ABSTRACT
BACKGROUND: To handle the increasing complexity of congestive heart failure (CHF) care, several new models for the care of patients with CHF have been developed to replace traditional strategies. We undertook this study to evaluate the potential benefit of implementing a CHF disease management program at a tertiary care center, particularly in terms of beta-blocker use and cost to the health care system. METHODS: After reviewing the literature regarding therapies and management strategies for patients with CHF, we developed the Duke Heart Failure Program. All enrolled patients had 1 of the following: recent CHF hospitalization, ejection fraction less than 20%, or symptoms consistent with New York Heart Association class III or IV. We compared preenrollment and postenrollment medication use and resource utilization. RESULTS: We enrolled 117 patients from July 1998 to April 1999. Mean enrollment time was 4.7 months. beta-Blocker use and dose significantly increased (52% vs 76% for beta-blocker, P<.01; 6% vs 13% of target dose, P<.01). The hospitalization rate decreased (1.5 vs 0 hospitalizations per patient-year, P<.01), while the number of clinic visits increased (4.3 vs 9.8 clinic visits per patient-year, P<.01). The Duke University Health System saved a median of $8571 per patient-year. CONCLUSIONS: Implementing a CHF disease management program was associated with improved CHF medication dosing and with decreased hospitalization for patients with CHF. A CHF disease management program is an effective method for a health care system to care for patients with CHF.
Subject(s)
Health Plan Implementation/economics , Heart Failure/economics , Managed Care Programs/economics , Adrenergic beta-Antagonists/administration & dosage , Adrenergic beta-Antagonists/adverse effects , Adrenergic beta-Antagonists/economics , Aged , Angiotensin-Converting Enzyme Inhibitors/administration & dosage , Angiotensin-Converting Enzyme Inhibitors/adverse effects , Angiotensin-Converting Enzyme Inhibitors/economics , Cost-Benefit Analysis , Dose-Response Relationship, Drug , Female , Heart Failure/rehabilitation , Humans , Male , Middle Aged , North Carolina , Patient Readmission/economics , Practice Patterns, Physicians'/economics , Referral and Consultation/economics , Utilization ReviewABSTRACT
BACKGROUND: Patients with congestive heart failure (CHF) may have a high prevalence of depression, which may increase the risk of adverse outcomes. OBJECTIVE: To determine the prevalence and relationship of depression to outcomes of patients hospitalized with CHF. METHODS: We screened patients aged 18 years or older having New York Heart Association class II or greater CHF, an ejection fraction of 35% or less, or both, admitted between March 1, 1997, and June 30, 1998, to the cardiology service of one hospital. Patients with a Beck Depression Inventory score of 10 or higher underwent a modified National Institute of Mental Health Diagnostic Interview Schedule to identify major depressive disorder. Primary care providers coordinated standard treatment for CHF and other medical and psychiatric disorders. We assessed all-cause mortality and readmission (rehospitalization) rates 3 months and 1 year after depression assessment. Logistic regression analyses were used to evaluate the independent prognostic value of depression after adjustment for clinical risk factors. RESULTS: Of 374 patients screened, 35.3% had a Beck Depression Inventory score of 10 or higher and 13.9% had major depressive disorder. Overall mortality was 7.9% at 3 months and 16.2% at 1 year. Major depression was associated with increased mortality at 3 months (odds ratio, 2.5 vs no depression; P =.08) and at 1 year (odds ratio, 2.23; P =.04) and readmission at 3 months (odds ratio, 1.90; P =.04) and at 1 year (odds ratio, 3.07; P =.005). These increased risks were independent of age, New York Heart Association class, baseline ejection fraction, and ischemic etiology of CHF. CONCLUSIONS: Major depression is common in patients hospitalized with CHF and is independently associated with a poor prognosis.
Subject(s)
Depressive Disorder, Major/complications , Heart Failure/mortality , Heart Failure/psychology , Patient Readmission , Adult , Aged , Analysis of Variance , Female , Humans , Logistic Models , Male , Middle Aged , Odds Ratio , Prevalence , Prognosis , Risk , Severity of Illness IndexABSTRACT
Heart failure will continue to present many challenges to health care providers. Research is ongoing to further understand the pathophysiology of this complex disease process. New therapies will be developed that hopefully will have a tremendous impact on the morbidity and mortality of this costly chronic illness. A multidisciplinary approach to treatment offers new opportunities to improve the overall management and quality of life of this population.
Subject(s)
Cardiotonic Agents/therapeutic use , Heart Failure , Aged , Diet , Exercise , Heart Failure/drug therapy , Heart Failure/mortality , Heart Failure/physiopathology , Humans , Incidence , PrognosisABSTRACT
AUDIENCE: This article is designed for primary care physicians, cardiovascular specialists, medical directors, and other managed care administrators responsible for heart failure patients. GOAL: To provide the reader with a basic understanding of heart failure epidemiology, heart failure management, and different strategies for the management of this particular patient population. OBJECTIVES: 1. To describe the impact of heart failure on the healthcare system in the United States. 2. To briefly describe the current practice for managing heart failure. 3. To describe the evidence for care by cardiologists of heart failure patients. 4. To describe the different disease management strategies being utilized in heart failure management.
