Quality still doesn't pay in heart failure management

Abstract

Virtually every contemporary discussion of heart failure starts with an obligatory citation of statistics that make 3 basic points: First, the disease is quite prevalent in North America and Europe. Second, in aggregate, heart failure is one of the most expensive of diseases, with much of the expense concentrated in the elderly population (eg, >65 years). And finally, both the prevalence and associated expense are expected to increase dramatically in the next 25 years. In part, the coming epidemic of heart failure is being created by our partial therapeutic victories of the past 25 years. We are much better than we used to be at keeping patients with coronary disease alive, but we do less well at keeping them healthy and fully functional. As Lewis Thomas pointed out more than 30 years ago, such “halfway technologies” are usually enormously expensive. In heart failure, much of the expense is attributable to the need for hospitalizations for episodes of decompensation. These “failures” of outpatient care may relate in part to the deficiencies of our current therapeutic tools. In particular, we still have no practical way to replace dead heart muscle. However, a growing body of evidence suggests that a significant portion of these decompensations can be attributed to our failure to aggressively apply in practice what we know. For example, we know from large well-done clinical trials that angiotensinconverting enzyme (ACE) inhibitors and -blockers can both improve survival and reduce the need for hospitalizations in heart failure patients. As highlighted in a recent report from the Institute of Medicine, however, these life-saving therapies remain significantly underused in clinical practice. The gap between what we know and what we do in heart failure management has been described as a “quality chasm.” One important set of strategies designed to bridge gaps in the quality of conventional medical care consists of process of care interventions broadly referred to as “disease management.” These programs contain a variable mix of patient education, optimization of congestive heart failure (CHF) therapies, interventions to improve compliance, and early problem solving to prevent the need for subsequent hospital-based care. Some programs consist of a nurse calling a patient over the phone, whereas others involve a team of specialists providing support to the patient at the direction of a designated coordinator. Some programs begin during a hospitalization for heart failure, whereas others are initiated in the outpatient setting. The overarching concept is to provide a means to identify vulnerable patients who are getting into trouble early and to provide preemptive problem solving so that need for hospitalization can be avoided. A meta-analysis of 11 randomized trials of disease management programs published through 1999 found a significant 23% decrease in hospitalization rate for the multidisciplinary form of disease management, but no effect of the telephone based type. In this issue of the Journal, McDonald and Ledwidge propose that disease management strategies should be extended to the inpatient phase of care for CHF. In particular, the authors recommend a structured program involving care by a cardiologist, use of proven medical therapies in proper dosage, education of the patient and family by a specialist heart failure nurse, and use of explicit criteria to assess discharge readiness. In a preliminary report of a randomized trial of this multidisciplinary program, with 70 patients enrolled there were no rehospitalizations out to 1 month for the new program or for conventional care. In contrast, the hospitalization From the Duke University Medical Center, Durham, North Carolina, and Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, North Carolina. Reprint requests: Daniel B. Mark, MD, MPH, Professor of Medicine, Duke Clinical Research Institute, 2400 Pratt Avenue, Room 0311, Durham, NC 27705. © 2003 Elsevier Inc. All rights reserved. 1071-9164/03/0904-0004$30.00/0 doi:10.1054/jcaf.2003.52 Journal of Cardiac Failure Vol. 9 No. 4 2003