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Impact of a Guideline-Based Disease Management Team on Outcomes of Hospitalized Patients With Congestive Heart Failure
Ottorino Costantini, MD;
Kimberly Huck, ND, RN, CCRN;
Mark D. Carlson, MD;
Karen Boyd, RN;
Carol M. Buchter, MD;
Pauline Raiz, MS;
Gregory S. Cooper, MD
Arch Intern Med. 2001;161:177-182.
ABSTRACT
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Background Congestive heart failure is the most common reason for hospitalization
in the United States, and guidelines to improve the quality of care for patients
with congestive heart failure have been developed. However, adherence is typically
low. We hypothesized that a guideline-based care management team would result
in greater quality and efficiency of care than guidelines alone.
Methods A faculty cardiologist and nurse care manager at an academic medical
center reviewed each patient's data and made guideline-based recommendations.
Hospital length of stay, total costs, and use of recommended guidelines were
compared between 173 patients before team implementation but with available
guidelines, 283 care-managed patients, and 126 concurrent non–care-managed
patients.
Results Care-managed patients achieved higher rates of use of angiotensin-converting
enzyme inhibitor than baseline or non–care-managed patients (95%, 60%,
and 75%, respectively; P<.001), as well as increased adherence
to guidelines for daily weight monitoring and assessment of left ventricular
function. Hospital length of stay was lower (median, 3, 4, and 5 days, respectively; P<.001) as were costs of hospitalization (median, $2934, $3209,
and $4830, respectively; P<.01). These differences persisted
after adjustment for severity of illness.
Conclusions When compared with dissemination of guidelines alone, an active care
management approach was associated with significant improvements in quality
and efficiency of care for hospitalized patients with congestive heart failure.
INTRODUCTION
IN THE UNITED STATES, congestive heart failure (CHF) is the leading
discharge diagnosis by diagnosis related group, accounting for nearly 1 million
hospitalizations and causing 200 000 deaths each year.1
Annual expenditures for CHF are estimated to be $38 billion, of which $23
billion is for inpatient care.2 Medicare expenditures
for CHF exceed those for acute myocardial infarction and cancer combined.
In the past decade, a variety of therapies, including angiotensin-converting
enzyme (ACE) inhibitors and certain ß-adrenoceptor antagonists, have
been shown to improve functional status and survival for patients with CHF.3, 4, 5, 6 Specific
diagnostic tests (echocardiography, cardiac gated blood pool scan, etc) have
also been shown to improve heart failure management. In addition, experts
have reached consensus and have published guidelines regarding the appropriate
management of heart failure.2, 7, 8
However, despite compelling medical evidence, the drugs, tests, and recommendations
have not been used optimally in all patients.1, 9, 10
Although a care path for CHF that included comprehensive and specific
recommendations for patient care on each hospital day had been implemented
at our institution in 1995, the adherence was low. For example, in 1996, only
25% of patients with heart failure were enrolled and treated according to
the care path. Given the previous problems with implementation, we developed
simple guidelines targeted at specific patient-care decisions for the treatment
of CHF caused by left ventricular systolic dysfunction. Consensus among caregivers
was gained by involving nurses, primary care physicians, and the full- and
part-time faculty in the design process. Finally, we proposed to implement
the guidelines by means of a physician expert and a nurse care manager who
reviewed each patient's case daily and made recommendations when appropriate
regarding patient treatment. We hypothesized that this process would increase
the use of the recommendations outlined in the national guidelines, improve
the quality of care, and reduce length of stay for patients with CHF by ensuring
early discharge when appropriate.
MATERIALS AND METHODS
INTERVENTION DESIGN
The CHF disease management program was developed at University Hospitals
of Cleveland, Cleveland, Ohio, a 950-bed urban tertiary care hospital that
includes both full-time and part-time faculty. Approximately 50% to 60% of
patients are cared for by house staff, and the remainder by nurse practitioners
or physician assistants. Although patients with CHF are typically admitted
to general medical floors, the admitting physician can opt to admit the patient
to a telemetry ward or intensive care bed, if clinically indicated. However,
with the exception of the cardiac intensive care unit, formal involvement
of a cardiologist in patient care is left to the discretion of the attending
physician.
Before the design of the new program, we conducted a series of interviews
with nurses, house officers, primary care physicians, and cardiologists to
ascertain reasons thought to be responsible for the limited success of the
previous care path. Although cardiologists had designed the care path, consensus
had not been gained among primary care physicians. Many physicians and nurses
were unaware of the existence of a heart failure care path, and it was thought
to be too complicated and cumbersome. Physicians were not involved in the
care path implementation process. All of those interviewed thought that absence
of physician participation in care path implementation had limited the program's
success.
A disease management team was assembled to achieve the primary goals
of adhering to nationally published guidelines for the care of patients with
heart failure and of identifying opportunities to improve quality and efficiency
of care for hospitalized patients. This team initially consisted of a nurse
care manager, a faculty cardiologist, and a physician representative from
the 3 major part-time faculty groups with admitting privileges. The team reviewed
published literature and national care guidelines to develop evidence-based
recommendations for the inpatient treatment of patients with CHF. In addition,
surveys were mailed to all admitting physicians to gain consensus regarding
several care issues that might influence practice patterns, including monitoring
intake and output vs daily weight measurements, and the use of monitored beds.
Based on the literature review and establishment of physician consensus, we
then identified 3 principal interventions for improvement of quality and/or
efficiency of care. These included the use of ACE inhibitor medications, documentation
of left ventricular function by echocardiography, and the consistent use of
admission and daily weights. Specific guidelines are listed below.
A. Treatment with ACE inhibitors
- Recommended for all patients with left ventricular
systolic dysfunction
- Contraindications include history of intolerance
or angioedema, serum potassium level greater than 5.5 mmol/L, symptomatic
hypotension, systolic blood pressure less than 90 mm Hg, and serum creatinine
level greater than 221 µmol/L (2.5 mg/dL)
- For patients with documented intolerance to ACE
inhibitors or for patients symptomatic during treatment with maximally tolerated
doses of ACE inhibitors and diuretics, add hydralazine hydrochloride and isosorbide
dinitrate or angiotensin II receptor blockade
B. Use of echocardiogram
- When there was no previous assessment of left
ventricular function
- When there is marked change in clinical status
suggesting deterioration of left ventricular function (not applicable if dysfunction
is known to be severe)
- When there is new or markedly changed cardiac murmur
C. Implementation of daily weights
- Obtain admission weight on all newly admitted patients
- Perform daily weights in early morning before daily
rounds
After the guidelines were disseminated, the nurse care manager screened
newly admitted patients to identify cases of CHF appropriate for care management.
A care management sheet was developed to aid the physicians caring for the
patient in summarizing patient data and assessing progress. This 1-page sheet
included the history, previous heart failure evaluation, medications, and
clinical presentation. It also tracked the daily response to medical treatment
with an ongoing summary of pertinent factors, such as vital signs, daily weight,
dose of diuretics given, important laboratory values, and medication changes.
The nurse care manager and faculty cardiologist reviewed the clinical response
and treatment plan, offering daily recommendations, based on the previously
developed care guidelines. Because individual patients may respond differently
to interventions such as ACE inhibitors, there was variability in recommendations
from patient to patient. The recommendations were written on the care management
sheet, which was placed in the patient's chart. If the treatment plan by the
clinicians varied significantly from the guidelines, the nurse care manager
contacted the house officer, nurse practitioner, or physician assistant directly
to discuss the recommendations. On occasion, the faculty cardiologist also
contacted the attending physician to review the current guidelines and recommendations.
The nurse care manager also interviewed the patients to provide patient
education, to assess discharge needs, and to evaluate the patient's ability
to comply with a prescribed plan. Education on self-management was provided,
with emphasis on diet, medications, fluid and weight monitoring, recognition
of symptoms, and activity and exercise guidelines. Patients were also screened
as potential candidates for clinical trials, cardiac rehabilitation, and cardiac
transplant evaluation, and were referred as needed to ancillary services such
as physical therapy, social services, and dietary and substance abuse counseling.
MEASURES
The care-managed group consisted of all patients with CHF discharged
during the second through fourth quarters of 1997 in whom guideline-based
recommendations were made, regardless of whether they were adhered to. Two
comparison groups were also included. First, the baseline period included
patients with a principal diagnosis of CHF who were discharged during the
first quarter of 1997, which was immediately prior to implementation of the
disease management program. Note that, during this period, a set of comprehensive
guidelines had been in place for almost 2 years, but the other program features
(ie, daily nurse and physician expert involvement) had not. Second, all patients
discharged during the second to fourth quarters with a principal diagnosis
of CHF but who were not examined and followed up by the team composed the
non–care-managed group. These patients were missed by the screening
process primarily because the nurse care manager was unavailable, the admitting
diagnosis did not seem likely to be related to heart failure, or the patient
was in "observation" status and therefore did not appear on the admitting
list. In this group, written care guidelines were available for the clinician
to use independently, but there was no active intervention undertaken by the
CHF care management team. Medical record review was also used to verify the
diagnosis of CHF for all patients in the baseline period and for non–care-managed
patients.
The nurse care manager collected disease-specific clinical data on all
care-managed patients, including use and dosage of ACE inhibitors, compliance
with daily weight measurement, and use and appropriateness of echocardiograms.
Similar data were collected through medical record review for all patients
during the baseline period and for non–care-managed patients for the
second through fourth quarters of 1997. The hospital's financial database
was also used to measure resource utilization in both care-managed and non–care-managed
patients during the study period. Data elements included length of hospital
stay, total hospital costs, and intensive care unit costs, measured with the
Cost Management Information System software (Eclipsys Corporation, Delray
Beach, Fla).
To determine if potential outcome differences could be attributed to
case mix rather than the interventions, 2 severity measures were used. First,
the hospital's financial database included the All Patient Refined Diagnosis
Related Group (APR-DRG) classification,11 which
was based on International Classification of Diseases, Ninth
Revision, Clinical Modification12 discharge
diagnosis codes and was developed to predict resource consumption for a specific
diagnosis related group. The APR-DRG assigned patients to a 4-point scale
of severity of illness (1, mild; 2, moderate; 3, severe; and 4, catastrophic)
based on the presence or absence of relevant codes. Second, a previously developed
and validated disease-specific multivariable model was used to predict hospital
length of stay. This measure was obtained from the Cleveland Health Quality
Choice (CHQC) coalition13, 14 and
included data elements from the history, physical examination, and admission
laboratory studies. On the basis of the model coefficients, a predicted length
of stay was determined for each patient and used to assess severity of illness
in subsequent analyses.
ANALYSIS
Comparisons of the use of specific interventions (ie, ACE inhibitor)
and outcomes in care-managed and non–care-managed patients during concurrent
periods, as well as care-managed patients and patients from the baseline period,
were made with the  2 test and Wilcoxon rank sum test for categorical
and continuous variables, respectively. Because of the skewed distribution,
average length of stay and costs were expressed as median and interquartile
range (Q1-Q3). Within a given stratum of APR-DRG severity
score, length of stay and costs were also compared between care-managed and
non–care-managed patients by means of the Wilcoxon rank sum test. Finally,
2 multivariable linear regression models included care management and severity
of illness as determined by the CHQC database as independent variables and
either length of stay or total costs as dependent variables. The coefficient
associated with care management indicated its independent association with
outcome.
RESULTS
We identified 173 patients with CHF who were discharged during the baseline
period (first quarter of 1997) and for whom a written care path was available.
After implementation of the disease management team (second to fourth quarters
of 1997), 283 patients constituted the care-managed group, whereas 126 patients
constituted the non–care-managed group. The characteristics of the 3
patient groups are shown in Table 1.
There were no differences between the 3 groups in age and sex distribution,
but patients who were non–care-managed were less likely to have Medicare
and more likely to have Medicaid as their primary insurance. Non–care-managed
patients were also more likely than the care-managed group to have normal
left ventricular function as measured by echocardiography, and had a somewhat
higher severity of illness according to the APR-DRG classification. In contrast,
severity of illness according to the CHQC model was somewhat greater during
the baseline period than for care-managed patients, but similar for non–care-managed
patients.
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Table 1. Clinical Characteristics of Patients in Baseline Period, Non-Care-Managed
Patients, and Care-Managed Patients*
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When compared with baseline and non–care-managed patients, the
care-managed group showed significant improvements in the targeted clinical
measures of quality of care (Table 2),
including the use of ACE inhibitors at hospital discharge, recording of hospital
admission and daily weights, and assessment of left ventricular function.
Hospital length of stay of the patients in the care-managed group was also
significantly lower than for the baseline period or the non–care-managed
group (Table 2). The reduction
in length of stay was not attenuated by an increase in the 30-day readmission
rate or in-hospital mortality rate. The cost per case was lower for care-managed
patients than for non–care-managed patients or patients who were treated
during the baseline period (Table 2).
Finally, care-managed patients had a significantly lower cost per intensive
care unit admission than the other 2 groups.
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Table 2. Clinical and Economic Outcomes in Baseline Period, Non-Care-Managed
Patients and Care-Managed Patients*
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When patients were stratified according to severity of illness as determined
by the APR-DRG score, care management was generally associated with shorter
hospital stay and lower total costs (Table
3). With the exception of the lowest severity stratum, which accounted
for only 20 patients, both length of stay and hospital cost per case were
significantly lower (P<.05) in care-managed patients.
As the severity level increased, there was a progressively greater improvement
in length of stay and hospital cost associated with care management. Within
each stratum, all 3 groups were similar with regard to severity of illness
according to the CHQC index.
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Table 3. Observed and Predicted Length of Stay and Hospital Costs in
Non–Care-Managed and Care-Managed Patients, Stratified by Severity of
Illness*
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Multivariable models were also used to determine the independent association
of care management with both length of stay and cost of care. In a linear
regression model adjusting for admission severity of illness according to
the CHQC model, care management was associated with a 2.2-day reduction in
hospital length of stay (P<.001). In a second
model, care management was associated with a $2204 reduction in severity-adjusted
total hospital costs (P<.001).
COMMENT
This study provides evidence that an active care management approach
is superior to clinical practice guidelines alone in improving quality and
efficiency of care in hospitalized patients with congestive heart failure.
Implementation of this program, which focused on a finite number of evidence-based
interventions, was associated with measurable improvements in use of recommended
therapies and diagnostic studies, as well as reductions in resource consumption.
Moreover, these differences were observed for both concurrent non–care-managed
patients and for patients admitted before program implementation and persisted
after adjustment for patient severity of illness.
In an attempt to improve physicians' decision making and quality of
care, clinical practice guidelines have been designed to define the best practice
for specific clinical situations. The American Medical Association lists more
than 1000 medical practice guidelines for health care delivery.15
The recent impetus for guidelines arises from the recognition of large practice
variation among physicians, the perception of overuse of expensive resources
in health care, and the accelerating growth of managed care and other drivers
of cost containment and quality assurance.15, 16, 17
Despite the fact that clinical guidelines have been developed throughout the
country for many common disease processes, physicians are reluctant to embrace
them. Most studies report a 50% or less compliance with established national
guidelines.9, 18 Efficacy of guidelines
depends in part on the type of practitioners who implement them (specialist
vs primary care),1 the type of hospital in
which guidelines are used, the complexity of the guidelines ("user-friendliness"),
and the availability of the guidelines to practitioners.
More recent efforts have focused on an active multidisciplinary approach
to the care of patients with common conditions such as congestive heart failure.19 In one study, patients followed up in a cardiomyopathy
clinic had a significant decrease in hospital admissions and emergency department
visits and an improvement in functional status when compared with those who
were given usual care.19 Similar results were
obtained in patients enrolled in an outpatient interactive home monitoring
program20 and for patients with advanced heart
failure followed up through a comprehensive active management program after
discharge.2 All of these efforts have shown
that a disease-specific, active management team is more likely to adhere to
nationally recommended clinical guidelines than are individual physicians
who may not be comfortable, for example, with initiating ACE inhibitors in
patients with borderline hypotension and/or tenuous renal function.21 However, unlike these programs, in the present study,
the nurse care manager and faculty cardiologist were not directly responsible
for patient care.
While an active management approach has been successful in an outpatient
setting, few studies have examined the effectiveness of such an approach in
the hospitalized patient. Weingarten et al10
found that the use of a CHF practice guideline to reduce the length of stay
in a coronary care unit was not embraced by physicians, despite verbal and
written recommendations to promote the early transfer of "low-risk" patients
to unmonitored beds. However, the investigators did not follow up the patients
throughout the hospital course. In fact, physicians may have compensated for
a statistically insignificant reduction in monitored length of stay by significantly
increasing the length of stay in unmonitored beds.10
More recently, despite the well-established role of echocardiography in the
diagnosis of CHF and of ACE inhibitors in its treatment, only 18% of patients
were discharged with the appropriate ACE inhibitor dose prescribed,22 and only 63% of patients with newly diagnosed CHF
underwent an echocardiogram.23
In this study, the nurse care manager and faculty cardiologist helped
to ensure that the physicians directly involved in the care of the patient
followed national guidelines. Rather than assuming care of the patient, the
nurse wrote daily notes in the chart with simple suggestions, in the spirit
of the national recommendations, and maintained continued interaction with
caregivers. For example, from a quality standpoint, we recommended the use
of echocardiography if indicated, initiating or increasing the dose of ACE
inhibitors in patients with borderline hypotension and/or renal function,
and using daily weights as a gauge for diuretic dosing. It is important to
note that all patients, not only those who were care managed, had a clinical
care path for CHF available that had been developed at the hospital approximately
2 years before the initiation of our program. However, during the baseline
period, only 60% of patients received ACE inhibitors or had an echocardiogram
to assess left ventricular function. It is also notable that ACE inhibitor
use and daily weight recording increased in the non–care-managed patients
compared with the baseline period, which may represent a "trickle-down" effect
of the program. Thus, through the constant education of physicians and nursing
staff who also cared for care-managed patients, the non–care-managed
group, missed by our screening, probably also benefited.
We recognize several limitations of the study. First, this study was
observational and not a randomized trial. Although severity adjustment was
performed by 2 indexes, the non–care-managed group was composed of patients
who were not captured by the screening process. Therefore, there may be potential
differences in patient severity of illness that were unmeasured by our risk
adjustment methods and could account for some of the observed results. Also,
it is worth noting that a significant minority of patients in all 3 groups
had normal left ventricular function. The majority of these patients had,
as a final diagnosis, diastolic dysfunction and may have been treated as if
they had left ventricular dysfunction until the results of the echocardiogram
were available. Because of the nature of their disease, these patients were
less likely to benefit from our active management program, which was designed
primarily for systolic heart failure. Although the non–care-managed
and baseline groups consisted of a greater proportion of patients with normal
left ventricular function than the care-managed group (Table 2), this difference should not affect the results of our study.
Given the better prognosis of patients with diastolic dysfunction, it could
favor the non–care-managed group. Finally, given temporal trends in
the treatment of CHF, the guidelines are periodically updated and currently
differ somewhat from those during the period of this study. For example, more
recent guidelines have specified a target dose for ACE inhibitors and have
included treatment algorithms with ß-blockers.24
The heart transplantation program that was developed after this study has
also subsequently affected guideline content and resource utilization.
We conclude that, when compared with dissemination of guidelines alone,
an active care management approach was associated with significant changes
in practice for hospitalized patients with CHF. These differences suggest
that the constant education and written recommendations were responsible for
the difference in quality and efficiency of care. Future studies should address
the benefit of this approach in improving long-term outcomes of this patient
population, as well as its impact on the care of patients with other cardiovascular
and medical diagnoses.
AUTHOR INFORMATION
Accepted for publication July 20, 2000.
From the Department of Medicine, University Hospitals of Cleveland
and Case Western Reserve University School of Medicine, Cleveland, Ohio.
Corresponding author: Gregory S. Cooper, MD, Division of Gastroenterology,
University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106 (e-mail: gxcl2{at}po.cwru.edu).
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