Elsevier

Journal of Cardiac Failure

Volume 10, Issue 6, December 2004, Pages 473-480
Journal of Cardiac Failure

Clinical Investigation
A multicenter disease management program for hospitalized patients with heart failure

https://doi.org/10.1016/j.cardfail.2004.02.005Get rights and content

Abstract

Background

Despite the availability of proven therapies, outcomes in patients with heart failure (HF) remain poor. In this 2-stage, multicenter trial, we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF.

Methods and results

In Stage 1, a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme (ACE) inhibitors and other HF medications. Before discharge (Stage 2), patients were randomized to a patient support program (PSP) (education about HF, self-monitoring, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge) or usual care. In Stage 1 (766 patients) ACE inhibitor use increased from 58% on admission to 83% at discharge (P < .0001), and the daily dose (in enalapril equivalents) increased from 11.3±8.8 mg to 14.5±8.8 mg (P < .0001). In Stage 2 (276 patients) there was no difference in ACE inhibitor adherence, but a reduction in cardiovascular-related emergency room visits (49 versus 20, P = .030), hospitalization days (812 versus 341, P = .003), and cost of care ($CDN 2,531 less per patient) in favor of the PSP.

Conclusion

Simple interventions can improve ACE inhibitor use and patient outcomes.

Section snippets

Study design and patient eligibility

REACT was a multicenter 2-stage trial consisting of an in-hospital intervention in all patients (Stage 1), followed by a randomized trial of a patient support program (Stage 2). Ten hospitals participated in REACT (Appendix A). Before study commencement, the local research coordinators (a hospital pharmacist or nurse) attended a training workshop to review current HF management guidelines8., 9. and study procedures to ensure consistency in the delivery of the patient support program among

Results

Recruitment took place between September 1999 and April 2000. A total of 766 patients were entered into Stage 1 (Fig. 2). The baseline characteristics of the patients entered into Stage 1 are indicated in Table 2. These patients represent a typical hospitalized patient population with HF with 55% males and an average age of 74. The majority of patients were in New York Heart Association functional class II and III and the majority of patients had an ischemic etiology of their HF. Eighty percent

Discussion

As a highly prevalent condition with high mortality and morbidity,1., 2., 3., 5., 6., 7. even small increments in the improvement of the care of patients with HF may have large public health implications. The results of this study indicate that a dedicated HF program using hospital pharmacists and nurses can result in an improvement in ACE inhibitor usage and dosing, with reductions in clinical events and costs.

Conclusion

A simple and practical in-hospital HF disease management program improved the utilization of ACE inhibitors by almost 50% and also promoted the usage of higher doses of ACE inhibitors. A 6-month patient education and support program for outpatients with HF had little impact on ACE inhibitor adherence however reduced utilization of health care resources, resulting in a cost reduction of $CDN 2531 per patient for CV-related events. Given the high prevalence and poor outcomes in this patient

Acknowledgements

We thank Marilou Hervas-Malo, MSc, Epidemiology Coordinating and Research (EPICORE) Centre, Division of Cardiology, University of Alberta, Edmonton, Alberta, for conducting some of the statistical analyses.

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    Dr Johnson is a Population Health Investigator with Alberta Heritage Foundation for Medical Research and holds a Canada Research Chair in Diabetes Health Outcomes.

    Funded by an unrestricted educational grant from Parke Davis Canada (now Pfizer Canada) and the University of Alberta Hospital Foundation.

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