Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital Admission

Heart failure (HF) is a complex clinical syndrome in which the heart is unable to deliver adequate cardiac output at normal filling pressures. There are proven pharmacological and clinical management strategies that can improve care and reduce associated health care costs, but these are underutilized. The Advanced Heart Failure Program (AHFP) was developed at the Dorn Veterans Administration Medical Center to provide a comprehensive multidisciplinary management approach to persons with advanced HF. Before enrollment in the AHFP, the average annual all-cause hospital admission rate was 3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, the mean all-cause hospital admission rate was 1.2. HF patients had an average annual hospitalization cost of $28,936.32 before enrollment in the AHFP. After enrollment, average hospitalization cost dropped to $10,851.12 per patient. Taking into account the 50-week cost of $3036.14 for a patient enrolled in the clinic, participation in the AHFP was associated with a significant decrease in the number of HF-related admissions, saving an average of $15,049.06 per patient. (Drug Benefit Trends. 2008;20:54-59)

Heart failure (HF) is a complex clinical syndrome characterized by dyspnea and fatigue and caused by structural or functional abnormalities of ventricular function.^1,2 These abnormalities manifest as an inability of the heart to deliver adequate cardiac output at normal filling pressures at rest and during exercise. There are proven treatments for HF that can decrease mortality and morbidity for persons with left ventricular systolic dysfunction and dramatically reduce associated health care expenditures.^1,2 These include pharmacological treatments (eg, angiotensin-converting enzyme [ACE] inhibitors and β-blockers) and nonpharmacological therapy (eg, use of multidisciplinary teams and/or a clinical pharmacist).^3-6

Despite this body of evidence, management of HF remains suboptimal. In a study of more than 11,000 patients hospitalized with acute symptoms of HF, an echocardiogram was obtained on admission in only two-thirds of them.⁷ ACE inhibitors and β-blockers were prescribed for 62% and 37% of patients, respectively, and only 17% received all 3 recommended therapies: ACE inhibitor, β-blocker, and diuretic.⁷ Suboptimal treatment of HF leads to increased mortality and health care expenditures.^1,2,8 Current models of health care delivery are reactive and focus exclusively on the patient and his or her doctor.⁸ A patient perceives a problem and then makes an appointment to see a physician. This typically leads to treatment of a medical problem that could have been prevented.

Current HF treatment annually accounts for 12 million to 15 million office visits, 6.5 million hospital bed days, more Medicare dollars spent than for any other single diagnosis, and $27.9 billion in direct and indirect costs.^1,2,9 The current model of care for HF patients is not achieving the outcomes desired and needs to be evaluated to optimize patient outcomes. Patients need to be an integral part of the health care delivery model and become partners in their care.¹⁰ The ideal health care model provides continuous care coordination and support.

An example of the ideal health care delivery model is the use of multi disciplinary treatment teams. Multidisciplinary interventions can decrease mortality rates, reduce hospital admission and readmission rates, and decrease use of health care resources.^5,10-14 A meta-analysis of the HF literature shows that use of multidisciplinary teams decreases mortality rates by 20%, all-cause hospital admission by 13%, and HF hospital admissions by 30%.¹⁰ The mortality reduction in HF with multidisciplinary teams is similar to that reported with the use of ACE inhibitors.^10,15 The model of health care delivery is an important part of the effectiveness of multidisciplinary teams in HF patients. Home-based HF interventions successfully decreased the number of all-cause admissions, HF admissions, and mean days in the hospital.¹⁰ However, the decrease in HF mortality was not significant. Use of telephone-based interventions decreased HF admission and mortality rates but led to a nonsignificant decrease in all-cause admissions.¹⁰ Some of these studies included home monitoring with self-reported or electronically transmitted daily measurements of vital signs, including body weight, blood pressure, and respiratory rates.

Randomized clinical trials based on the self-care paradigm in which the ambulatory monitoring of symptoms and vital signs combined with medication adjustment protocols have shown improved outcomes.^5,10 These trials demonstrated decreases in readmission rates, hospitalization days, and overall cost of care, combined with an increase in the time to hospital readmission. Interventions delivered solely in a clinic, hospital, or general practice have not shown positive outcomes.^5,10 Clinical trials of multidisciplinary teams with positive outcomes shared 2 key components: (1) 1-to-1 patient education on HF; medication, diet, and exercise counseling; and symptom monitoring; and (2) self-management recommendations.^5,10 Effects of multidisciplinary teams on HF patients have remained constant over time, despite the growing body of evidence supporting the use of ACE inhibitors and β-blockers.¹⁰ This suggests that multidisciplinary teams have a positive impact on the outcomes of HF patients, in addition to the use of pharmacological agents.

As the burden of chronic illnesses continues to grow in the United States, health care providers and payers struggle to find ways to maintain high-quality care while controlling spiraling costs. The high readmission rates for HF patients are a particularly appropriate target for intervention because the population at risk can be identified and the factors that contribute to this phenomenon are well known. This article describes an intervention strategy to improve outcomes of patients with chronic HF at the Dorn Veterans Administration (VA) Medical Center in Columbia, SC. This initiative was analyzed using a multivariate framework that evaluates the cost and consequences of this HF intervention.

Methods

Intervention description. The Advanced Heart Failure Program (AHFP) was developed at the Dorn VA Medical Center to provide a comprehensive multidisciplinary management approach to persons with advanced HF. The AHFP targeted patients with (1) American College of Cardiology (ACC)/American Heart Association (AHA) stage C/D or New York Heart Association(NYHA) class III/IV HF; (2) HF hospitalized 2 or more times in a 1-year period; and (3) HF with an irreversible cause. Persons with HF with terminal cancer in hospice care or who are receiving dialysis were not enrolled in the program.

The goals of the AHFP were to decrease hospital admission/readmission rates, decrease health care expenditures, and improve the quality of life (QOL) for persons with advanced HF. Health care professionals participating in the AHFP included a cardiologist, internal medicine specialist, nurse practitioner, nurse, case managers, physician assistant, pharmacist, and clinical researchers. The pharmacist involved in the AHFP had clinical and research responsibilities. Clinical responsibilities included discussion with the HF treatment team about appropriate medications and doses, monitoring and patient counseling of medications, and evaluation of patient adherence. Research responsibilities included preparation of clinical protocol, database development, analysis of data, and manuscript preparation.

Once enrolled in the AHFP, patients visited the clinic every 2 weeks for the first 2 months, then monthly thereafter. Patients initially reported every 2 weeks so that their condition could be “stabilized.” Stabilization was considered achieved when HF patients were able to tolerate their maximum dose of β-blockers for 14 days.

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