Journal of General Internal Medicine

, Volume 14, Issue 2, pp 130–135

Comprehensive multidisciplinary programs for the management of patients with congestive heart failure

  • Edward F. Philbin
Clinical Review

Abstract

Objective

To evaluate the impact of comprehensive, multidisciplinary management programs on the process of care, resource utilization, health care costs, and clinical outcomes in patients with congestive heart failure.

Measurements and main results

A MEDLINE search identified seven english-language reports that compared the process of care, clinical outcomes, or economic variables related to implementation of a multidisciplinary congestive heart failure management program of at least 3 month’s duration to a control or reference group. The primary intent of the programs was to emphasize compliance with recommended therapeutic principles, enhance patient education, and provide careful patient surveillance. Five of the studies reported improved functional status, aerobic capacity, or patient satisfaction. Six of the studies reported a 50% to 85% reduction in the risk of hospital admission. Three studies reported economic analyses with suggestive but not compelling evidence of financial benefit.

Conclusions

Comprehensive, multidisciplinary management programs for congestive heart failure can improve functional status and reduce the risk of hsspital admission, and they may lower medical costs.

Key words

congestive heart failure disease management health care costs health services research quality improvement 

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References

  1. 1.
    Captopril Multicenter Research Group. A placebo-controlled trial of refractory chronic congestive heart failure. J Am Coll Cardiol. 1983;2:755–63.Google Scholar
  2. 2.
    Packer M, Lee WH, Yushak M, Medina N. Comparison of captopril and enalapril in patients with severe chronic heart failure. N Engl J Med. 1986;315:847–53.PubMedGoogle Scholar
  3. 3.
    Kjekshus J, Swedberg K. Tolerability of enalapril in congestive heart failure. Am J Cardiol. 1988;62:A67–72.CrossRefGoogle Scholar
  4. 4.
    The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study. N Engl J Med. 1987;316:1429–35.Google Scholar
  5. 5.
    The 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.Google Scholar
  6. 6.
    Rogers WJ, Johnstone DE, Yusuf S, et al. Quality of life among 5,025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol. 1994;23:393–400.PubMedCrossRefGoogle Scholar
  7. 7.
    Cohn JN, Johnson G, Zieshe S, et al. A comparison of enalapril with hydralazine-isosorbide in the treatment of chronic congestive heart failure. N Engl J Med. 1991;325:303–10.PubMedGoogle Scholar
  8. 8.
    Pfeffer MA, Braunwald E, Moye LA. et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 1992;327:669–77.PubMedGoogle Scholar
  9. 9.
    Philbin EF, Rocco TA. The utility of angiotensin-converting enzyme inhibitors in heart failure with preserved systolic function. Am Heart J. 1997;134:188–95.PubMedCrossRefGoogle Scholar
  10. 10.
    Paul SD, Kuntz KM, Eagle KA, Weinstein NC. Costs and effectiveness of angiotensin converting enzyme inhibition in patients with congestive heart failure. Arch Intern Med. 1994;154:1143–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Konstam MA, Dracup K, Bottoroff MB. et al. Quick Reference Guide For Clinicians, No. 11: Heart Failure: Management of Patients with Left Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, United States Department of Health and Human Services: 1994. AHCPR publication 94-0613.Google Scholar
  12. 12.
    Johnstone DE, Abdulla A, Arnold JMO. et al. Diagnosis and management of heart failure. Can J Cardiol. 1994;10:613–31.PubMedGoogle Scholar
  13. 13.
    The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997;336:525–33.CrossRefGoogle Scholar
  14. 14.
    Philbin EF, Rocco TA, Cotto M, Jenkins PL. Association between attenuated diuretic response and death in acute heart failure. Am J Cardiol. 1997;80:519–22.PubMedCrossRefGoogle Scholar
  15. 15.
    Packer M, Bristow MR, Cohn JN. et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med. 1996;334:1349–55.PubMedCrossRefGoogle Scholar
  16. 16.
    Doval HC, Nul DR, Vancelli HO, Elizari M. Randomized trial of low-dose amiodarone in severe congestive heart failure. Lancet. 1994;344:493–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Costanzo MR, Augustine S, Bourge R. et al. Selection and treatment of candidates for heart transplantation: a statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology. American Heart Association. Circulation. 1995;92:3593–612.PubMedGoogle Scholar
  18. 18.
    Killip T, Passamani E, Davis K. Coronary Artery Surgery Study (CASS): a randomized trial of coronary bypass surgery: eight years follow-up and survival in patients with reduced ejection fraction. Circulation. 1985;72(suppl V):V-102–9.Google Scholar
  19. 19.
    Smith W, McAnulty JH, Rahimtoola SH. Severe aortic stenosis with impaired left ventricular function and clinical heart failure: results of valve replacement. Circulation. 1978;58:258–64.Google Scholar
  20. 20.
    Moss AJ, Hall WJ, Cannom DS. et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med. 1996;335:1933–40.PubMedCrossRefGoogle Scholar
  21. 21.
    Domanski MJ, Garg R, Yusuf S. Prognosis in congestive heart failure. In: Hosenpud JD, Greenberg BH, eds. Congestive Heart Failure: Pathophysiology, Diagnosis and Comprehensive Approach to Management. New York, NY: Springer-Verlag; 1994:622–7.Google Scholar
  22. 22.
    Parmley W. Pathophysiology and current treatment of congestive heart failure. J Am Coll Cardiol. 1989;13:771–85.PubMedGoogle Scholar
  23. 23.
    Cardiology Preeminence Roundtable. Beyond Four Walls. Cost-Effective Management of Chronic Congestive Heart Failure. Washington, DC: The Advisory Board Company: 1994:39–47.Google Scholar
  24. 24.
    Krumholz HM, Parent EM, Tu N. et al. Readmission after hospitalization for congestive heart failure among Medicare beneficaries. Arch Intern Med. 1997;157:99–104.PubMedCrossRefGoogle Scholar
  25. 25.
    Philbin EF, DiSalvo TG. Managed care for congestive heart failure: influence of payer status on process of care, resource utilization and clinical outcomes. Am Heart J. 1998;136:553–61.PubMedCrossRefGoogle Scholar
  26. 26.
    Philbin EF, Lynch LJ, Rocco TA. et al. Does quality improvement work? The Management to Improve Survival in Congestive Heart Failure (MISCHF) Study. Jt Comm J Qual Improv. 1996;22: 721–33.PubMedGoogle Scholar
  27. 27.
    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:S107–12.PubMedGoogle Scholar
  28. 28.
    Philbin EF, Andreou C, Rocco TA, Lynch LJ, Baker SL. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol. 1996;77:832–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Philbin EF. Factors determining angiotensin-converting enzyme inhibitor use in heart failure in the community setting. Clin Cardiol. 1998;21:103–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Ashton CM, Kuykendall DH, Johnson ML, Wray NP, Wu L. The association between the quality of inpatient care and early readmission. Ann Intern Med. 1995;122:415–21.PubMedGoogle Scholar
  31. 31.
    Philbin EF, Rocco TA, Lynch LJ, Rogers VA, Jenkins P. Predictors and determinants of hospital length of stay in congestive heart failure in ten community hospitals. J Heart Lung Transplant. 1997;16:548–55.PubMedGoogle Scholar
  32. 32.
    Weingarten S, Riedinger M, Conner L, Johnson B. Reducing lengths of stay in the coronary care unit with a practice guideline for patients with congestive heart failure: insights from a controlled clinical trial. Med Care. 1994;32:1232–43.PubMedCrossRefGoogle Scholar
  33. 33.
    Fonarow GC, Stevenson LW, Walden JA. et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol. 1997;30:725–32.PubMedCrossRefGoogle Scholar
  34. 34.
    Kornowski R, Zeeli D, Averbuch M. et al. Intensive home-care surveillance prevents hospitalization and improves morbidity among elderly patients with severe congestive heart failure. Am Heart J. 1995;129:762–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Rich MW, Beckman 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;333:1190–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Shah NB, Der E, Ruggerio C, Heidenreich PA, Massie BM. Prevention of hospitalizations for heart failure with an interactive home monitoring program. Am Heart J. 1998;135:373–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Tilney CK, Whiting SB, Horrar JL, Perkins BD, Vance RP, Reeves JD. Improved clinical and financial outcomes associated with a comprehensive congestive heart failure program. Dis Manage. 1998; 1:175–83.CrossRefGoogle Scholar
  38. 38.
    Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? N Engl J Med. 1996;334:1441–7.PubMedCrossRefGoogle Scholar
  39. 39.
    West JA, Miller NH, Parker KM. et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol. 1997;79:58–63.PubMedCrossRefGoogle Scholar
  40. 40.
    Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol. 1997;30:518–26.PubMedCrossRefGoogle Scholar
  41. 41.
    Reis SE, Holubkov R, Edmundowicz D. et al. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol. 1997;30:733–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Philbin EF, Weil HF, Erb T. Outcomes in heart failure based on specialty care. Circulation. 1996;94[8 suppl 1]: 1–50. Abstract.Google Scholar
  43. 43.
    Shah N, Edep M, Massie BM. Differences between cardiologists and heart failure specialists in the management of congestive heart failure. Circulation. 1995;92[suppl 1]: 1–666. Abstract.Google Scholar
  44. 44.
    Retchin SM, Brown B. Elderly patients with congestive heart failure under prepaid care. Am J Med. 1991;90:236–42.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 1999

Authors and Affiliations

  • Edward F. Philbin
    • 1
  1. 1.Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular MedicineHenry Ford HospitalDetroit

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