(Circulation. 1997;96:2755-2757.)
© 1997 American Heart Association, Inc.
Articles |
Specialized Centers for Heart Failure Management
From the Heart Failure Program (W.T.A.) and Division of Cardiology (M.R.B.), University of Colorado Health Sciences Center (Denver).
Correspondence to Michael R. Bristow, MD, University of Colorado Health Sciences Center, 4200 E Ninth Ave, Box B-139, Denver, CO 80262.
Key Words: Editorials • heart failure
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Introduction |
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 Top Introduction References |
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The incidence of many forms of cardiovascular disease, such as acute myocardial infarction and stroke, has been on the decline over the past two decades. During this same time, the incidence of heart failure has markedly increased.1 2 In 1970, there were 250 000 new cases of heart failure diagnosed in the United States.1 By 1988, this number had grown to 400 000 cases,1 and in 1992, nearly 700 000 new cases of heart failure were identified.2 This increasing incidence of heart failure in the United States has resulted in a current prevalence of heart failure of nearly 5 million cases, or
1.5% of the US
population.2 Moreover, heart failure is a disease syndrome
associated with aging; that is, both the incidence and prevalence of
heart failure increase in the elderly population. For example, if one
examines the prevalence of heart failure in those more than 75 years
old, nearly 10% of this elderly population exhibits the clinical
syndrome of chronic heart failure.3 Given this, heart failure is now the most common diagnosis-related group (DRG) discharge diagnosis for those aged more than 65 years old, and it is the fourth leading cause of hospitalization in US adults.4 This has resulted in a substantial economic burden. Estimates of the total direct costs of heart failure treatment in the United States range from $10 billion to nearly $40 billion.2 5 6 Data recently summarized by Konstam et al5 for the Agency for Health Care Policy and Research indicate the following annual expenditure for heart failure in 1990 through 1991: hospital days, $7.5 billion; nursing home days, $1.9 billion; drugs, $0.2 billion; and physician visits, $0.7 billion. In 1991, the Health Care Financing Administration (HCFA) spent $5.45 billion for the inpatient management of heart failure (DRG 127) or 4.8% of the total DRG budget.2 This expenditure compares with $2.24 billion for all types of cancer (DRGs 82, 172, 203, 239, and 403), and $3.18 billion dollars for myocardial infarction (DRGs 121 and 122).
Heart failure is also associated with very high rates of morbidity and
mortality. It is estimated that at any given time, 30% of the heart
failure population falls into New York Heart Association functional
class III or IV, compatible with an advanced degree of disability.
Moreover, despite recent advances in pharmacological therapy, the
1-year mortality rate is on the order of 40% to 50% for advanced
heart failure7 and 15% to 25% for those with
mild-to-moderate symptoms.8 9 10
In this issue of Circulation, Hanumanthu and colleagues11 present their experience with the effect of a heart failure program on hospitalization frequency and exercise tolerance in patients with chronic heart failure referred to the Vanderbilt Heart Failure and Heart Transplantation Program between July 1994 and June 1995. A total of 187 patients were referred. Of these, 138 were referred as ambulatory outpatients, whereas 49 patients were transferred to Vanderbilt Hospital from other hospitals. Fifty-four patients were women and 133 were men. The average age of the heart failure patients was 52±12 years. Heart failure was due to nonischemic cardiomyopathy in 97 patients, coronary artery disease in 81 patients, and various other causes in the remaining 9 patients. Of these 187 patients, 134 were followed for >30 days as outpatients by the Vanderbilt Heart Failure and Heart Transplantation Program and were the focus of the report of Hanumanthu et al. All patients were managed according to standards that are generally typical of this and other comprehensive regional heart failure centers. Patients were followed on a long-term basis by three physicians who work exclusively with heart failure and heart transplantation patients. Dedicated cardiovascular nurse specialists assisted with the management of patients. All patients underwent assessment of left ventricular function, and those who were able to exercise underwent cardiopulmonary exercise testing. Serial measurements of left ventricular function and exercise capacity were used frequently in this patient population, as was exercise testing with invasive hemodynamic monitoring. All of these strategies are standard practice in specialized heart failure/transplant centers but are not likely to be systemically applied in other settings in which heart failure care is delivered.
The two primary end points of this evaluation, hospitalization and exercise capacity, were favorably affected by the heart failure management program. The annualized rate of first hospitalization was 94% during the year before referral. This was significantly reduced to 44% during the year after referral. Total cardiovascular hospitalizations decreased significantly from 210 to 104, mainly due to a reduction in hospitalizations for decompensated heart failure from 164 to 60, representing a 63% reduction. Serial cardiopulmonary exercise testing data were available for 88 patients. At the time of referral, these patients exhibited an average peak exercise VO2 of 12.8±4.7 mL · kg-1 · min-1. After 3 to 6 months' treatment in the program, the peak exercise response increased significantly to 15.7±4.8 mL · kg-1 · min-1. Of note, the 1-year survival for the entire group was 87%, a figure that is substantially better than historical controls with moderate-to-severe heart failure.
These reductions in hospitalizations and improvements in exercise capacity were, in part, likely attributable to more aggressive diuretic therapy. On average, the dose of loop diuretics was doubled during the first 6 months in the program. Remarkably, the use of ACE inhibitors and digoxin was high at the time of referral: 76% and 88%, respectively. In the case of ACE inhibitors, this utilization is substantially better than published national averages. The appropriately high utilization of these medications at the time of referral was not significantly affected by referral to the Heart Failure Program.
The current report from Hanumanthu and colleagues supports the notion that patients with complicated chronic disease syndromes such as heart failure should be managed by specialists or in specialty clinics devoted to the care of such patients. However, 83% of patients now being treated for heart failure are cared for by physicians other than cardiologists.2
That highly organized specialty centers deliver more efficacious treatment to patients affected with complex disease syndromes is not novel to heart failure. Other evidence also indicates that specialists and specialty clinics may produce better clinical and economic outcomes for diseases in which significant cognitive skill and an integrated delivery system are required. An example of this may be found in asthma management, where specialist care by pulmonologists or allergists results in more intensive therapy, better symptomatic relief, improved exercise tolerance, and decreased emergency department or hospital utilization compared with generalists' care.12 13 14 A similar outcome has be seen in the management of unstable ischemic heart disease, in which myocardial infarction and hospital death rates tend to be lower in those patients treated by cardiologists versus those treated by internists.15 Moreover, cardiologists were significantly more likely to prescribe aspirin, heparin, and ß-adrenergic receptor–blocking agents in these patients.
In the heart failure arena, several observations support better outcomes when patients are managed by specialists compared with generalists. For example, the use of ACE inhibitors in heart failure reduces mortality and has been demonstrated to be cost-effective, either in absolute terms or when taken in the context of cost-effectiveness expressed in terms of years of life extended. Moreover, ACE inhibitors now constitute first-line therapy for chronic heart failure according to published guidelines from the Agency for Health Care Policy and Research,5 the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,16 and the Task Force of the Working Group on Heart Failure of the European Society of Cardiology.17 Given this, it is significant to note that ACE inhibitor use for the treatment of heart failure is consistently demonstrated to be higher when patients are treated by cardiologists compared with generalists.18 This observation has recently been confirmed in the university hospital environment. Unpublished data for 1430 patients from 49 academic medical centers included in the University HealthSystem Consortium (Chicago, Ill) Congestive Heart Failure Clinical Benchmarking Project demonstrated that 76% of heart failure patients treated on the Cardiology Service were discharged from the hospital on a ACE inhibitor, whereas only 65% of such patients treated on noncardiology services received an ACE inhibitor at the time of hospital discharge. Moreover, one study of ACE inhibitor use for heart failure performed in an academically affiliated city-county health system demonstrated similar ACE inhibitor use among generalists versus cardiologists but indicated that cardiologists prescribed these medications at the higher doses shown to be efficacious in large randomized clinical trials.19
At least three other reports support the findings of Hanumanthu and colleagues. Rich and associates20 conducted a prospective, randomized trial of the effect of a nurse-directed multidisciplinary intervention on rates of readmission within 90 days of hospital discharge, quality of life, and cost of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure. The primary end point of study was 6-month survival without readmission. This primary end point was reached in significantly fewer patients in the intervention group than in the usual care group (53.6% versus 64.1%, respectively). Quality of life scores were higher and total cost of care was lower in the intervention group. Fonarow and associates21 examined the impact of a specialized center for heart transplantation on hospitalization rates and patient functional status in the 6 months before referral compared to the 6 months after referral. Hospitalizations were significantly reduced from 2.0 per patient during the 6 months before referral to 0.29 per patient in the 6 months after referral. New York Heart Association functional class improved from 3.3 to 2.4, and peak VO2 improved from 11 to 15.2 mL · kg-1 · min-1. Finally, Smith et al22 presented their preliminary findings of a 50% reduction in overall health care expenditures in the 6 months after referral to a specialty cardiomyopathy clinic.
Moreover, specialized heart failure centers offer complex, cost-effective treatments not available in other settings, such as cardiac transplantation, high-risk cardiac surgery in lieu of transplantation, and experimental medical treatments not yet approved by the FDA. An example of the latter would be carvedilol, a third-generation ß-blocker whose Phase III trials ended in February 1995. Carvedilol was only recently approved for delaying the progression of heart failure, and it came to market >2 years after completion of phase III trials. During this interval, it was available only in specialty heart failure centers.
The above observations support the ongoing development of comprehensive regional heart failure centers for the management of patients with chronic heart failure. These efforts are analogous to those previously accomplished for the treatment of cancer though the establishment of the National Cancer Institute Cancer Centers Program and to the development of specialty care centers for human immunodeficiency virus disease. In the case of cancer centers, the initiative was originally provided by the National Cancer Act of 1971. The purpose of this program was to promote fundamental research in clinical and basic sciences, serve as a focus for evaluating the output of research and development, lead in the planning and coordination of various organ- specific programs, develop special competence in each individual center, and link the output of cancer research efforts with medical practice. This program has been highly successful by regionalizing the management of this difficult clinical problem and encouraging formalized collaboration.
In view of the present and future socioeconomic burden of heart failure, it may be that an analogous approach is warranted: that is, federal support/guidelines for specialized heart failure centers. Interestingly, the federal government is already involved in regulating heart failure/transplant centers through the United Network for Organ Sharing (UNOS), a highly successful organ procurement system mandated by the National Organ Transplant Act of 1984. This is a revenue-neutral system composed of regional not-for-profit organ banks supported through cost-recovery from third-party payers; the federal role was a congressional mandate that the system be established. In other words, there are examples of creative ways in which the federal government has acted to improve specialized health care in a cost-effective manner, and the treatment of heart failure could be potentially improved by such an action. At a minimum, large health care provider networks should view specialized heart failure centers as highly desirable for improving outcomes and lowering costs.
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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TopIntroductionReferences |
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1. American Heart Association. 1988 Heart Facts. Dallas, Tex: American Heart Association; 1988.
2. O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant. 1994;13:107-112.
3. Kannel WB. Epidemiological aspects of heart failure. Cardiol Clin. 1989;7:1-9.[Medline] [Order article via Infotrieve]
4.
Ghali JK, Cooper R, Ford E. Trends in
hospitalization for heart failure in the United States, 1973-1986:
evidence for increasing population prevalence. Arch
Intern Med. 1990;150:769-773.
5. Konstam MA, Dracup K, Baker DW. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research; Clinical Practice Guideline No. 11, 1994.
6. Parmley WW. Cost-effective cardiology: cost-effective management of heart failure. Clin Cardiol. 1996;19:240-242.[Medline] [Order article via Infotrieve]
7. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med. 1987;316:1429-1435.[Abstract]
8. SOLVD Investigators. Effect of enalapril on survival in patients with reduced left-ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293-302.[Abstract]
9. Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong M. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991;325:303-310.[Abstract]
10. Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE, Dunkman WB, Jacobs W, Francis GS, Flohr KH. Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J Med. 1986;314:1547-1552.[Abstract]
11.
Hanumanthu S, Butler J, Chomsky D, Davis S, Wilson
JR. Effect of a heart failure program on hospitalization
frequency and exercise tolerance. Circulation. 1997;96:2842-2848.
12. Bucknall CE, Robertson C, Moran F, Stevenson RD. Differences in hospital asthma management. Lancet. 1988;1:748-750.[Medline] [Order article via Infotrieve]
13. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990;112:801-802.
14. Zeiger RS, Heller S, Mellon MH, Wald J, Falkoff R, Schatz M. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991;87:1160-1168.[Medline] [Order article via Infotrieve]
15. Schreiber TL, Elkhatib A, Grines LC, O'Neill WW. Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes. J Am Coll Cardiol. 1995;26:577-582.[Abstract]
16. Williams JF, Bristow MR, Fowler MB, Francis GS, Garson A, Gersh BJ, Hammer DF, Hlatky MA, Leier CV, Packer M, Pitt B, Ullyot DJ, Wexler LF, Winters WL, Committee on Evaluation and Management of Heart Failure. Guidelines for the evaluation and management of heart failure: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 1995;5:1376-1398.
17.
Remme WJ. The treatment of heart failure: the
Task Force of the Working Group on Heart Failure of the European
Society of Cardiology. Eur Heart
J. 1997;18:736-753.
18. Rajfer SI. Perspective of the pharmaceutical industry on the development of new drugs for heart failure. J Am Coll Cardiol. 1993;22(suppl A):198-200.
19. Havranek EP, Graham GW, Pan Z, Lowes B. Process and outcome of outpatient management of heart failure: a comparison of cardiologists and primary care providers. Am J Managed Care. 1996;2:783-789.
20.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland
KE, Carney RM. A multidisciplinary intervention to prevent the
readmission of elderly patients with congestive heart failure.
N Engl J Med. 1995;333:1190-1195.
21. Fonarow GC, Stevenson LW, Walden JA, Hamilton MA, Natterson BJ, Steimle AE, Moriguchi JD, Middlekauff HR. Impact of a comprehensive management program on the hospitalization rate for patients with advanced heart failure. J Am Coll Cardiol. 1995;25(suppl):264A-265A.
22. Smith LE, Fabbri SA, Heywood JT. The cost effectiveness of managing patients in a cardiomyopathy clinic. Circulation. 1996;94(suppl I):I-169. Abstract.
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