Hebert, P. L., Sisk, J. E., Wang, J. J., Tuzzio, L., Casabianca, J. M., Chassin, M. R., et al. (2008). Cost-effectiveness of nurse-led disease management for heart failure in an ethnically diverse urban community. Annals of Internal Medicine, 149 (8), 540–548.
Determining the cost-effectiveness of nurse management of HF in the minority community is an important step toward identifying potential strategies to reduce the burden of HF in this population. Minorities have the most rehospitalizations for HF and lower understanding of HF disease management compared to nonminority populations. This study aims to estimate the cost-effectiveness of nurse management of HF. The study was performed in conjunction with a randomized trial on a population in Harlem, New York, between 1999 and 2003.
Patients were recruited from four out-patient clinics serving East and Central Harlem. A total of 406 patients were randomly assigned to one of two groups, 203 to usual care and 203 to a nurse-managed program. Most of the participants were African American and Hispanic of low socioeconomic status. The nurse-managed group experienced one in-person visit with a nurse and follow-up telephone calls over 12 months. The interventions focused on low-salt diet management and medication adherence. The nurses worked closely with physicians to ensure that medication clinical guidelines for HF were implemented.
Physical function was measured by the Short Form—12 (SF-12). Surveyors blinded to the study called members of both groups every 3 months for 18 months to administer the SF-12 and obtain information on healthcare use, amount of informal care received, and patients' estimate of their time engaged in receiving healthcare over the past 3 months. Cost-effectiveness was measured by using the incremental cost-effectiveness ratio (ICER). The ICER is the difference in average costs between the nurse-managed and usual care groups divided by the difference in mean quality-adjusted life-years (QALY).
Societal costs include intervention costs and medical and nonmedical costs, and were estimated using the guidelines for cost-effectiveness analysis. Interventions included:
* materials such as scales
* telephone service for two patients who did not have it
* patients' transportation costs to initial nurse meeting
* nurses' salaries and benefits
* physician time
* office space
* equipment used by nurses.
Administrative records from the four participating hospitals were reviewed to determine inpatient, outpatient, and emergency room use. Inpatient costs were converted to 2001 U.S. dollars using the Producer Price Index. The 2001 Medicare fee schedule for the NYC region was applied to outpatient and emergency room costs.
* Patients in the nurse-managed group maintained better physical functioning compared to the usual care group over 12 months.
* QALY scores were higher in the nurse-managed groups.
* Outpatient procedures such as lab services and home care were more costly in nurse-managed group.
* Costs per person for hospitalization were lower in the nurse-managed group.
* A gain of 1 year of healthy life had an estimated societal cost of less than $25,000.
* Intervention patients with less severe HF as baseline had the greatest benefit of maintaining their quality of life throughout the study period.
Although the study shows that the nurse-managed HF program produces a reasonable cost to gain 1 year of healthy life, the real savings are not clear. The nurse-managed group had a lower rate and cost associated with rehospitalization; however, these costs were offset by the increased cost of maintenance in the community. There were also several limitations to the study. Costs and quality of life were not projected past the 12 months of the study. The study population for this initiative may not be representative of populations in other settings, limiting the generalizability of the results. Finally, there were a large number of no responses to the surveys. This led to the use of imputed cost and quality-of-life scores by the study investigators.
Implication for Home Care
The cost of maintaining HF patients in the community continues to rise. This population experiences rehospitalization at a high rate, complex medication regimens, poor adherence to medication regimens, decreased quality of life, and increased caregiver needs. As stated in the article, there are not many studies that analyze the costs related to HF management. More studies of nurse-managed programs or nurse-led interventions in the community and their effects on HF costs versus outcomes are needed. Further investigation is also needed to determine the long-term effects of nurse-managed programs on the functional status and the quality of life of the HF population. Implementation of nurse-managed programs may be the key to reducing rehospitalizations and cost in the HF patient over the long term.
Jaarsma, T., van der Wal, M. H., Lesman-Leegte, I., Luttik, M. L., Hogenhuis, J., Veeger, N. J., et al. (2008). Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Archives of Internal Medicine, 168 (3), 316–324.
HF remains difficult to manage in the community. Many HF management programs have been designed and implemented but their effectiveness has not been proven. Although several components of the program have been identified, it has been difficult to determine which interventions contribute to a successful program.
Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) was a randomized controlled study designed to evaluate the effects of two levels of nurse-led interventions on HF patients in contrast to usual care over 18 months. The study population consisted of patients hospitalized at one of 17 centers for HF and had a New York Heart Association functional classification of II to IV. Patients were excluded from participation in the study due to concurrent inclusion in another study or HF clinic, inability to complete the questionnaires, invasive procedure or cardiac surgery intervention performed within the last 6 months or such procedure or intervention planned to be performed within the next 3 months, ongoing evaluation for heart transplantation, and inability or unwillingness to give informed consent. During hospitalization, patients, 18 years or older, were randomized by computer to the basic support group, intensive support group, or control group.
A total of 1,023 study participants were randomized into one of three groups: the control group that had four contacts with a cardiologist; a basic support group that had four contacts with the cardiologist and nine contacts with the nurse; and the intensive support group that had four contacts with the cardiologist, 18 contacts with the nurse, two home care visits, and two multidisciplinary advise sessions. The first cardiology contact occurred less than 2 months after discharge and then every 6 months. To increase adherence patients were taught using a protocol and behavioral strategies. Patients in the basic and intensive groups were instructed to contact the nurse if there was any change in their condition. Patients in the intensive support group had monthly contact with the nurse. In the first month after hospital discharge, weekly telephone contacts were made and the patient was visited at home by the HF nurse. The intensive support group also received telephone calls and two home visits, and multidisciplinary advice given by a physiotherapist, dietitian, and social worker.
* The control group had 33% more contacts with the cardiologist than anticipated, basic support group had 40% more contacts, and the intensive support groups had 10% more contacts.
* There was no significant difference in the total number of days lost related to death or hospitalization among the three groups.
* There were slightly more hospitalizations in the intensive group compared to the control group.
* The length of hospital stay on readmission for the basic and intensive support groups was shorter than the control group.
* Adding nurse management to cardiology management did not reduce rehospitalizations in the basic or intensive support groups.
* The 15% reduction in mortality noted in the basic and intensive support groups is consistent with findings in previous meta-analysis.
Implications for Home Care
Although this study does not show a correlation between nurse-managed interventions and decreased rehospitalization in HF clients, there is still much to be learned. Medical follow-up with a cardiologist or a primary care physician shortly after discharge is instrumental in delaying and preventing rehospitalization for the HF patient. Other studies have shown that nurse-managed programs can improve the outcomes of the HF population. Home care will be further benefited by additional studies that examine the nurse-managed interventions as applied to the HF population. HF, whether nurse or MD managed, must be handled by aggressive medication and symptom management, teaching, and follow-up.
Clark, R. A., Inglis, S. C., McAlister, F. A., Cleland, J. G., & Stewart, S. (2007). Telemonitoring or structured telephone support programs for patients with chronic heart failure: Systematic review and meta-analysis. British Medical Journal, 334(7600), 942.
As the number of cases of HF increases, so does the burden on the community. Nonpharmacologic measures to address this burden need to be explored. The study investigators searched 15 databases using search methods recommended by the Cochrane Heart Review Group. All randomized trials on remote monitoring programs between January 1, 2002 and May 6, 2006 were included. A hand search on reference lists was performed on 21 published systematic reviews, 149 review articles on telephone support programs in chronic disease, and all studies identified in the electronic search. Two independent investigators reviewed the results of the searches for inclusion in the study.
Studies on telemonitoring were included as long as the monitoring was initiated within 1 month of discharge from the hospital and was the only aftercare intervention in place. The studies were subclassified as telemonitoring if telephone contact was made, information was obtained on symptoms, and physiologic data were transmitted. Structured telephone support was considered symptom reporting alone (without transmission), counseling, and/or medical management.
Data were analyzed using the DerSimonian and Laird random effects model. Risk ratios were calculated by subtracting the risk of the event in the usual group from the treatment group. These data were presented with a 95% confidence interval.
Of the 234 studies reviewed 14 randomized controlled trials were included. Four trials evaluated telemonitoring, nine trials evaluated telephone support, and one trial evaluated both. The trials ranged in length from 3 to 16 months. The mean age of those who participated ranged from 57 to 75 years.
* All trials reported a statistically significant 20% reduction in all-cause mortality, with telemonitoring showing a greater benefit.
* Eight trials reported rates of all-cause admissions to the hospital; however, the results were not statistically significant in either group.
* Nine trials reported reductions in hospital admissions for HF with the combined results showing a 21% reduction for telemonitoring and telephone support programs.
* Three of six trials studying effect on quality of life reported a significant improvement.
Overall, telemonitoring and telephone support programs for HF patients in the community reduced HF hospitalizations and all-cause mortality by one fifth. This study did have limitations, one being the small sample size (n = 14). Also, most trials did not go beyond 6 months; therefore, it is difficult to extrapolate data from the short term and apply it to the long term. Although the sample size was small, this meta-analysis indicates that telemonitoring and telephone support have a definite place in the management of HF patients. Although the reported reduction in hospitalizations was small, it is significant enough to warrant further investigation.
Implications of Home Care
As previously stated, HF costs are steadily rising and management of this chronic condition is more complex. As home healthcare nurses, we need to be aware of all possible interventions to manage this population and decrease the burden on society. Telemonitoring and telephone support programs can assist in early identification of symptoms of HF exacerbation and implementation of medical care. It is important to remember that telemonitoring and telephone support are short-term intervention and do not replace the need for patient education and patient self-management.
Fonarow, C. G., Abraham, W. T., Albert, N. M., Gattis Stough, W., Gheorghiade, M., Greenberg, B.H., et al.; for the OPTIMIZE-HF Investigators and Hospitals. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes. Archives of Internal Medicine, 168(8), 847–854.
HF is the most frequent cause of hospitalization among adults over 65 in this country, and these episodes are very expensive and contribute to the high costs of treating this disease. The 3.6 million hospitalizations for HF in the United States each year are also associated with considerable mortality and morbidity. It is important to understand the factors that contribute to exacerbations of HF and the resulting admissions to hospitals, particularly those factors that are avoidable.
Factors that have been identified with HF and contribute to hospitalizations are arrhythmia, myocardial ischemia, respiratory infections, uncontrolled hypertension, and nonadherence to medications and diet. There have been few studies that have examined the frequency of these factors among hospitalized HF patients. The studies that have been done have had small sample sizes at single medical centers.
The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) is a registry and performance improvement program for hospitalized HF patients. It not only studies the frequency of the contributing factors, but also seeks to improve the understanding of the extent to which these factors affect clinical outcomes, inpatient length of stay, hospital mortality, early after hospital mortality and death/rehospitalization.
Patients qualified for the study if they were hospitalized for worsening HF or if HF symptoms developed during a hospitalization with another primary diagnosis where HF was the discharge diagnosis. Between March 3, 2003 and December 31, 2004, 48,612 patients at 259 medical centers in the USA were enrolled in the registry. The patients were in community hospitals as well as large tertiary care centers. A 10% subgroup provided 60- to 90-day follow-up data. Mean age was 73.1 years; 52% were women and 71% white. Frequent comorbitities were hypertension, diabetes mellitus, and chronic obstructive pulmonary disease.
At admission the factors that led to the hospitalization were identified and included myocardial ischemia, arrhythmias, nonadherence to medications and diet, pneumonia/respiratory process, hypertension, and deteriorating renal status. The study used multivariate analyses for length of stay, in-hospital mortality, 60- to 90-day follow-up mortality, and death/rehospitalization.
* Twenty-nine thousand eight hundred fourteen of 48,612 patients (61.3%) demonstrated precipitating factors, with the most frequent being respiratory/pneumonia (15.3%), ischemia (14.7%), and arrhythmia (13.5%).
* Pneumonia and deteriorating renal function were associated with higher in-hospital deaths, whereas uncontrolled hypertension was associated with lower in-hospital death.
* Ischemia and deteriorating renal function were also associated with a higher risk of follow-up death, whereas uncontrolled hypertension was associated with a lower risk of death or rehospitalization after the hospital discharge.
The authors indicated that because hypertension is more easily addressed in the hospital with close monitoring and medication adjustments, these patients were able to be discharged more easily than those with other clinical presentations.
Implications for Home Care
By identifying and understanding precipitating factors that led to the original hospitalization, home care clinicians may be able to implement interventions that can prevent rehospitalization. Rigorous influenza and pneumococcal vaccination programs can help address the most common precipitating factor of hospitalization for HF patients—pneumonia/respiratory distress. Monitoring and early identification of deteriorating concomitant conditions is also warranted. HF patients can also be taught self-management strategies such as daily monitoring of blood pressure and daily weights, which can continue to warn of precipitating factors even after the patients are discharged from home care.
© 2010 Lippincott Williams & Wilkins, Inc.