Original Article

Efficacy of Multidisciplinary Outpatient Management (MOM) Program in Long Term Heart Failure Care

Authors: Rahul Jain, MD, Ariana Evenson, MSIV, Rohit Jain, MD, Elizabeth Biddison, MSIII, Darshan Dalal, MD, MPH, Kathleen M. Kelly, CRNP, Arezo J. Karmand, MSIII, Heide Hullsiek, MSIII, Jyothi Punnam, MD, Stephen Plantholt, MD

Abstract

Background: Heart failure (HF) management programs worldwide have reported conflicting outcomes in the past.


Objectives: We sought to determine retrospectively whether the multidisciplinary outpatient management (MOM) program [heart failure clinic (HFC)], decreased readmission rates (RR), duration of hospital stay, and/or mortality in HF patients.


Methods: Records of 138 HF patients who had their first encounter either as admission for HF at St. Agnes Hospital or visit to HFC during the period June 2005 through June 2006 were evaluated for outcomes through September 2007. Twenty-seven patients were followed in the HFC and 111 were in the non-HFC group. During follow up, 39 of the non-HFC group patients crossed over to the HFC group. All baseline parameters, except age (P = 0.006), were similar in both groups.


Results: In the HFC group 4 patients had a total of 5 readmissions, whereas 85 patients had a total of 187 readmissions (P < 0.001) in the non-HFC group. Average lengths of hospitalization were 5.2 ± 4.8 days and 4.2 ± 3.2 days (P = 0.18) and the number of readmissions/patient/year was 0.3 and 1.45 (P < 0.001) in the HFC and non-HFC groups, respectively. In the subgroup analysis of cross overs (n = 39), there was a 60% reduction in the readmission rate after crossing over to the HFC group. The significance of decreased mortality in the HFC group could not be assessed due to the small sample size.


Conclusion: The study suggests that the MOM program can significantly reduce RR secondary to HF.


Key Points


* There was a significantly higher readmission rate for heart failure exacerbation in patients not attending the clinic compared to those who did attend the clinic.


* There was no difference in the length of hospitalization in the two groups.


* This study was done in a community hospital and signifies the role of a structured heart failure clinic beyond pharmacological treatment in heart failure management.

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References

1.Heart disease and stroke statistics—2008 update at a glance. 2008. Available at: http://www.americanheart.org/downloadable/heart/final.pdf. Accessed July 18, 2008.
 
2.Hunt SA; American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to update the 2001 guidelines for the evaluation and management of heart failure). J Am Coll Cardiol 2005;46:e1–e82.
 
3.Ansari M, Alexander M, Tutar A, et al. Incident cases of heart failure in a community cohort: importance and outcomes of patients with preserved systolic function. Am Heart J 2003;146:115–120.
 
4.Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol 2003;41:62–68.
 
5.Philbin EF, Weil HFC, Erb TA, et al. Cardiology or primary care for heart failure in the community setting. Chest 1999;116:346–354.
 
6.Rich MW. Heart failure disease management: a critical review. J Card Fail 1999;5:64–75.
 
7.McAlister FA, Lawson FM, Teo KK, et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med 2001;110:378–384.
 
8.Cleland JG, Louis AA, Rigby AS, et al; TEN-HMS Investigators. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol 2005;45:1654–1664.
 
9.Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190–1195.
 
10.Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999;354:1077–1083.
 
11.Cline CM, Israelsson BY, Willenheimer RB, et al. Cost effective management programme for heart failure reduces hospitalisation. Heart 1998;80:442–446.
 
12.Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999;281:613–620.
 
13.Krumholz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002;39:83–89.
 
14.McDonald K, Ledwidge M, Cahill J, et al. Heart failure management: multidisciplinary care has intrinsic benefit above the optimization of medical care. J Card Fail 2002;8:142–148.
 
15.Kasper EK, Gerstenblith G, Hefter G, et al. A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol 2002;39:471–480.
 
16.Kashem A, Droogan MT, Santamore WP, et al. Managing heart failure care using an internet-based telemedicine system. J Card Fail 2008;14:121–126.
 
17.Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002;105:2861–2866.
 
18.Laramee AS, Levinsky SK, Sargent J, et al. Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Arch Intern Med 2003;163:809–817.
 
19.Costantini O, Huck K, Carlson MD, et al. Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure. Arch Intern Med 2001;161:177–182.
 
20.Riegel B, Carlson B, Glaser D, et al. Which patients with heart failure respond best to multidisciplinary disease management? J Card Fail 2000;6:290–299.
 
21.Philbin EF, Rocco TA, Lindenmuth NW, et al. The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators. Am J Med 2000;109:443–449.
 
22.Ceresa M, Capomolla S, Pinna G, et al. Anemia in chronic heart failure patients: comparison between invasive and non-invasive prognostic markers. Monaldi Arch Chest Dis 2005;64:124–133.
 
23.Krumholz HM, Parent EM, Tu N, et al. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med 1997;157:99–104.
 
24.Vinson JM, Rich MW, Sperry JC, et al. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290–1295.
 
25.Monane M, Bohn RL, Gurwitz JH, et al. Noncompliance with congestive heart failure therapy in the elderly. Arch Intern Med 1994;154:433–437.
 
26.Ghali JK, Kadakia S, Cooper R, et al. Precipitating factors leading to decompensation of heart failure. Traits among urban blacks. Arch Intern Med 1988;148:2013–2016.
 
27.Chin MH, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health 1997;87:643–648.
 
28.Marcantonio ER, McKean S, Goldfinger M, et al. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med 1999;107:13–17.
 
29.Jaarsma T, Halfens R, Huijer Abu-Saad H, et al. Effects of education and support on self-care and resource utilization in patients with heart failure. Eur Heart J 1999;20:673–682.