers for the Internet group were provided by LifeMasters. Ruggerio personally went to each patient’s home to help set up the computer and help seniors learn how to use the computer to access the Internet and input their vital signs on the customized Web site. "Repetition was very important. I made sure that patients used the Internet to enter their vital signs once or twice with me watching," she notes. "I also sat with them while they learned to e-mail and do research on the Internet."
Not only did the Internet group experience better outcomes than the IVR group; seniors in the Internet group embraced their new computer prowess. "Roughly 90% of patients in the Internet group elected to continue using the computer for Internet entry of vital signs, health care monitoring, and other purposes," says Ruggerio. "It only takes about four or five minutes for patients to enter their vital signs on the Web site, but patients in the Internet group spent an average of 37 minutes on-line each day. They told us they used the Internet to e-mail friends and family, watch stocks, research their interests, chat, and play on-line games."
In fact, Ruggerio encouraged seniors in the study to use the computer to play games like Solitaire in order to learn how to use a mouse. "Most of the patients had never used a computer before, and playing games helped them practice with the mouse," she says. "It helped increase their flexibility."
LifeMasters learned through trial and error how to make the Internet user-friendly for seniors. Ruggerio shares these tips for making the Internet more accessible to older patients:
- Use large 17" monitors.
- Place monitors at a proper distance and angle to be used with bifocal lenses.
- Increase font sizes used on Web sites.
- Include plenty of white space on Web sites.
- Use dark buttons on Web sites.
"Patients with diabetic retinopathy have difficulty seeing light pastels," Ruggerio points out. "We finally went to dark blue buttons with yellow printing, which were easy for patients to see."
In some ways, older patients embrace the Internet more readily than younger ones, she adds. "We found this group of older patients was much more tolerant of the slow speed than younger patients we’ve worked with on Internet disease management programs," she explains. "It was quite refreshing, really. The site itself works fairly quickly, but accessing the library can take time, and seniors were much more patient than younger patients."
LifeMasters is encouraged by the results of this pilot and plans to continue working to integrate the Internet into its disease management programs. "We have several younger populations, such as diabetics, who could benefit from this type of Internet monitoring and education intervention," Ruggerio explains. "Our diabetics are mostly working people. They are not going to make a phone call from work and tie up the phone line, but they can quickly access the Internet, enter their data, and continue with their own work. The Internet offers people alternatives for disease management and monitoring. I’m very pleased with both the clinical and anecdotal evidence of how the computer not only provides effective disease management but also serves as a lifeline for patients with chronic disease."
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