Study shows CHF clinics optimize patient care
Study shows CHF clinics optimize patient care
Practice patterns in focused factories’ excel
A group of Canadian investigators recently set out to determine if a clinic devoted to CHF may foster better practice patterns and patient care than traditional settings.1 It found a specialized outpatient clinic devoted to the management of CHF can optimize the use of proven efficacious therapy. The finding that 83% of patients received ACE inhibitors is a marked improvement from 32% to 54% reported in recent North American practice audits that the investigators cite and clearly demonstrates the effectiveness of a specialized clinic in closing the care gap in the use of ACE inhibitors.
CHF specialists are founding more and more specialized multidisciplinary clinics providing intensive outpatient care for CHF patients. Typically, such clinics are under the guidance of cardiologists with a special interest and expertise in treating patients with complex or severe CHF, and many are connected to heart transplant programs. They often offer programs that focus on patient education, diet, lifestyle, and medication compliance; careful patient monitoring; and intensification of previous medical therapy.
The researchers concentrated on a multidisciplinary Heart Function Clinic based at the University of Alberta Hospital in Edmonton, Alberta, Canada, and paid particular attention to a comparison of the progress of patients with left ventricular systolic dysfunction and that of patients with preserved function.
The Alberta clinic is managed by a team of physicians, specialized nurse practitioners, pharmacists, dietitians, and social workers. The study involved 566 patients, whom the investigators followed for seven years. Mean age at enrollment was 66; more than half were men; 67% had an ischemic cause of heart disease; and 78% had systolic dysfunction. The study findings suggest that a specialized outpatient clinic can have improved practice patterns for patients with CHF.
Objective assessments by echocardiography, radionuclide, or contrast ventriculography of left ventricular ejection fraction (LVEF) were obtained in all patients for the study so they could be categorized as left ventricular systolic dysfunctional and as having preserved function. Patients were defined as having CHF caused by systolic dysfunction if their LVEF was less than 45%. If patients had an LVEF >/= 45%, or if the tests indicated that the predominant problem was in ventricular diastolic relaxation, they were classified as having preserved systolic left ventricular function.
The causes of the patients’ CHF were classified as ischemia, hypertension, or other: idiopathic dilated cardiomyopathy, valvular heart disease of any cause, history of exposure to cardiotoxic drugs, or excessive alcohol consumption with objective evidence of dilated cardiomyopathy and no ischemic cause.
Although ACE inhibitor therapy was stressed by clinic policy, no explicit protocols or critical pathways were used during the period of this study. Prescribing patterns differed for the two groups. Overall, 83% of patients received an ACE inhibitor, but there was less use of ACE inhibitors, diuretics, aspirin, and amiodarone and more use of beta-blockers and calcium channel blockers in patients with preserved systolic function vs. systolic dysfunction. The most commonly prescribed were enalapril (10.7 mg/day), lisinopril (10.3 mg/day), and captopril (62.1 mg/day). Of patients prescribed digoxin, less than half had atrial arrhythmia; 42% of patients with preserved systolic function and 59% of patients with systolic dysfunction who received digoxin were in sinus rhythm. Anticoagulation with warfarin for atrial arrhythmia was received by 61% of the 44 patients with preserved systolic function and 57% of the 122 patients with systolic dysfunction who had this rhythm.
During follow-up, 148 patients died, most from cardiac causes:
¤ One-year survival rates were 95% for NYHA class I, 93% for class II, 83% for class III, and 70% for class IV patients.
¤ Two-year survival rates were 87% for NYHA class I, 83% for class II, 69% for class III, and 52% for class IV.
¤ At three years, they were 84%, 77%, 60%, and 34%, respectively.
Beta blockers and ACE inhibitors were associated with a reduced mortality risk, whereas metolazone, thiazides, and loop diuretics were associated with increased mortality risk.
Patients in this study received lower doses of ACE inhibitors than were used in major CHF clinical trials. The authors wrote that although higher doses have been shown to be more beneficial, patients attending heart failure clinics, particularly the sicker patients, are often frail, hypotensive, and cannot tolerate higher doses of ACE inhibitors — for example, 32.5 mg to 35 mg daily of lisinopril.
Randall Williams, MD, a cardiologist at a specialized CHF program at Evanston (IL) Hospital, says, "We’ve been doing this focused factory’ approach for more than four years now, and we believe it makes a lot of sense in terms of efficiencies in how we deliver care. Patients get close attention to their day-to-day care." All the CHF resources are under one roof, he says, and because of that they have seen improvements in clinical and quality of life outcomes and a reduction in unnecessary costs.
"Others have come to mimic our provider-driven disease management model," says Williams, whose program accounts for all phases of CHF clinical care through critical pathways and education programs. Most of the program’s focus is on outpatient management including telemanagement services and linkage to resources such as home care, cardiac rehab, and support programs. (For more on that telephone system, see CHF Disease Management, August 1999, p. 92.)
The clinic serves 350 patients at any one time and employs another cardiologist, three advanced practice nurses, a pharmacist, and an exercise physiologist, and there is access to specialized dietary and social work support at the hospital. "Our outcomes go beyond the use of best practice standards’ for the disease," he says. "We also look at patient satisfaction outcomes and reduction of hospitalization and readmission rates." The national admission rate for CHF runs at 1.7 times per patient per year, and the Evanston clinic’s rate is 0.2-0.3. "Patients managed in this type of program typically don’t need to be hospitalized at all, he says. "Hospitalization for CHF has come to be viewed as a failure of the system."
Williams describes his clinic as a co-gatekeeper model. "All our patients continue to maintain ongoing care relationships with their primary care doctors. We assume responsibility for managing their CHF and any cardiac comorbidities. If they have ischemic heart disease or hypertensive heart disease, if they need their cholesterol managed or their rhythm disturbances managed or need a pacemaker, we are the coordinator for those cardiovascular problems." But, he adds, patients may have a number of comorbidities that the specialist is not focused on. "Our scope of expertise is around the CHF, not the diabetes, kidney problems, or asthma. In those scenarios, patients benefit from care by their primary care physicians who continue to be involved in their ongoing management."
Steven M. Pezzella, MD, at the Fallon Clinic in Worcester, MA, agrees. "We provide intensive education for the primary care physicians because the care we offer is a combination between us and them. I don’t think the cardiologists can take all the credit for the excellent outcomes we’ve seen here."
William T. Abraham, MD, associate professor of medicine and director of the section of heart failure and cardiac transplantation at the University of Cincinnati, runs a CHF center of exercise physiologists, dietitians, nurses, case managers, nurse practitioners, and physicians. "If you do the same thing day in and day out, you get very good at it," he says. "While there’s a lot of heart failure, a physician cannot see enough of it to truly become an expert unless he or she concentrates on it in a subspecialty environment. While all clinicians know the basics of managing heart failure, few have the time or inclination or support to optimize care. A multidisciplinary team approach and subspecialty environment can facilitate all that."
The CHF specialist
"The specialist can be nurse practitioner, an internist, or, of course, a cardiologist," he says. "There are data in the literature that clinics directed by any of those individuals can be successful. The main thing is building the infrastructure and the multidisciplinary team, and having leadership from someone who focuses his or her time in the heart failure arena."
He says an internist who takes care of heart failure on a full-time basis will probably ultimately give better care than a general cardiologist who doesn’t focus on heart failure. "The key is being a heart failure specialist, and you don’t necessarily have to be a cardiologist to do that," says Abraham. "What you do have to do is have a commitment to heart failure and focus on it."
There is a nurse practitioner-directed clinic in Cincinnati, he says, that is an example of a broad, community-based approach that works. The clinic focuses on all the processes of care that work in heart failure — patient education, dietary counseling, monitoring of daily weights, compliance with pharmacologic therapy, and so on.
"They do this in conjunction with a primary care physician," says Abraham, "and the physician maintains control of the patient. The doctor sees the patient as often as he normally would in a traditional setting." Neither the patient nor the primary care physician pays anything for access to the clinic. The city’s health system recoups its investment by reducing hospital readmission rates and lengths of stay, two desirable quality of care improvements. "So patient outcomes and quality of life are improved, but also improved is the bottom line for the system. That makes the whole system sustainable."
Reference
1. McAlister FA, Teo KK, Taher M, et al. Insights into the contemporary epidemiology and outpatient management of congestive heart failure. Am Heart J 1999; 138(1):87-94.
Suggested reading
• Abraham WT, Bristow MR. Specialized centers for heart failure management. Editorial. Circulation 1997; 96:2,755-2,757.
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