doi: 10.1161/01.CIR.0000021745.45349.BB
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(Circulation. 2002;105:2810.)
© 2002 American Heart Association, Inc.
Editorial |
Improving Outcomes in Heart Failure
It’s Not Unusual Beyond Usual Care
From Cardiovascular Nursing, College of Nursing, University of Kentucky, Lexington; and Winters Center for Heart Failure Research, Baylor College of Medicine, and the Houston VAMC, Houston, Tex.
Correspondence to Debra K. Moser, DNSc, RN, Professor and Gill Chair of Cardiovascular Nursing, University of Kentucky, College of Nursing, 527 CON/HSLC Building, 760 Rose Ave, Lexington, KY 40536-0232. E-mail dmoser{at}uky.edu
Key Words: Editorials • heart failure • mortality
Heart failure is approaching epidemic proportions worldwide and is associated with substantial public and personal burden.1–3 The public burden of heart failure is evident in the enormous costs of caring for patients with heart failure.4 Indeed, heart failure is the largest single Medicare expenditure and is the leading cause of hospitalization for those >65 years of age in many industrialized countries, including the United States. The majority of these healthcare costs can be attributed to hospitalizations for exacerbation of congestive heart failure.4 The 6-month readmission rate for congestive heart failure is close to 50%.5–6 The personal burden of heart failure includes debilitating symptoms, frequent rehospitalizations, and high rates of mortality. Five years after receiving a diagnosis of heart failure, <40% of men or women are still alive.7–8 Thus, the report in this issue of Circulation by Stewart and colleagues9 that patients randomized to a home-based heart failure disease management intervention instead of usual care had 36% fewer rehospitalizations and a 28% reduction in risk of death from all causes is of more than casual interest to patients, healthcare providers, and the institutions that provide health care for these patients. Before we discuss the significance and potential impact of the findings by Stewart et al,9 however, it will be useful to digress and briefly review the existing literature about the types of heart failure disease management programs that have proved useful thus far.
See p 2861
Strategies for Improving Outcomes in Heart Failure
The traditional model of care delivery, "usual care," is thought to contribute to frequent hospitalizations because in these brief, episodic encounters, little attention may be paid to the common, modifiable factors that precipitate many hospitalizations. As many as two thirds of hospitalizations may be preventable.10–13 The most common causes of these preventable hospitalizations are patients’ failure to adhere to their prescribed drug and diet regimen and their failure to seek early treatment for escalating symptoms.10–14 Other common modifiable factors associated with preventable heart failure exacerbations include poor discharge planning, haphazard follow-up after discharge, failure of patients’ social support systems, and providers’ failure to address patient characteristics such as cognitive impairments, low income, depression, and multiple comorbidities that make them vulnerable to rehospitalization.10,15
Because usual care seems to be inadequate for most heart failure patients, clinicians and researchers have tested a number of alternative healthcare delivery models over the past 2 decades in attempts to improve patient outcomes.16–21 Such alternatives generally fall under the category of heart failure disease management. These heart failure disease management efforts can be categorized broadly into 2 types of models, either heart failure specialty clinics or home-based interventions. Most are multidisciplinary and all use a variety of components that can include optimization of drug therapy, aggressive and vigilant follow-up of patients so that problems are recognized early, easy access by patients to a member of the healthcare team, and identification and management of patients’ unique problems that can contribute to heart failure exacerbations. All heart failure specialty care reported in the literature includes education and counseling. Although there is significant variation in the content and delivery of such education and counseling, the following are common to many programs: (1) educating both patients and family or caregiver; (2) discussing behavioral strategies to increase adherence to prescribed diet and medications; (3) offering advice about increasing physical activity and strategies to improve ability to perform desired activities; (4) teaching about monitoring for signs and symptoms of decompensation, including daily weighing; and (5) offering advice about what to do in case of escalating signs and symptoms.
Although a few reports indicate a neutral impact of heart failure disease management,22 the great majority of heart failure disease management programs, regardless of their type, have demonstrated positive outcomes.15–21 Patients who are cared for in these programs experience substantially fewer rehospitalizations, incur lower healthcare costs, demonstrate improved functional and symptom status, and enjoy better quality of life compared with either a preintervention time period or patients treated with usual care. Earlier studies of heart failure disease management largely used nonrandomized pretest–posttest designs, but increasingly, randomized, controlled designs are used in studies of heart failure disease management. This body of literature provides compelling evidence for the superiority of heart failure disease management compared with usual care. Disease management has a clear impact on every important outcome in heart failure, with the exception of one—mortality. To date, few programs have had adequate power or have monitored patients long enough to demonstrate a survival benefit of heart failure disease management, although some studies suggested that improved survival was possible for participants of these interventions.
In the present issue of Circulation, Stewart et al9 report on a randomized, controlled trial of a home-based heart failure specialty intervention in Australia in which they demonstrated that patients randomized to the intervention had a better survival rate and fewer rehospitalizations than those who received usual care. These investigators enrolled patients 
55 years of age with heart failure from left ventricular systolic dysfunction during a hospitalization for exacerbation of failure in 2 randomized controlled trials of a home-based heart failure disease management intervention. To evaluate the long-term outcomes of the intervention, they combined the 2 cohorts and followed up with a total of 297 patients. This study is notable for its long follow-up period. In previous studies, typical follow-up was 3 to 12 months. Stewart et al9 followed up with patients for an average of 4.2 years, and none was lost to follow-up.
Patients received either usual care alone or usual care combined with a structured home visit conducted 1 to 2 weeks after hospital discharge. The home-based program consisted of assessment of and intervention for, as needed, patients’ social support system, knowledge of and adherence to their treatment plan, other individual factors that could contribute to rehospitalization or death, and physical status. The intervention was conducted by an experienced cardiac nurse who coordinated efforts to optimize management, conducted phone follow-up, and facilitated interactions with other healthcare providers as needed.
Patients assigned to the home-based intervention group experienced better rehospitalization, survival, and cost outcomes compared with those assigned to the usual care group. Event-free survival was longer in the intervention group who experienced a median of 7 months of event-free survival versus 3 months in the usual care group. Considering all-cause mortality alone, median survival in the intervention group was 40 months versus 22 months in the usual care group. Patients in the home-based intervention group had fewer hospitalizations and their stays were shorter, as well as less expensive, despite the initially greater number of outpatient clinic visits for intervention patients.
The results of this study and those of previous studies suggest that heart failure disease management programs are clearly superior to the traditional usual care management strategies for heart failure. To place this in perspective, the magnitude of impact on mortality seen in the study by Stewart et al9 approaches the magnitude of reduction in all-cause mortality observed in the recent trials with ß-blockers in heart failure patients.23–24 Indeed, heart failure disease management programs have a similar or greater impact than drug therapy alone on quality of life, rehospitalization rates, and survival for heart failure patients. Moreover, this effect is not simply the result of optimization of drug therapy.19,21 Thus, on the basis of the findings reported by Stewart et al9 in this issue of Circulation, as well as the other studies discussed above, one could argue that the standard of care should include some form of heart failure disease management program for heart failure patients after discharge from the hospital.
On the basis of the arguments raised in the foregoing discussion, it is reasonable to ask whether the results of Stewart et al9 and other heart failure disease management interventions can be generalized to all patients with heart failure. Although the answer to this question is not known, it is important that several previous studies have demonstrated a trend toward an improvement in survival for patients who are managed in heart failure disease management programs. Furthermore, the accumulating evidence of the superiority of heart failure disease management programs over usual care in terms of other outcomes, including resource utilization, suggests that these programs favorably impact the natural history of heart failure. If heart failure disease management programs do favorably impact the natural history of the disease process, this raises an important question about what type(s) of heart failure disease management practitioners should use. Unfortunately, despite the many studies in this area, the lack of systematic research that builds on and expands previous findings limits our ability to answer this question definitively.
Within the broad categories of clinic-based or home-based disease management, there is marked variability in the individual components used in each program. There have been no studies comparing the impact on outcomes of individual components. Moreover, there are no data indicating whether clinic-based models are better or worse than home-based models, or whether some patients do better in one type of care than in another. Heart failure disease management programs are usually either physician directed or nurse directed. There have been no comparisons of nurse-directed versus physician-directed programs to tell us if one is better than the other or if they are comparable with regard to patient outcomes. Nurses deliver the bulk of care in most programs, but whether outcomes depend on the level of educational preparation of the nurse is unknown. Furthermore, no study has investigated the intensity of intervention needed, so it is unclear how to determine what "dose" of intervention is needed for various subgroups of patients.
Beyond the aforementioned issues of process of care, there are also important questions about the types of patients that will benefit most from heart failure disease management programs. The extant literature suggests that not all patients benefit from disease management. For example, one study suggests that heart failure disease management programs for patients with New York Heart Association class I heart failure increase healthcare resource use and costs.25 On the other hand, there may be specific high-risk subgroups of patients who could be targeted for more intensive disease management. For example, patients with poor social support systems, depression, cognitive impairments, or poor quality of life are at increased risk for early rehospitalization and death.10,12,13–15,26–27 It is possible that intensive heart failure disease management, through a number of mechanisms, could decrease negative outcomes in these patients. Before specific heart failure disease management programs can be widely implemented, these types of questions should be asked and answered by well-designed clinical outcomes studies. This area of research is one of the major focuses of the Veterans Administration’s Quality Enhancement Research Initiative (QUERI) in Chronic Heart Failure.28
Conclusion
A large body of evidence now suggests that heart failure disease management programs will prevent hospitalizations, decrease symptoms, and improve quality of life for patients with heart failure. The article by Stewart et al9 in the present issue of Circulation confirms and expands on these findings by showing that heart failure disease management programs can prolong life as well. If the results of the study by Stewart et al9 are confirmed by others and can be generalized to larger, more diverse populations with heart failure, there will be not only an economic incentive to enroll patients in such programs, but also compelling medical reasons for enrolling patients in these types of programs as well.
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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