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Outcomes from a comprehensive heart failure disease management program
S86 Journal of Cardiac Failure Vol. 9 No. 5 Suppl. 2003 316
317
The Effectiveness of Angiotensin Converting Enzyme Inhibitors in Medicare Beneficiaries with Heart Failure and Left Ventricular Systolic Dysfunction: Results of the National Heart Care Project Frederick A. Masoudi,1,2,3 Saif S. Rathore,4 Yongfei Wang,4 Edward P. Havranek,1,2,3 JoAnne M. Foody,4 Harlan M. Krumholz3,4—1Department of Medicine, Denver Health Medical Center, Denver, CO; 2Department of Medicine, University of Colorado Health Sciences Center, Denver, CO; 3Colorado Foundation for Medical Care, Aurora, CO; 4Department of Medicine, Yale University School of Medicine, New Haven, CT
Outcomes from a Comprehensive Heart Failure Disease Management Program Patty M. Orr,1 Josephine M. Dimengo1—1Clinical Integrity, American Healthways, Nashville, TN
Background: Although the efficacy of angiotensin converting enzyme (ACE)-inhibitors in reducing mortality of patients with heart failure and left ventricular systolic dysfunction (LVSD) has been demonstrated in randomized trials, the effectiveness of these agents in community-based populations is unknown. Methods: Using data from the Centers for Medicare and Medicaid Services-sponsored National Heart Care Project, we studied two cross-sectional national cohorts of patients ⱖ65 years of age discharged alive after hospitalization with the principal diagnosis of heart failure between April 1998-March 1999 and July 2000-June 2001. Patients with at least moderate LVSD (or LVEF ⬍ 40%) and without an absolute contraindication to ACEinhibitor treatment were included. We assessed the relationship between ACE-inhibitor prescription at discharge and 1-year mortality with a weighted multivariable hierarchical logistic model, adjusting for patient characteristics and other discharge medications. Odds ratios were converted to estimated risk ratios (RR). Results: Of the 17,456 patients eligible for the analysis, 32% were not treated with ACE-inhibitor at discharge. Crude one-year mortality was 42% in the untreated group and 33% in treated patients. In the multivariable model, ACE-inhibitor prescription was associated with an 18% reduction in overall mortality (RR 0.82, 95% CI 0.86-0.90). Significant reductions in mortality were seen in a wide range of patient subgroups, including those over age 75 (RR 0.78, 0.72-0.84), women (RR 0.83, 0.78-0.88), non-white patients (RR 0.79, 0.70-0.89), patients without diabetes (RR 0.76, 0.71-0.80), patients without coronary artery disease (RR 0.77, 0.69-0.82), and patients with mild to moderate renal insufficiency (creatinine 1.5-2.5 mg/dL, RR 0.80, 0.74-0.85). The association between ACEinhibitor prescription and reduced mortality was similar in the two sampling time frames. Conclusions: In this nationally representative sample, ACE-inhibitor prescription was consistently associated with significant mortality benefits in a wide range of patients with heart failure and LVSD. Greater efforts to increase the utilization of ACE-inhibitors in all eligible patients with LVSD will be important to optimizing heart failure outcomes.
Disease management programs are designed with the goal of improving clinical outcomes and decreasing the cost of medical care by overcoming barriers to patient and provider adherence to proven evidenced based treatment guidelines. This abstract reports on clinical, utilization, and financial outcomes after participation for 2 years by a large patient population in a comprehensive, large-scale heart failure (HF) disease management program. The disease management program focuses on supporting the primary care physician to implement standard HF guidelines with each patient and employing registered nurses to provide standard interventions. Standard interventions include regularly scheduled telephonic care calls, which serve as a basis for conducting the health assessment, providing disease specific education, medication review, review of needed standards of care, and using behavior change techniques to guide the patient in optimal self-care. The nurse also supports and coaches the patient in effective communication with their physician to promote achievement of agreed upon health care goals. Based upon assessment data and risk stratification, care calls can occur from weekly to every 6 weeks. Higher risk patients are placed on home monitors that measure daily weights, pulse, and blood pressure, which are evaluated daily by the nurse and reported to the primary care physician if the values are outside of agreed upon parameters. The nurse evaluates the home monitoring readings for trends that indicate increasing fluid retention, worsening BP control, or abnormal pulse and takes action in response to those changes. For increasing weight the nurse assesses diet adherence, medication compliance, and breathing patterns and notifies the physician if physician intervention is needed in addition to nursing intervention. 1,034 commercial patients from a health plan participated in the program for a 2 year period. Outcome variables for the second year of the program were compared to participant historical data in the year prior to engagement in the program. Appropriate use of ACE inhibitors was a clinical improvement focus for the nurses in their interventions. The percentage of all patients on an ACE inhibitor at baseline compared to the second year following enrollment resulted in a 19.2% improvement with 57.2% on an ACEI prior to vs 68.2% following 2 years of enrollment. Admissions per thousand patients decreased by 26.4%. Baseline admissions per 1000 patients were 1002.80, and the second year admissions per 1000 were 738.49. Bed days per thousand decreased by 33.7% when baseline (6931.2 bed days per 1000) was compared to the end of the second year (4597.73 bed days per 1000) of participation. Pharmacy costs increased by 27% from baseline ($146.98 PMPM for baseline compared to $186.70 PMPM for the second year). Total per member per month (pmpm) cost decreased by 33.7%, with the base year pmpm cost being $1,298.81 and the second year pmpm cost being 861.53. Educating and empowering patients to optimally self-manage their HF, promoting the patient-physician relationship, and supporting the physician in implementing evidence based care guidelines resulted in positive clinical, utilization, and financial outcomes.
318
319
Response of Doxorubicin-Induced Cardiomyopathy to the Current Management Strategy of Heart Failure Jose A. Tallaj,1,2 Veronica Franco,2 Barry K. Rayburn,2 Laura J. Pinderski,2 Raymond L. Benza,2 Brian A. Foley,2 Robert C. Bourge2—1Department of Medicine, Birmingham VA Medical Center, Birmingham, AL; 2Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
Relationship of N-BNP with Hospital Admission in Elderly Symptomatic Patients in the Community: Follow Up from the Natriuretic Peptides in the Community Study Sue P. Wright,1 Robert N. Doughty,1 Ann Pearl,1 Greg Gamble,1 Tim Yandle,2 Norman Sharpe,1 Mark Richards2—1Medicine, University of Auckland, Auckland, Auckland, New Zealand; 2Medicine, University of Otago, Christchurch, Christchurch, New Zealand
Background: Doxorubicin (D) (Adriamycin) is a potent and efficacious chemotherapeutic agent in various forms of cancer. Its use has been limited by the development of cardiac toxicity. Historically, D-induced cardiomyopathy (CMP) has been refractory to therapy. Cardiac transplantation remains the only proven therapy for this form of cardiac disease. We report the University of Alabama at Birmingham’s experience with this form of CMP. Results: Twenty-four patients (19 women, 6 men) with the clinical diagnosis of D-CMP were referred to our program between 1990 to 2002 and followed for 71.5 ⫾ 56.0 months. The most common cancers treated with D were breast (12) and lymphoma (6). The mean total dose of D was 469 ⫾ 302 mg/m2. The time to develop heart failure (HF) after the administration of D was 6.85 ⫾ 4.81 years. On presentation to our program, 75% were New York Heart Association (NYHA) class III or IV, and the average left ventricle ejection fraction (LVEF) was 26.3 ⫾ 9.2%. Twenty-two patients were treated with ACE-inhibitors (ACEi) and 13 with the combination of ACEi and beta-blockers (BB). In addition, they were treated with digoxin (20), diuretics (22), spironolactone (10) and coumadin (9). Two patients were transplanted, 2 died from progressive HF and 1 was lost to follow-up. With medical therapy, the LVEF improve significantly (26.3 ⫾ 9.2 vs 32.5 ⫾ 15.8%, p ⫽ 0.027), as well as the NYHA class (p ⬍ 0.0276) (see figure). Of the 19 survivals (or not transplanted or lost to follow-up) 16 (84%) were NYHA class I or II with medical therapy, with half of them being class I. In the group treated with the combination of ACEi and BB there was a higher incidence of normalization of LVEF with medical therapy (5/13, 38%). The improvement in functional class was also more impressive in this group, with 8/13 patients being NYHA class I or II at follow-up. Conclusions: In the current era of HF management, D-CMP carries a better prognosis than previously described. The early addition of a BB provides a more favorable effect in patients’ symptoms and may further improve the LVEF. Transplantation or more invasive therapies should be reserved for those patients who fail medical therapy.
Background: Previous studies have shown N-terminal brain natriuretic peptide (NBNP) to be a powerful predictor of outcome in a wide range of patient groups including those hospitalised for heart failure and following acute myocardial infarction. The aim of this study was to determine the relationship between N-BNP and hospital admission in a cohort of symptomatic elderly people recruited prospectively from primary care. Methods: The patients were those presenting to their general practitioner with symptoms of dyspnoea and/or oedema that were recruited for the Natriuretic Peptides in the Community Study. All pts underwent clinical evaluation, N-BNP assay and an echocardiogram (echo). The gold standard diagnosis of HF was the decision of an expert panel using ESC criteria. Patients were followed for a minimum of 6 months with data on hospital admissions determined from GP and hospital records. Kaplan-Meier survival curves were constructed to examine hospital admissions in patients with and without heart failure, and patients stratified at a N-BNP level of 200 pmol/L. Results: 305 patients were involved, mean age 72 years, 65% women. 77 (25%) patients met the case definition for heart failure. Median follow up was 13 monthsduring which time 27% of patients were admitted to hospital. 61 of 244 patients (25%) with a N-BNP of less than 200 pmol/L had been hospitalised, compared to 19 of 41 (46%) patients with a N-BNP ⱖ 200 pmol/L (46%), p ⫽ 0.0008. N-BNP was an independent predictor of hospital admission, odds ratio 2.0 (95% CI 1.07, 3.9). Analysis stratified by presence of heart failure and N-BNP level showed that NBNP ⱖ 200 pmol/l only predicted hospital admission in those patients who had heart failure. N-BNP did not predict hospital admission in those patients without heart failure (see figure). Conclusions: N-BNP is an independent predictor of hospital admission in elderly community dwelling subjects with heart failure but does not predict hospital admission in those symptomatic subjects without heart failure. Newly diagnosed heart failure patients in the community with N-BNP ⱖ 200 pmol/L are at very high risk of hospital admission.
317
The Effectiveness of Angiotensin Converting Enzyme Inhibitors in Medicare Beneficiaries with Heart Failure and Left Ventricular Systolic Dysfunction: Results of the National Heart Care Project Frederick A. Masoudi,1,2,3 Saif S. Rathore,4 Yongfei Wang,4 Edward P. Havranek,1,2,3 JoAnne M. Foody,4 Harlan M. Krumholz3,4—1Department of Medicine, Denver Health Medical Center, Denver, CO; 2Department of Medicine, University of Colorado Health Sciences Center, Denver, CO; 3Colorado Foundation for Medical Care, Aurora, CO; 4Department of Medicine, Yale University School of Medicine, New Haven, CT
Outcomes from a Comprehensive Heart Failure Disease Management Program Patty M. Orr,1 Josephine M. Dimengo1—1Clinical Integrity, American Healthways, Nashville, TN
Background: Although the efficacy of angiotensin converting enzyme (ACE)-inhibitors in reducing mortality of patients with heart failure and left ventricular systolic dysfunction (LVSD) has been demonstrated in randomized trials, the effectiveness of these agents in community-based populations is unknown. Methods: Using data from the Centers for Medicare and Medicaid Services-sponsored National Heart Care Project, we studied two cross-sectional national cohorts of patients ⱖ65 years of age discharged alive after hospitalization with the principal diagnosis of heart failure between April 1998-March 1999 and July 2000-June 2001. Patients with at least moderate LVSD (or LVEF ⬍ 40%) and without an absolute contraindication to ACEinhibitor treatment were included. We assessed the relationship between ACE-inhibitor prescription at discharge and 1-year mortality with a weighted multivariable hierarchical logistic model, adjusting for patient characteristics and other discharge medications. Odds ratios were converted to estimated risk ratios (RR). Results: Of the 17,456 patients eligible for the analysis, 32% were not treated with ACE-inhibitor at discharge. Crude one-year mortality was 42% in the untreated group and 33% in treated patients. In the multivariable model, ACE-inhibitor prescription was associated with an 18% reduction in overall mortality (RR 0.82, 95% CI 0.86-0.90). Significant reductions in mortality were seen in a wide range of patient subgroups, including those over age 75 (RR 0.78, 0.72-0.84), women (RR 0.83, 0.78-0.88), non-white patients (RR 0.79, 0.70-0.89), patients without diabetes (RR 0.76, 0.71-0.80), patients without coronary artery disease (RR 0.77, 0.69-0.82), and patients with mild to moderate renal insufficiency (creatinine 1.5-2.5 mg/dL, RR 0.80, 0.74-0.85). The association between ACEinhibitor prescription and reduced mortality was similar in the two sampling time frames. Conclusions: In this nationally representative sample, ACE-inhibitor prescription was consistently associated with significant mortality benefits in a wide range of patients with heart failure and LVSD. Greater efforts to increase the utilization of ACE-inhibitors in all eligible patients with LVSD will be important to optimizing heart failure outcomes.
Disease management programs are designed with the goal of improving clinical outcomes and decreasing the cost of medical care by overcoming barriers to patient and provider adherence to proven evidenced based treatment guidelines. This abstract reports on clinical, utilization, and financial outcomes after participation for 2 years by a large patient population in a comprehensive, large-scale heart failure (HF) disease management program. The disease management program focuses on supporting the primary care physician to implement standard HF guidelines with each patient and employing registered nurses to provide standard interventions. Standard interventions include regularly scheduled telephonic care calls, which serve as a basis for conducting the health assessment, providing disease specific education, medication review, review of needed standards of care, and using behavior change techniques to guide the patient in optimal self-care. The nurse also supports and coaches the patient in effective communication with their physician to promote achievement of agreed upon health care goals. Based upon assessment data and risk stratification, care calls can occur from weekly to every 6 weeks. Higher risk patients are placed on home monitors that measure daily weights, pulse, and blood pressure, which are evaluated daily by the nurse and reported to the primary care physician if the values are outside of agreed upon parameters. The nurse evaluates the home monitoring readings for trends that indicate increasing fluid retention, worsening BP control, or abnormal pulse and takes action in response to those changes. For increasing weight the nurse assesses diet adherence, medication compliance, and breathing patterns and notifies the physician if physician intervention is needed in addition to nursing intervention. 1,034 commercial patients from a health plan participated in the program for a 2 year period. Outcome variables for the second year of the program were compared to participant historical data in the year prior to engagement in the program. Appropriate use of ACE inhibitors was a clinical improvement focus for the nurses in their interventions. The percentage of all patients on an ACE inhibitor at baseline compared to the second year following enrollment resulted in a 19.2% improvement with 57.2% on an ACEI prior to vs 68.2% following 2 years of enrollment. Admissions per thousand patients decreased by 26.4%. Baseline admissions per 1000 patients were 1002.80, and the second year admissions per 1000 were 738.49. Bed days per thousand decreased by 33.7% when baseline (6931.2 bed days per 1000) was compared to the end of the second year (4597.73 bed days per 1000) of participation. Pharmacy costs increased by 27% from baseline ($146.98 PMPM for baseline compared to $186.70 PMPM for the second year). Total per member per month (pmpm) cost decreased by 33.7%, with the base year pmpm cost being $1,298.81 and the second year pmpm cost being 861.53. Educating and empowering patients to optimally self-manage their HF, promoting the patient-physician relationship, and supporting the physician in implementing evidence based care guidelines resulted in positive clinical, utilization, and financial outcomes.
318
319
Response of Doxorubicin-Induced Cardiomyopathy to the Current Management Strategy of Heart Failure Jose A. Tallaj,1,2 Veronica Franco,2 Barry K. Rayburn,2 Laura J. Pinderski,2 Raymond L. Benza,2 Brian A. Foley,2 Robert C. Bourge2—1Department of Medicine, Birmingham VA Medical Center, Birmingham, AL; 2Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
Relationship of N-BNP with Hospital Admission in Elderly Symptomatic Patients in the Community: Follow Up from the Natriuretic Peptides in the Community Study Sue P. Wright,1 Robert N. Doughty,1 Ann Pearl,1 Greg Gamble,1 Tim Yandle,2 Norman Sharpe,1 Mark Richards2—1Medicine, University of Auckland, Auckland, Auckland, New Zealand; 2Medicine, University of Otago, Christchurch, Christchurch, New Zealand
Background: Doxorubicin (D) (Adriamycin) is a potent and efficacious chemotherapeutic agent in various forms of cancer. Its use has been limited by the development of cardiac toxicity. Historically, D-induced cardiomyopathy (CMP) has been refractory to therapy. Cardiac transplantation remains the only proven therapy for this form of cardiac disease. We report the University of Alabama at Birmingham’s experience with this form of CMP. Results: Twenty-four patients (19 women, 6 men) with the clinical diagnosis of D-CMP were referred to our program between 1990 to 2002 and followed for 71.5 ⫾ 56.0 months. The most common cancers treated with D were breast (12) and lymphoma (6). The mean total dose of D was 469 ⫾ 302 mg/m2. The time to develop heart failure (HF) after the administration of D was 6.85 ⫾ 4.81 years. On presentation to our program, 75% were New York Heart Association (NYHA) class III or IV, and the average left ventricle ejection fraction (LVEF) was 26.3 ⫾ 9.2%. Twenty-two patients were treated with ACE-inhibitors (ACEi) and 13 with the combination of ACEi and beta-blockers (BB). In addition, they were treated with digoxin (20), diuretics (22), spironolactone (10) and coumadin (9). Two patients were transplanted, 2 died from progressive HF and 1 was lost to follow-up. With medical therapy, the LVEF improve significantly (26.3 ⫾ 9.2 vs 32.5 ⫾ 15.8%, p ⫽ 0.027), as well as the NYHA class (p ⬍ 0.0276) (see figure). Of the 19 survivals (or not transplanted or lost to follow-up) 16 (84%) were NYHA class I or II with medical therapy, with half of them being class I. In the group treated with the combination of ACEi and BB there was a higher incidence of normalization of LVEF with medical therapy (5/13, 38%). The improvement in functional class was also more impressive in this group, with 8/13 patients being NYHA class I or II at follow-up. Conclusions: In the current era of HF management, D-CMP carries a better prognosis than previously described. The early addition of a BB provides a more favorable effect in patients’ symptoms and may further improve the LVEF. Transplantation or more invasive therapies should be reserved for those patients who fail medical therapy.
Background: Previous studies have shown N-terminal brain natriuretic peptide (NBNP) to be a powerful predictor of outcome in a wide range of patient groups including those hospitalised for heart failure and following acute myocardial infarction. The aim of this study was to determine the relationship between N-BNP and hospital admission in a cohort of symptomatic elderly people recruited prospectively from primary care. Methods: The patients were those presenting to their general practitioner with symptoms of dyspnoea and/or oedema that were recruited for the Natriuretic Peptides in the Community Study. All pts underwent clinical evaluation, N-BNP assay and an echocardiogram (echo). The gold standard diagnosis of HF was the decision of an expert panel using ESC criteria. Patients were followed for a minimum of 6 months with data on hospital admissions determined from GP and hospital records. Kaplan-Meier survival curves were constructed to examine hospital admissions in patients with and without heart failure, and patients stratified at a N-BNP level of 200 pmol/L. Results: 305 patients were involved, mean age 72 years, 65% women. 77 (25%) patients met the case definition for heart failure. Median follow up was 13 monthsduring which time 27% of patients were admitted to hospital. 61 of 244 patients (25%) with a N-BNP of less than 200 pmol/L had been hospitalised, compared to 19 of 41 (46%) patients with a N-BNP ⱖ 200 pmol/L (46%), p ⫽ 0.0008. N-BNP was an independent predictor of hospital admission, odds ratio 2.0 (95% CI 1.07, 3.9). Analysis stratified by presence of heart failure and N-BNP level showed that NBNP ⱖ 200 pmol/l only predicted hospital admission in those patients who had heart failure. N-BNP did not predict hospital admission in those patients without heart failure (see figure). Conclusions: N-BNP is an independent predictor of hospital admission in elderly community dwelling subjects with heart failure but does not predict hospital admission in those symptomatic subjects without heart failure. Newly diagnosed heart failure patients in the community with N-BNP ⱖ 200 pmol/L are at very high risk of hospital admission.