Disease Management

Heart Failure
for
DISCLAIMER: The information contained in this annotated bibliography was obtained from the publications listed. The National
Pharmaceutical Council (NPC) has worked to ensure that the annotations accurately reflect the information contained in the publi-
cations, but cannot guarantee the accuracy of the annotations or the publications. There are articles available on the treatment of
heart failure that are not included in this bibliography and that may include relevant information not covered herein. The inclusion of
any publication in this bibliography does not constitute an endorsement of that publication by NPC or an endorsement of the serv-
ices, programs, treatments, or other information contained in such publication.

This bibliography is designed for informational purposes only, and should not be construed as professional advice on any specific
set of facts and circumstances. This bibliography is not intended to be a comprehensive source of disease management services
or programs for the treatment of heart failure, or a substitute for informed medical advice. If medical advice or other expert assis-
tance is required, readers are urged to consult a qualified health care provider or other professional. NPC is not responsible for
any claims or losses that may arise from any errors or omissions in the information contained in this bibliography or in the listed
publications, whether caused by NPC or originating in any of the listed publications, or any reliance thereon, whether in a clinical
or other setting.

© October 2004 National Pharmaceutical Council, Inc.

Disease Management for Heart Failure
Introduction
The Disease Management Association of America
defines disease management as a system of coordinated
health care interventions and communications for
populations with conditions in which patient self-care
efforts are significant.1 Disease management supports the
clinician-patient relationship and plan of care, and
emphasizes prevention of exacerbations and
complications using evidence-based practice guidelines
and patient empowerment strategies.1 It also evaluates
clinical, humanistic, and economic outcomes on an
ongoing basis with the goal of improving overall health.1
More specific goals of disease management include:2
• Improving patient self-care through means such as
patient education, monitoring, and communication.
• Improving physician performance through feedback
and/or reports on patient progress in compliance with
protocols.
• Improving communication and coordination of services
between the patient, the physician, the disease
management organization, and other providers.
• Improving access to services, including prevention
services and prescription drugs as needed.
The following functions are components of disease
management:2
• Identification of patient populations.
• Use of evidence-based practice guidelines.
• Support of adherence to evidence-based medical
practice guidelines by providing medical treatment
guidelines to physicians and other providers,
reporting on the patient’s progress in complying with
protocols, and providing support services to assist
the physician in monitoring the patient.
• Provision of services designed to enhance the
patient’s self-management and adherence to his or
her treatment plan.
• Routine reporting and feedback.
• Communication and collaboration among providers
and between the patient and his or her providers.
• Collection and analysis of process and outcomes
measures.
Disease management programs are widely used for
asthma, diabetes mellitus, and heart failure.3-5
Considerations in selecting a disease for disease
management include:
• Availability of treatment guidelines with consensus
about what constitutes appropriate and effective care.
• Presence of generally recognized problems in
therapy that are well documented in the medical
literature.
• Large practice variation and a range of drug
treatment modalities.
• Large number of patients with the disease whose
therapy could be improved.
• Preventable acute events that often are associated
with the chronic disease (e.g., emergency
department or urgent care visits).
• Outcomes that can be defined and measured in
standardized and objective ways and that can be
modified by application of appropriate therapy (e.g.,
decreased number of emergency department visits or
hospitalizations).
• Potential for costs savings within a short period (e.g.,
less than 3 years).
Three major not-for-profit organizations whose mission
is to promote quality health care have recognized the
contribution of disease management activities to quality
health care by establishing disease management
certification or accreditation programs. The Joint
Commission on Accreditation of Healthcare Organizations,
an independent, not-for-profit organization and the nation’s
predominant standards-setting and accrediting body in
health care, offers disease-specific care program
certification. Program certification is based on an
assessment of compliance with consensus-based national
standards, effective use of established clinical practice
guidelines to manage and optimize care, and an
organized approach to performance measurement and
improvement activities.6
The National Committee for Quality Assurance accredits
disease management programs on the basis of standards
Disease Management for Hear Failure
that are patient oriented, practitioner oriented, or both. It
also offers organizations certification for program design
(i.e., content development), systems (i.e., clinical
information and other support systems), or patient or
practitioner contact (e.g., for nurse call centers and other
organizations without comprehensive activities).7
The Utilization Review Accreditation Commission
(URAC), also known as the American Accreditation
HealthCare Commission, establishes standards for the
health care and insurance industries. URAC’s goal is to
[1]
 promote excellence among purchasers, providers, and
patients through continuous improvement in the quality
and efficiency of health care delivery. It achieves this goal
by establishing standards, education and communication
programs, and a process of accreditation. URAC has
accreditation programs for disease management as well
as case management, claims processing, core
accreditation, credential verification, health call centers,
health networks, health plans, health provider
credentialing, health utilization management, health Web
sites, Health Insurance Portability and Accountability Act
privacy and security, independent review, and workers’
compensation utilization management.8
Penetration And Trends
The ultimate goal of disease management is to produce
optimal health outcomes for patients. Therefore, virtually all
stakeholders in health care want to be involved. Disease
management is of interest to providers, patients, managed
care organizations, insurance companies, government
agencies, pharmacy benefit management (PBM) firms,
and employer purchasing coalitions.9 Most disease
management programs are implemented through health
maintenance organizations (HMOs), PBM firms, or
Medicaid agencies.4 Some organizations choose to hire a
vendor and contract out disease management services,
whereas others choose to develop their own programs.
Each method has advantages and disadvantages;
success often depends on the organization and its level of
resources and commitment.
Managed Care Organizations and
Pharmacy Benefit Management Firms
Managed care organizations and PBM firms were the
first to implement disease management programs. PBM
firms offer disease management programs and services to
employers and managed care clients as part of their
Disease Management for Hear Failure
overall benefit management services.10 The 1998 Novartis
Pharmacy Benefit Report indicated that 75% of PBM
pharmacy directors were expending resources to develop
disease management programs for conditions that
respond to or depend on pharmaceutical products and
services. HMOs reported that 16% of their disease
management programs were provided thorough a PBM.10
Most employers reported using PBM firms to manage
costs, and many employers used PBM firms to provide
disease management services.10
[2]
America’s Health Insurance Plans (a trade association
created by the joining of the American Association of
Health Plans and the Health Insurance Association of
America) represents more than 1300 HMOs, preferred
provider organizations, and other network-based plans.
Members of the association provide health care to more
than 200 million Americans nationwide. In a 2000 survey of
a random sample of association members, 99% of
member health plans offered a disease management
program.5
State Medicaid Programs
In the rapidly changing environment of Medicaid
managed care, it is essential for Medicaid directors and
their top managed care staff to remain abreast of
innovations in organization and payment that are occurring
to serve the special needs of the Medicaid population.
Traditionally, state Medicaid programs either have retained
insurance risk and paid on a fee-for-service basis or have
outsourced risk and contracted with Medicaid HMOs.
Disease management represents a method of managed
care in the middle between traditional fee-for-service and
HMOs. Four types of models are emerging:
1. Medicaid health outcomes partnerships are
usually applied to an existing fee-for-service
primary care case management program.
Medicaid programs focus on high-priority
diseases, offering a number of support systems
to help existing Medicaid providers better serve
the patients assigned to them.11
2. Disease management organizations are outside
contractors who are retained by the state to
address particular diseases, either by
supplementing existing Medicaid providers and
their case management activities or by taking
over responsibility for targeted patients.
3. Pay-for-performance approaches establish new
rules for scope of practice or referrals and involve
nontraditional providers in the care of patients
with specific diseases. The nontraditional
providers are paid a special fee contingent on
improving health outcomes or lowering costs.
4. Centers of Excellence focus on particular disease
episodes for high-cost, high-volume diseases and
select a network of hospitals, physicians, and
other providers who are already organized to
receive a prospective, bundled payment per
episode of care. To meet criteria for designation
 as a center of excellence, an organization must
provide written documentation of the quality and
outcomes of care for a selected disease.
Most states are actively involved in the disease
management process. By far, the diseases most often
focused on in these programs are asthma and diabetes.
Other diseases and conditions included in state disease
management programs are arthritis, heart failure,
depression, gastrointestinal disease, hemophilia, HIV
infection/AIDS, hyperkinetic activity, dyslipidemia, mental
health, otitis media, pregnancy, smoking, ulcer, and upper-
respiratory infections. Current information about state
disease and case management activities is available on
the Web at http://www.dmnow.org/state_activities/.
Why Focus on Heart Failure?
Over the last decade, managed care organizations
began an intense utilization review process to identify
areas where cost control measures would be
appropriate.12 Heart failure was one of the first diseases
selected because there is great opportunity to treat this
disease more effectively and to develop programs that will
help payers and plans manage the high costs associated
with it.12
Economic Impact
In the United States, the direct and indirect costs of
heart failure in 2004 are estimated at $25.8 billion.13 This
figure includes $23.7 billion in direct costs for expenses
related to hospitalization, nursing home care, physicians
and other health professionals, medications, and home
health care. The indirect costs for lost productivity and
earnings due to death from heart failure amount to $2.1
billion.
Hospitalization is the largest component of the direct
costs of heart failure, and the rate of hospitalization for
heart failure has increased substantially over the past
decade.14,15 In 1999, Medicare payments to beneficiaries
hospitalized with heart failure amounted to more than
$5000 per patient discharged and a total of $3.6 billion.13
Nearly 75% of the hospitalization expense is incurred
within the first 48 hours of hospitalization (except for the
daily room charge).14 Annual expenditures for medications
to treat heart failure amount to approximately $500
million.15
Epidemiology
An estimated 5 million Americans have heart failure, and
approximately 550,000 new cases are diagnosed each
year.13 The prevalence of heart failure increases with age; it
is approximately 1% at age 50 and 5% at age 75.16 Four
out of five cases of heart failure occur in persons 65 years
of age or older.17 Heart failure is the most common cause of
hospitalization in this age group, and nearly half of elderly
patients with a discharge diagnosis of heart failure are
readmitted within 6 months.17 Men are more likely to be
affected by heart failure than are women, probably
because the incidence of ischemic heart disease is greater
in men than in women.13,18 Roughly 9 out of 10 patients with
a diagnosis of heart failure survive for 1 year.19 However,
only 5 out of 10 patients are alive 5 years after diagnosis,
and the quality of life is impaired in many of these
patients.19 Approximately 39,000 Americans die from heart
disease annually, and the disease contributes to the deaths
of another 225,000 people each year.16 Death is sudden in
40% of patients, suggesting that it is the result of serious
ventricular arrhythmia.18 Mortality from heart failure is twice
as high for African Americans as it is for whites.16
What Is Heart Failure?
Heart failure is the result of dysfunction of the cardiac
ventricles during diastole (filling), systole (contraction), or
both.18 This dysfunction may have a variety of causes,
including hypertension (which increases the workload for
the heart) and diseases of the cardiac valves, muscle, and
pericardium (the sac surrounding the heart). Myocardial
infarction is a common cause of decreased contractility;
damage to heart muscle fibers due to an insufficient
oxygen supply impairs the ability of the fibers to shorten
during systole. Myocardial infarction also can increase the
stiffness of the ventricles and restrict filling during diastole.
In most cases, heart failure is characterized by
dysfunction of the left ventricle during systole and a low
cardiac output (the volume of blood pumped per minute)
Disease Management for Hear Failure
and ejection fraction (the portion of the left ventricle
volume expelled during systole).18 Common causes of left
ventricular systolic dysfunction include hypertension,
coronary artery disease, and idiopathic dilated
cardiomyopathy.18
Heart failure is a condition in which the heart cannot
pump enough blood to meet the needs of the body’s other
organs. It can result from:
• Narrowed arteries that supply blood to the heart
muscle (i.e., coronary artery disease).
[3]
 • A past heart attack, or myocardial infarction, with
scar tissue that interferes with the heart muscle’s
normal work.
• High blood pressure.
• Heart valve disease due to past rheumatic fever
or other causes.
• Primary disease of the heart muscle itself, called
cardiomyopathy.
• Defects in the heart present at birth (i.e.,
congenital heart disease).
• Infection of the heart valves and/or heart muscle
itself (i.e., endocarditis and/or myocarditis).
The “failing” heart keeps working, but it doesn’t work as
efficiently as it should. People with heart failure cannot
physically exert themselves because they become short of
breath and fatigued. As blood flow out of the heart slows,
blood returning to the heart through the veins often backs up,
causing congestion in the tissues. Swelling (edema) results,
most commonly in the lower legs, ankles, and feet, but
possibly in other parts of the body as well. Sometimes fluid
collects in the lungs and interferes with breathing, causing
shortness of breath, especially when a person is lying down.
Heart failure also affects the ability of the kidneys to excrete
sodium and water. Water retention worsens the edema.
Compensatory mechanisms involving the blood
vessels, kidneys, nervous system, and hormones (e.g., the
renin-angiotensin-aldosterone system) allow the
cardiovascular system to temporarily adapt to underlying
pathologic conditions, maintain a normal cardiac output,
and forestall the onset of heart failure signs and
symptoms.18 These mechanisms include hypertrophy of the
ventricles (an increase in muscle mass and wall
thickness), dilatation of the ventricles (i.e., increased
volume), and sympathetic nervous stimulation (to increase
heart rate, contractility, and cardiac output). However,
some compensatory mechanisms can worsen heart failure;
Disease Management for Hear Failure
these mechanisms are referred to as maladaptive
responses. For example, low renal blood flow due to low
cardiac output results in activation of the renin-
angiotensin-aldosterone system, which increases blood
pressure and promotes sodium and water retention and
volume overload.18 Although sympathetic stimulation
increases the heart rate, contractility, and cardiac output, it
also increases blood pressure and oxygen demand on the
heart. Heart failure signs and symptoms manifest when the
maladaptive responses overwhelm the beneficial effects of
[4]
compensatory mechanisms.18 Maladaptive responses
contribute to disease progression in patients with heart
failure.
Signs and symptoms of heart failure include fatigue,
shortness of breath, difficulty breathing (especially at
night, when lying down, or during physical exertion),
cough, weight gain (from fluid retention), and swelling of
the feet and ankles.16,18 The New York Heart Association
functional classification may be used to classify functional
disability in patients with heart failure on the basis of the
extent to which physical activity is limited because of
symptoms. Class I is no impairment (i.e., symptoms only at
levels of physical activity that limit normal persons), and
Class IV is severe impairment (i.e., symptoms at rest).
Table 1 lists commonly used authoritative guidelines for
managing heart failure. Up-to-date information on treatment
guidelines from various sources also is available from the
National Guideline Clearinghouse (http://www.guideline.gov/).
The management of heart failure, based on information in
the guidelines, is discussed in Appendix A. Table 2
provides a list of organizations with information about heart
failure for patients.
Health Goals in Patients with Heart
Failure
Some of the conditions that cause heart failure (e.g.,
diseased heart valves) can be corrected. However, in most
cases, a cure is not possible. Nevertheless, lifestyle
modifications and drug therapies may be used to manage
chronic illness. The goals of treatment are to increase
survival, reduce symptoms, and improve functional status
and quality of life.16
Review of Heart Failure Disease
Management Literature
A comprehensive search of the heart failure disease
management literature was conducted in preparing this
bibliography. The goal was to identify reports describing
educational interventions or disease management
programs designed to improve the management of heart
failure. Thus, whereas some reports describe
comprehensive disease management programs, others
describe educational interventions directed at patients,
health care providers, or both.
MEDLINE is the National Library of Medicine’s premier
database. It contains more than 12 million citations and
abstracts from more than 4800 biomedical journals
 Table 1. Authoritative Guidelines for Managing Congestive Heart
Failurea
1. American Heart Association
Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and
prevention. Available in print (Circulation. 2003;107:1210-1225) and online at: http://circ.ahajournals.org/cgi/reprint/107/8/1210.

2. Canadian Cardiovascular Society

The 2002-2003 Canadian Cardiovascular Society consensus guideline update for the diagnosis and management
of heart failure. Available in print (Can J Cardiol. 2003;19:347-356).

3. Heart Failure Society of America

Heart Failure Society of America guidelines for management of patients with heart failure caused by left ventricular systolic
dysfunction: pharmacological approaches. Available in print (J Card Fail. 1999;5:357-382, Pharmacotherapy. 2000;20:495-522,
or Congestive Heart Failure. 2000;6:11-39) and online at: http://www.hfsa.org/pdf/lvsd_heart_failure.pdf. Update in progress.

4. Institute for Clinical Systems Improvement

Health care guidelines on (1) Inpatient Management of Heart Failure (2004) and (2) Heart Failure in Adults (2003). Available
online at: http://www.icsi.org.

5. European Society of Cardiology

Guidelines for the diagnosis and treatment of chronic heart failure. Available in print (Eur Heart J. 2001;22:1527-1560) and
online at: http://www.escardio.org/NR/rdonlyres/83B0E854-D56A-47C1-988F-585F4EBFEAF8/0/CHF_diagnosis.pdf.

a
Clinical practice is subject to constant change, and the guidelines in this list may become outdated or be superseded by newer ones. The reader is
encouraged to consult the National Guideline Clearinghouse (http://www.guideline.gov/), a public resource for evidence-based clinical practice
guidelines sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), in partnership
with the American Medical Association and the American Association of Health Plans (now America’s Health Insurance Plans), for the most current
guidelines.

published in the United States and 70 other countries.
Topics span the fields of medicine, nursing, dentistry,
veterinary medicine, the health care system, and the
preclinical sciences. Earlier versions of this bibliography
were based on searches of the MEDLINE database for the
period from January 1985 to May 2002 using the search
terms “disease” AND “management” AND “congestive
heart failure.” In preparing this updated version of this
bibliography, an additional search of the MEDLINE
database was performed for the period from May 2002
Reports on 68 disease management programs met
these criteria. Appendix B presents summaries of these
reports, and Appendix C displays associated
methodological information and outcome data in tabular
form.
Methodologies
The educational interventions or disease management
programs were targeted at adults, including a large
percentage of patients more than 55 years of age. Aside
Disease Management for Hear Failure

through May 2004 using the search terms “disease
management” AND “heart failure” to reflect changes to the
National Library of Medicine’s controlled vocabulary. This
search was limited to clinical trials.
The primary criteria for inclusion of a report in this
analysis were:
• An educational intervention undertaken to
improve the management of heart failure.
• Measurement of the impact of the intervention or
program.
from three studies with mixed patient populations (one study
included patients with chronic obstructive pulmonary
disease [COPD] or congestive heart failure [CHF], another
included patients with CHF or cardiomyopathy, and a third
included patients with CHF, COPD, or diabetes), all
interventions and programs were targeted at individuals with
heart failure, including the congestive state. The size of the
patient population ranged from to 15 to nearly 5000 patients.
Patient participants in the disease management
programs and educational interventions were recruited

[5]
 Table 2. Organizations With Information About Congestive
Heart Failure for Patients
American Heart Association
7272 Greenville Avenue
Dallas, TX 75231
1-800-AHA-USA-1
or 1-800-242-8721
http://www.americanheart.org
Heart Failure Society of America
Court International—Suite 240 S
2550 University Avenue West
Saint Paul, MN 55114
651-642-1633
http://www.hfsa.org
from various sites, including hospitals, clinics, private
medical groups, and special heart failure centers. Some
interventions and programs focused on patients with
specific risk factors for hospital readmission. For example,
14 interventions and programs were conducted with
patients who were elderly or had severe heart failure,
including 2 programs affiliated with heart transplantation
centers. In one case, a medical claims database was used
to identify all patients with a heart failure-based claim of
more than $50 as well as a recent hospital admission or
emergency department visit.
Fifty-two of the educational interventions or disease
management programs were specifically intended for
patients; families of the patients were involved in nine
cases. The program content typically included information
about:
• Heart failure (e.g., pathophysiology, signs,
Disease Management for Hear Failure
symptoms).
• Appropriate diet, weight, activity level, and other
lifestyle factors.
• Medications and the importance of treatment
adherence.
• Self-monitoring techniques to facilitate the daily
measurement and reporting of body weight,
dietary intake, and evidence of acute heart failure
exacerbation (e.g., weight gain, edema,
shortness of breath).
[6]
Heart Rhythm Society
Six Strathmore Road
Natick, MA 01760-2499
508-647-0100
http://hrspatients.org/
National Heart, Lung, and Blood Institute
P.O. Box 30105
Bethesda, MD 20824-0105
301-592-8573
http://www.nhlbi.nih.gov/
Texas Heart Institute
P.O. Box 20345
Houston, TX 77225-0345
1-800-292-2221
http://www.tmc.edu/thi/topics.html
Various settings and formats were used to present the
educational material, including individualized and small-
group sessions held at a hospital, outpatient clinic, or the
patient’s home. Information presented orally usually was
supplemented by audiovisual or printed materials (e.g.,
workbooks, medication calendars, brochures). Common
methods to reinforce educational material and promote
treatment adherence included home visits by a nurse and
outpatient clinic visits by patients.
Telemonitoring—ranging from regular, provider-initiated
telephone calls to the transmission of patient self-reported
data via an automated telemanagement system—was
used in many interventions and programs. New
technologies allow for the education of patients at home
by health care professionals at a remote location. Some
devices also provide for the measurement and transmittal
of patient health data from the home to the remote location
for review by a health care professional. The use of these
technologies has reduced the need for frequent home
visits by health care professionals and patient trips to a
health care facility.
Thirteen educational interventions or disease
management programs were directed at both patients and
health care professionals. In addition to offering patient
education, these programs and interventions provided
health care professionals (including physicians) with
information about:
 • The program itself or patient status (i.e., patient
self-monitoring data).
• The appropriate use of practice guidelines
developed locally or nationally.
• Techniques for improving patient adherence.
• The early management of complications.
Three interventions were directly solely at health care
providers. These interventions involved the development
and implementation of critical and clinical pathways for
management of patients with heart failure.
All or certain aspects (e.g., patient teaching,
medication dosage adjustments, critical pathways) of 20
disease management programs or educational
interventions were based on guidelines widely accepted in
the medical community. These include guidelines issued
by the Agency for Health Care Policy and Research (now
the Agency for Healthcare Research and Quality), the
American Heart Association, and the American College of
Cardiology. Eighteen other interventions or programs relied
on internally developed guidelines or critical pathways, or
were based partly or entirely on:
• Unspecified protocols, guidelines, or critical
pathways.
• Guidelines issued by federal agencies (e.g.,
Medicare), nursing agencies, or home health care
agencies.
• Published research.
For example, target angiotensin converting-enzyme
(ACE) inhibitor dosages in one disease management
program were based on the results from randomized
clinical trials.
Most of the educational interventions and disease
management programs targeting patients were
administered by specially trained nurses or pharmacists.
Some interventions and programs were administered by a
multidisciplinary team of providers, including physicians,
nurses, pharmacists, dietitians, social workers,
psychologists, and home health care workers. However, a
nurse often coordinated the activities of these
multidisciplinary teams. Physicians, working alone or in
conjunction with another health care professional, often
conducted interventions or programs directed at health
care providers (i.e., the development and implementation
of critical pathways).
The studies included 27 randomized, controlled trials;
18 observational, pre- and post-intervention comparison
studies; and 5 retrospective chart reviews. Outcomes were
assessed over various periods after the intervention (e.g.,
30 days, 90 days, 6 months), with 29 studies providing
patient follow-up data for 1 year or longer.
Outcomes
A commonly measured outcome was the hospital
admission or readmission rate (readmissions), reflecting
the goal of most educational interventions and disease
management programs to reduce resource utilization.
These rates were measured over relatively short periods
(e.g., 30 or 90 days) in some studies and over longer
periods (e.g., 1 year) in others. Forty- nine of the 68
educational programs and disease management programs
used hospital admission or readmission rate as a measure
of effectiveness. Following the intervention, rates dropped
in 39 studies, remained unchanged in 7 studies, and
increased in 3 studies.
Other common hospital-related outcome measures
included total number of hospital days and average length
of stay (LOS). The average LOS decreased among
patients receiving the intervention in 13 of 14 studies in
which LOS was assessed. These changes were paralleled
by a decrease in the total number of hospital days in 17 of
the 18 studies in which this outcome measure was
evaluated. Other measures of resource utilization (e.g.,
emergency department visits) also showed similar
improvements.
Several studies evaluated the effect of the educational
intervention or disease management program on patients’
emotional or physical status. Patient-related outcome
measures in these studies included quality of life, mood,
and functional status. Improvement in quality-of-life scores
was found among patients participating in the intervention
in 17 of the 22 studies in which this parameter was
Disease Management for Hear Failure
assessed; improved mood also was observed in 3 studies.
In 12 studies that assessed functional status, significant
improvements were noted among patients participating in
the program or intervention compared with controls.
Several studies focused on the effectiveness of the
educational intervention or disease management program
in improving the disease-related knowledge or self-
management behavior of patients with heart failure. For
example, eight studies assessed patient knowledge of
[7]
 topics such as appropriate medication use, diet, and
exercise; improvements attributed to the intervention were
observed in seven of these studies. Eleven studies used
objective measures of adherence to the medication
regimen, dietary restrictions, and other aspects of
treatment. All of these studies documented improved
adherence among patients who participated in the
educational intervention or disease management program.
Knowledge of and compliance with practice guidelines
among providers were indirectly measured by evaluating
the appropriateness of medical management (e.g.,
appropriate use of an ACE inhibitor to reduce afterload in
a patient with heart failure who can tolerate such therapy).
Of the six studies that evaluated appropriate medical
management, five documented improved care associated
with the educational intervention or disease management
program, including more appropriate use or dosing of ACE
inhibitors in three studies.
Health-related costs were evaluated or projected in 37
studies. Thirty-two reports described reduced health-
related costs among patients who participated in the
educational intervention or disease management program.
The intervention had no impact on costs in one study. A
cost savings was projected in another four reports.
Disease Management for Hear Failure
[8]
The Future of Disease Management
Disease management can improve patient outcomes
and quality of life while potentially reducing overall costs. It
is an important approach to integrated care.
As health care payers incorporate disease
management principles into the delivery of care, they need
to become more sophisticated in contracting with outside
vendors for these services. The Disease Management
Association of America works with potential customers to
address issues associated with contracting, such as data
contracting and risk sharing. Currently, the Disease
Management Association of America has more than 100
corporate members that provide disease management
services.
Disease management vendors have begun using the
Internet to reach out to target populations. The Internet
allows two-way communication between clinicians and
patients, as well as immediate and free access to
educational materials. Compared with traditional office
visits and postal mailings, the Internet may save time and
money. Initially the Internet may be used to educate
Medicaid physicians, nurses, pharmacists, and other
providers about disease management. As more people
gain access to personal computers and enter the
“information superhighway,” the Internet will become an
increasingly powerful tool.
Disease management is a useful, efficient approach to
health care. It will continue to gain widespread
acceptance among health plans that provide care for
patients with chronic disease.
Appendix A.
Management of Heart Failure
Heart failure usually requires a treatment regimen that
includes rest, proper diet, modified daily activities, and
medications that include angiotensin-converting enzyme (ACE)
inhibitors, beta-blockers, digitalis, diuretics, and vasodilators.
The various medications used to treat heart failure perform
different functions. For example, ACE inhibitors and vasodilators
expand blood vessels and decrease resistance, allowing blood
to flow more easily and making the heart’s work easier or more
efficient. Beta-blockers can improve the function of the left
ventricle. Digitalis increases the pumping action of the heart,
while diuretics help the body eliminate excess salt and water.
When a specific cause of heart failure is discovered, it should
be treated or, if possible, corrected. For example, in some cases
treating high blood pressure can ameliorate heart failure. Some
patients are treated surgically by replacing abnormal heart
valves. When the heart becomes so damaged that it cannot be
repaired, a more drastic treatment such as a heart transplant
may be considered.
Most cases of mild or moderate heart failure are treatable.
With proper medical supervision, people with heart failure need
not become invalids.
Nonpharmacologic Therapy
Regular exercise is recommended for patients with stable
heart failure because it may improve functional status and
decrease symptoms.15,20 Moderate restriction of dietary sodium
intake is recommended.18 Excessive fluid intake should be
avoided, although fluid restriction is not necessary. Smoking
cessation, restriction of dietary fat intake, and treatment of lipid
disorders also may be recommended.15 Alcohol and illicit drug
use should be discouraged because they may increase the risk
of heart failure.15
Pharmacologic Therapy
Diuretics, ACE inhibitors, beta-blockers, and digitalis are
used to treat patients with heart failure.15 Aldosterone
antagonists (e.g., eplerenone), angiotensin receptor blockers
(e.g., losartan), hydralazine, and isosorbide dinitrate may be
considered for certain patients.15,21
Diuretics. Diuretics are used to correct and prevent fluid
retention.15 They promote the elimination of sodium and water by
the kidneys. Loop diuretics (e.g., furosemide) are the most
widely used diuretics for heart failure.18 Thiazide diuretics (e.g.,
hydrochlorothiazide) are weaker diuretics than loop diuretics,
although they may be used in combination with loop diuretics.
Adverse effects of loop and thiazide diuretics include the loss of
excessive amounts of potassium, weakness, muscle cramps,
joint pain, and impotence.16 The potassium-sparing diuretic
spironolactone acts as an aldosterone antagonist, which can be
beneficial in patients with moderate to severe heart failure.18
However, it can cause gynecomastia (breast pain) and
hyperkalemia.
Angiotensin-Converting Enzyme Inhibitors. ACE inhibitors
are recommended for patients with left ventricular dysfunction
(unless the patient has hyperkalemia, symptomatic hypotension,
a history of adverse reactions to ACE inhibitors, or another
contraindication to the use of ACE inhibitors).15 ACE inhibitors
reduce the conversion of angiotensin I to angiotensin II.
Angiotensin II is a vasoconstrictor that increases sympathetic
nervous activity and causes aldosterone release, which in turn
promotes sodium and water retention by the kidneys. ACE
inhibitors also may diminish local production of angiotensin II,
which is thought to contribute to ventricular hypertrophy and
dilatation in patients with heart failure.22 ACE inhibitors reduce
mortality from heart failure, delay the progression of the disease,
improve functional status, and decrease the need for
hospitalization.23,24 These agents also are recommended for
asymptomatic patients with moderately or severely impaired left-
ventricular systolic function (e.g., to prevent heart failure from
developing after a myocardial infarction).15 The use of ACE
inhibitors reduces the risk of heart failure in these patients.25
ACE inhibitors also are recommended for patients at high risk of
developing heart failure (e.g., patients with a history of
atherosclerotic vascular disease, diabetes mellitus, or
hypertension and associated cardiovascular risk factors).15
Agents that have been shown to reduce mortality in patients with
heart failure (e.g., captopril, enalapril, lisinopril, quinapril,
ramipril, trandolapril) are preferred over those without a
documented survival benefit.18 Cough is a common adverse
effect from ACE inhibitor therapy.16 Angiotensin receptor
blockers may be an alternative for patients who are unable to
tolerate ACE inhibitors.
Beta-Blockers. In the past, clinicians were advised to use
beta-blockers with care in patients with heart failure because of
the negative inotropic effect of these drugs.19 However, the use
of beta-blockers for asymptomatic and symptomatic heart failure
is now widely accepted because chronic sympathetic activation
is thought to play an important role in heart failure.15,18 Beta-
blockers have been shown to slow the progression of heart
failure and reduce hospitalization and mortality, possibly by
blocking sympathetic stimulation.26,27 Beta-blockers with intrinsic
sympathomimetic activity (e.g., acebutolol, pindolol) should be
avoided. Reductions in mortality have been demonstrated with
bisoprolol, carvedilol, and metoprolol.18 Small beta-blocker
dosages should be used initially, and dosages should be
increased gradually to avoid aggravating heart failure.18
Digoxin. Digoxin is recommended (in conjunction with an
ACE inhibitor and diuretic) for patients with symptomatic heart
failure.15 It is particularly useful for patients with certain
arrhythmias.18 Digoxin has a positive inotropic effect (i.e., it
increases the force of contraction) and increases cardiac output.
It also has antiarrhythmic activity and beneficial effects on
nervous and hormonal mechanisms that contribute to heart
Disease Management for Hear Failure
failure. Digoxin reduces symptoms, improves physical function
and quality of life, and decreases the rate of hospitalization in
patients with heart failure, although it does not appear to affect
mortality.28 Adverse effects from digoxin include arrhythmias,
anorexia, nausea, vomiting, diarrhea, confusion, vision
disturbances, fatigue, and dizziness.16,18
Nitrates and Hydralazine. Nitrates (e.g., isosorbide dinitrate)
and hydralazine are vasodilators that may be used in patients
who are unable to take ACE inhibitors because of
contraindications or adverse effects.18 Nitrates and hydralazine
relax vascular smooth muscle and often are used in
combination.18 They reduce mortality from heart failure, although
to a lesser extent than ACE inhibitors.29 Headache is a common
adverse effect from these agents.
[9]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure
Humana Congestive Heart Failure program cuts costs,
admissions.
Anon.
Healthcare Benchmarks. 1998;5:173-175.
The effects of a disease management program on hospital admis-
sions, hospital days, inpatient costs, and emergency department
visits were studied in nearly 5000 members of the Humana Inc.
health plan diagnosed with congestive heart failure (CHF). The pro-
gram, offered by a private Illinois-based company (Cardiac
Solutions), began with a home visit from a contracted home health
agency to assess the patient’s physical and psychosocial status,
diet, and medication compliance. Patients then received a simple
workbook that taught them how to manage the disease.
Experienced cardiac nurses reviewed the material with patients
individually by telephone using a script. The nurses also worked to
establish a relationship with each patient, using frequent phone
calls and postcards. Protocols for the program were based on
guidelines from the Agency for Health Care Policy and Research
(now the Agency for Healthcare Research and Quality) and the
American Heart Association. The nurses also followed protocols on
laboratory, medication, lifestyle, and symptom management, and
reported urgent patient problems or discrepancies between guide-
lines and treatments to attending physicians for clarification about
treatment. The content of all nurse-patient and nurse-physician
encounters was shared with physicians and patients.
In a 2-year study of the program’s effectiveness, the Humana Inc.
health plan observed a 58% drop in hospital admissions for all
diagnoses and a 61% reduction in inpatient health care costs over
a 2-year period. Hospital admissions decreased from 7,795 in
1995 to 3,309 in the period between 1996 and 1998. The number
of hospital days for CHF patients participating in the program
decreased by 58%, and emergency department visits decreased
by 49%. Health plan administrators concluded that the efficiency of
telephone contacts and the personal touch of as-needed home vis-
its improves care for CHF patients.
DM programs take different roads to CHF success.
Anon.
Disease Management for for Hear Failure
Healthcare Demand & Disease Management. 2000 Jun;6(6):80-85.
[Also reported in Clinical Resource Management. 2001 Feb;2(2):20-25.]
A controlled study of a telephone case management system in
which nurses provided congestive heart failure patients with educa-
tion about the disease, symptoms, importance of measuring body
weight daily, medications, and other aspects of disease manage-
ment is described. The nurses had specialized training in cardiac
care. Phone calls to patients were made weekly for 4 weeks,
biweekly for another 4 weeks, and monthly thereafter. Scales were
provided to patients who had none so that they could weigh them-
selves daily. The control group received usual care.
[10]
After 6 months of the program, the New York Heart Association
functional class and quality of life improved in a significant number
of patients in the intervention group (i.e., patients enrolled in the
telephone case management system). The annualized hospitaliza-
tion rate and costs decreased by 49% and 64%, respectively, in
the 6-month period after program enrollment compared with the 6-
month period before enrollment (the reductions in rate and costs
were 32% and 36%, respectively, for the control group).
Emergency department visits increased by 10% in the control
group and did not change in the intervention group. Total costs
decreased by 68% and 44% in the intervention group and the con-
trol group, respectively, after program enrollment.
Solid outcomes show e-health and chronically ill senior pop-
ulations are compatible.
Anon.
Disease Management Advisor. 2001 Jul;7(7):103-106.
A 1-year randomized, controlled pilot study comparing the cardiac
costs and rate and length of hospitalization associated with a com-
puter-based disease management program, interactive voice
response (IVR), and usual care in 69 elderly patients with moderate
to severe congestive heart failure (CHF) is described. Patients in the
computer group and the IVR group were taught to measure their
own blood pressure using a blood pressure cuff, as well as meas-
uring their pulse and their weight. These vital signs and various
symptoms of worsening CHF were reported to a nurse via the
Internet for the computer group or telephone for the IVR group
(using voice response or the telephone key pad). In-home assis-
tance with computer set up was provided for the computer group.
There were 20 hospitalizations for a total of 149 days in the com-
puter group and 39 hospitalizations for 258 days in the IVR group
over a 1-year period. Hospitalization data were not reported for the
usual care (control) group. Cardiac costs per patient per month
decreased by $247 in the computer group and $265 in the IVR
group and increased by $135 in the usual care group.
Web-based educational effort for CHF patients boosts out-
comes while cutting costs.
Anon.
Disease Management Advisor. 2001 Jun;7(6):92-96.
A computerized disease management program for 159 patients
with congestive heart failure (CHF) is described. Computer software
was developed to automatically sort Blue Cross/Blue Shield claims
data by International Classification of Diseases, 9th Revision codes
and utilization and pharmacy data using an algorithm. The software
also stratified patients by risk (to facilitate prioritization by the pro-
gram coordinator) and generated letters to all patients inviting them
to enroll in the disease management program. Patients completed
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
questionnaires that assessed education level, readiness to change,
and medical history; the forms were automatically read by comput-
er and a plan of action was generated. Physicians completed ques-
tionnaires about patients’ medications, medical history, contraindi-
cations, heart failure classification, target weight, and adherence to
medications and diet. Program coordinators used this information
and the action plan to conduct telephone counseling sessions with
patients 1 to 3 times per month. Patient education was provided in
these sessions to improve patients’ self-management skills.
Additional information was available on the Internet (on the program
Web site and through links to Web sites with good information).
Patients were advised to contact their physician if medical prob-
lems arose. Physicians received feedback about specific patients
and data for their patients as a group (e.g., rates of flu vaccination,
angiotensin-converting enzyme [ACE] inhibitor use).
After 18 months, 93% of participants reported improved disease
knowledge, 56% reported improved functional status, and 96%
were satisfied with the program. ACE inhibitor use increased by
more than 20% to 65%. Overall costs decreased by about 35%
due to decreases in emergency department use, hospital admis-
sions, and hospital length of stay.
[see also the summary for Hinkle AJ. Disease management: a
“smart” way to interact with patients. Health Management
Technology. 2000;21:38.]
DM programs take different roads to CHF success.
Anon.
Clinical Resource Management. 2001 Feb;2(2):20-25. [Also report-
ed in Healthcare Demand & Disease Management. 2000
Jun;6(6):80-85.]
The impact of a disease management program on angiotensin-
converting enzyme (ACE) inhibitor and beta-blocker use, use of tar-
get dosages of these medications, clinic visit rate, hospitalization
rate and length of stay, and costs for 117 patients with congestive
heart failure (CHF) at Duke University Medical Center is described.
The disease management program involved planning before hospi-
tal discharge, periodic follow-up and emergent care at a CHF clinic,
telephone follow-up, and patient education about medications, diet,
and what to do if symptoms of worsening CHF develop. The CHF
team comprised attending physicians, nurse practitioners, a nurse
specialist, a pharmacist, a social worker, and a nutritionist. The
pharmacist ensured that drug therapy was appropriate and the risk
of adverse drug reactions was minimized. Patients hospitalized for
CHF within the previous 6 months with New York Heart Association
functional class III or IV and an ejection fraction less than 20% (i.e.,
severe illness) were included.
The use of ACE inhibitors did not change after implementation of
the program, probably because most patients were receiving them
before program implementation. However, the percentage of
patients receiving the target dosage increased from 74% before
program implementation to 97% after implementation. The percent-
age of patients receiving beta-blockers increased from 52% at
baseline to 76% after program implementation, and the percentage
of patients receiving the target dosage increased from 24% to 40%
during that period. The average rate of hospitalization decreased
from 1.86 times per patient per year at baseline to 1.21 times per
patient per year after program implementation, and the average
length of stay decreased from 7.67 days to 6.07 days during that
period. The rate of clinic visits increased from 7.8 visits per patient
year to 12.9 visits per patient year. The outpatient costs increased
by 27%, and the inpatient costs decreased by 38%. The total cost
of care decreased by $1.1 million for the 117 patients, which is a
37% decrease.
Sacramento hospital boosts outcomes by focusing on high-
risk CHF patients.
Anon.
Data Strategies & Benchmarks. 2001 May;5(5):68-70.
A software program called Health Hero was implemented in a hos-
pital-based disease management program for patients with con-
gestive heart failure (CHF). Patients responded at home to prepro-
grammed questions about general health, diet, and medications
and transmitted their responses through an electronic appliance to
a nurse case manager. The program compiled a report for the
nurse case manager in which patients with potential problems are
“flagged.” Health Hero also provided patient education and
reminders to patients about diet and self-monitoring activities (e.g.,
measuring body weight).
The monthly cost of the Health Hero program was about $30 to
$60 per patient, but this cost was offset by savings in nursing time.
The use of Health Hero did not affect hospitalizations or visits to
the emergency department for CHF, but it reduced all-cause hospi-
talizations and emergency department visits by 23%. The total
number of bed days for all causes was reduced by about 50%.
The annual savings in direct costs for all causes amounted to
$1,266 per patient.
Disease Management for Heart Failure
CHF managers make the case for home-monitoring technol-
ogy.
Anon.
Disease Management Advisor. 2002 Oct;8(10):156-158, 145.
The usefulness of a home health-monitoring device was evaluated
in a 3-month pilot program involving 10 patients with congestive
heart failure (CHF). The device was programmed to measure
weight, blood pressure, heart rate, oxygen saturation, and temper-
ature on a daily basis at a convenient time selected by the patient.
[11]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
A recorded voice was used to cue patients to take the measure-
ments. The device had the capability to ask up to 10 questions.
Data were transmitted by pager or modem to a central location for
review by a nurse practitioner, who contacted the physician if
changes in drug therapy were needed.
The patient compliance rate with daily measurements was 97% on
average. Hospitalizations and emergency department visits were
eliminated during the 3-month pilot study. Patients experienced sig-
nificant improvements in how they felt and in their understanding of
the disease process.
Most insurance plans did not pay for the device. Arranging for visit-
ing nurses to install the device in patient homes and teach patients
to use the device properly is a strategy that was used because
insurance plans cover visiting nurse services.
Individualized care in patients with chronic congestive heart
failure.
Bertel O, Conen D.
Journal of Cardiovascular Pharmacology. 1987;2:S68–S72.
The impact of a comprehensive treatment program for congestive
heart failure (CHF) was evaluated in a nonrandomized, observation-
al study of 25 patients with similar degrees of disease despite ther-
apy. Program enrollees consisted of 25 consecutive patients
referred to this university-based hospital in Switzerland because of
severe CHF that was refractory to treatment.
The program focused on three issues: (1) individualized medical
therapy for CHF, (2) antiarrhythmic treatment and close follow-up
visits, and (3) continuing education of patients and physicians to
improve treatment compliance and facilitate the early management
of complications. Medical treatment was based on diuretic and
vasodilator therapy in all the patients, while positive inotropic sub-
stances were selectively administered. Patient education related to
the problems and complications of CHF. Education also addressed
necessary lifestyle adjustments (e.g., physical activity, reduction in
salt intake), and patients were asked to keep a diary of daily body
weight measurements, drug intake, and symptoms. All patients
Disease Management for for Hear Failure
were followed at short intervals of 1 to 2 weeks, independent of
their symptoms. However, daily visits were scheduled if symptoms
increased. To minimize unnecessary changes in the treatment regi-
men, patients were consistently evaluated by the same physician.
The outcomes of patients in the special-care program (intervention
patients) were compared with those of 21 consecutive patients
described in a previous study. Patients in the control group were
also referred to the institution for severe CHF refractory to treat-
ment, but were treated prior to development of the CHF program.
After evaluation, patients in the control group were sent back to
their family physicians, with a detailed letter containing treatment
[12]
recommendations. They were then followed only by telephone calls
from their treating physicians.
Reported outcomes for this study consisted of survival rates,
results of medical treatment for CHF, and results of medical treat-
ment for arrhythmias. The 1-year survival of all intervention-group
patients was 92%, which was significantly higher than the 1-year
survival rate in the control group of only 43%. In addition, the 2-
year survival rate for the intervention group was 83%, which report-
edly compares favorably with previously reported survival rates.
All patients received intensive diuretic and vasodilator therapy as
medical treatment of CHF. Vasodilator treatment was started with
prazosin in 22 patients and angiotensin-converting enzyme (ACE)
inhibitors in 3 patients. However, 55% of the patients on prazosin
had to be changed over to ACE inhibitors because of fading clinical
efficacy. Digoxin was used effectively in 8 of the 25 patients to con-
trol heart rates and/or arrhythmias. These 8 patients remained in
sinus rhythm after digoxin was withdrawn. Amiodarone was used
as the first-line drug to treat two patients with symptomatic ventric-
ular tachycardia and two survivors of ventricular fibrillation. Six of
the 11 patients treated for ventricular arrhythmias remained free of
symptoms from malignant ventricular arrhythmias.
Effect of a pharmacist-led intervention on diuretic compli-
ance in heart failure patients: a randomized controlled study.
Bouvy ML, Heerdink ER, Urquhart J, et al.
Journal of Cardiac Failure. 2003 Oct;9(5):404-411.
The effect of a pharmacist-led intervention on mediation compli-
ance was evaluated in a randomized controlled trial involving 7 hos-
pitals, 79 pharmacists, and 152 patients with congestive heart fail-
ure (CHF) that was treated with loop diuretics. Patients were ran-
domized to the intervention or a control group that received usual
care. The intervention involved an interview by the pharmacist in
which the patient medication history and reasons for noncompli-
ance were discussed. The pharmacist contacted the patient after-
wards on a monthly basis for up to 6 months. Compliance with the
prescribed loop diuretic was assessed in both groups by using a
container with a microchip that recorded the time and date of
opening.
Medication compliance during the 6-month study was greater in
the intervention group than in the control group. The intervention
group had 140 days without loop diuretic use out of 7,556 days,
and the control group had 337 days without loop diuretic use out
of 6,196 days. There were two consecutive days of loop diuretic
nonuse on 18 days out of 7,656 days in the intervention group and
46 days out of 6,196 days in the control group. There were no sig-
nificant differences between the two groups in rehospitalization,
mortality, or quality of life.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Cost/utility ratio in chronic heart failure: comparison
between heart failure management program delivered by
day-hospital and usual care.
Capomolla S, Febo O, Ceresa M, et al.
Journal of the American College of Cardiology. 2002;40:1259-
1266.
The effectiveness of a heart failure (HF) management program
delivered by a day hospital was compared with usual care in 234
chronic HF outpatients in a 12-month randomized controlled trial.
Patients were randomized to the intervention or usual care. The
intervention involved creation of a plan of care by a day hospital-
based multidisciplinary team comprising a cardiologist, nurses,
physiotherapists, dietitian, psychologist, and social assistant.
Cardiovascular risk stratification and tailoring of therapy according
to evidence-based criteria were performed, and health care educa-
tion and counseling were provided to the intervention group.
After 12 months, significantly fewer patients in the intervention
group had died than patients in the usual-care group. The hospital
readmission rate was significantly lower in the intervention group
(14%) than in the usual-care group (86%). In the intervention group,
New York Heart Association (NYHA) functional class was improved
in 23% of patients and it had worsened in 11% of patients, a differ-
ence that is significant. However, in the usual-care group, NYHA
functional class was improved in 13% of patients and it had wors-
ened in 16% of patients, a difference that is not significant.
The intervention was cost-effective, with a cost of $19,462 for each
quality-adjusted life-year saved. The cost/utility ratios for the inter-
vention and usual- care groups were similar ($2,244 for the inter-
vention group and $2,409 for the usual-care group). There was a
cost savings of $1,068 for each quality-adjusted life-year gained by
using the intervention instead of usual care.
Assessing the efficacy of a clinical pathway in the manage-
ment of older patients hospitalized with congestive heart
failure.
Cardozo L, Aherns S.
Journal of Healthcare Quality. 1999;21:12-16.
Hospital length of stay (LOS), cost of care, mortality, readmission
statistics, and performance rates of processes of care were evalu-
ated in a 12-month randomized retrospective study of 95 elderly
patients with congestive heart failure (CHF) who were managed
according to a clinical pathway. These data were compared with
those from a historical cohort of 200 patients who had been treat-
ed for CHF in a traditional manner. Study participants consisted of
patients who had been admitted to a tertiary-care teaching hospital
in metropolitan Detroit for management of CHF. These patients
were randomly admitted to medical wards, including two wards
participating in the pathway for the study’s duration. The CHF path-
way had been developed as part of a quality enhancement and
clinical resource management project designed to enhance care in
the elderly and improve resource management. Health care
providers were instructed to follow the clinical pathway, and a clini-
cal nurse manager monitored all processes of care. Any variances
in processes of care were reported to the attending physician for
corrective action. The control group consisted of patients who had
been hospitalized for CHF the year preceding the study, prior to
pathway implementation. Randomization was achieved in the con-
trol population by retrieving every third chart from a computerized
discharge log of patients with a primary diagnosis of CHF.
All patients were older than 65 years of age, and there were no sta-
tistically significant differences between groups in terms of sex or
New York Heart Association functional classification. Analysis of
outcome data revealed a significant reduction in LOS, from 6.36
days for the prepathway group (controls) to 5.25 days for the path-
way group. This reduction in LOS was accompanied by a signifi-
cant reduction in variable cost of $776 per patient. The mortality
rate during hospitalization remained unchanged at 3.5%. However,
the rate of readmission (at 31 days) showed a significant increase,
from 9.25% in the prepathway group to 13.5% for the pathway
group. Significant improvements were noted in performance of
three of the six processes of care evaluated (early discharge plan-
ning, patient education, and early patient mobilization); lesser
improvements were documented for the three remaining processes
(heparin prescription, recording of daily weights, use of echocardio-
graphy). The authors concluded that the lower costs of care in the
pathway patients compared with the prepathway patients reflected
the shorter LOS. The significant increase in hospital readmissions
observed in the pathway patients was considered “a matter for
concern” and is currently being investigated. Potential reasons for a
higher admission rate include sicker patients, comorbid illnesses,
premature discharges, and inadequate discharge plans.
Development of a heart failure center: a medical center and
cardiology practice join forces to improve care and reduce
costs.
Chapman DB, Torpy J.
American Journal of Managed Care. 1997;3:431-437.
Disease Management for Heart Failure
The effectiveness of The Heart Failure Center’s comprehensive out-
patient program in reducing hospital admissions, number of hospi-
tal days, and average length of stay was evaluated in 67 patients
with congestive heart failure (CHF). The Omaha-based Heart
Institute’s Heart Failure Center represented a partnership between a
private-practice cardiology group and a tertiary-care medical cen-
ter. Its program for CHF patients emphasized continuity of care and
patient education. Patients were assigned to a clinician group that
provided education and treatment using internally generated proto-
cols and standardized clinic visit forms. These protocols were
based on both the 1994 Cardiology Preeminence Report on CHF
[13]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
and a 2-day Cardiology Roundtable meeting. A medical director
physician helped to implement the program (and protocols) by
meeting with all department personnel and educating all staff mem-
bers. A registered nurse, with experience in treating CHF, was the
identified program coordinator.
Patient education was provided by a multidisciplinary team (nurse,
physician, pharmacist, dietician, nurse program coordinator). It
addressed a variety of issues (pathophysiology, appropriate diet,
medication compliance, weight loss). Patient education began with
a formal one-on-one curriculum prior to hospital discharge and
continued at later outpatient visits. Other elements of the program
included outpatient infusions of inotropic agents (to help reduce
hospital readmissions), electronic linkages between the clinic and
the emergency department (to reduce unnecessary clinic patient
admissions), and home health care visits by nurses. The latter were
intended to detect signs of clinical decompensation between clinic
visits. The nurses also saw the patients regularly at the clinic to
reinforce the need for adherence to medications, diet, and office
visits.
The 67 patients in this study were followed for a minimum of 1 year
before enrollment in the program and 16 months after enrollment.
The mean age of the patients was 64.7 years, and 50% had
advanced heart failure (New York Heart Association functional class
III or class IV). Comparison of pre- and post-enrollment data
revealed that hospital admissions dropped 30%, from 38 before
program enrollment to 27 after implementation. In addition, the
number of hospital days decreased by 42% from 202 to 118, and
the average length of stay decreased from 5.3 days to 4.4 days (a
decrease of 17%). The investigators also noted that a year of fre-
quent visits to the center costs less than one hospital admission.
Each year, the average patient was seen 15 to 20 times at the clin-
ic for an average cost of $2,000; the average cost of a hospitaliza-
tion was about $9,000. The authors concluded that an effective
heart failure outpatient program can reduce the economic burden
of CHF and improve the quality of patient care.
Congestive heart failure clinical outcomes study in a private
community medical group.
Disease Management for for Hear Failure
Civitarese LA, DeGregorio N.
Journal of the American Board of Family Practice. 1999;12:467-
472.
A 21-month, prospective study was conducted to assess whether
congestive heart failure (CHF) clinical practice guidelines, imple-
mented with a continuous quality improvement program, would
optimize use of angiotensin-converting enzyme (ACE) inhibitors
and, thus, decrease hospital admissions for systolic CHF. The
recipients of the program included 10 family practitioners and 10
internists at an independent medical group. The patients consisted
of all 275 patients admitted to the group’s primary community-
[14]
based hospital during the study with a confirmed discharge diagno-
sis of CHF.
The group physicians developed CHF guidelines by reviewing the
literature and guidelines from other hospital systems and health
plans. The new guidelines were presented to the group’s physi-
cians at a formal continuing medical education session at the
study’s outset. Physicians were provided an opportunity to modify
the guidelines, and each physician endorsed the final version. The
guidelines, available for reference at office and hospital sites, were
then reinforced at monthly quality improvement meetings. Other
points emphasized at each meeting included (1) assessment of left
ventricular function to optimize treatment, (2) appropriate use of
ACE inhibitors in patients with systolic CHF, and (3) instruction of
patients to obtain daily weights and contact the physician to report
a weight gain. Standardized inpatient orders were also developed
to parallel the guidelines, and physicians reviewed their own per-
formance data at quarterly meetings.
Rates of classifying systolic and diastolic dysfunction remained
unchanged during the study, and documentation of patient dis-
charge instructions was suboptimal. However, use of ACE inhibitor
therapy substantially improved for patients with systolic dysfunc-
tion. Pharmacy utilization data from Aetna U.S. Healthcare showed
a 39% increase in ACE inhibitor use by patients cared for by partic-
ipating physicians. By the study’s end, 100% of these patients had
been prescribed ACE inhibitors or had documentation that they
met exclusion criteria for such therapy. There was also a 49%
reduction in quarterly admissions for CHF due to systolic dysfunc-
tion during the study; patient admissions for diastolic dysfunction
remained stable. Associated economic effects were not addressed.
Thus, use of disease management guidelines, ongoing physician
education, and review of performance data significantly reduce
quarterly admissions for systolic dysfunction-based CHF and opti-
mized the use of ACE inhibitors.
Cost effective management programme for heart failure
reduces hospitalisation.
Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR.
Heart. 1998;80:442-446.
A 1-year prospective, randomized trial evaluated the effects of a
heart failure (HF) management program on outcomes in 190
patients with HF. Patients age 65-84 years who were hospitalized
at a Swedish university hospital for HF were eligible to participate.
Patients were randomly assigned to the intervention or control
group. Control patients received standard care at the university car-
diology department’s outpatient clinic following discharge.
Intervention-group patients underwent an educational program
managed by registered nurses followed by treatment at a HF clinic.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
The intervention began with two 30-minute hospital visits by a
nurse, followed by a 1-hour informational visit for patients and fami-
lies 2 weeks after discharge. Information about the pathophysiology
and treatment of HF was presented, with emphasis on compliance
with medications. Patients next received guidelines for the self-
management of diuretic therapy based on symptoms and signs of
worsening HF and were asked to record such data in a diary.
Finally, patients were followed at an easy-access, nurse-directed
outpatient clinic, in which patients could call or be seen on short
notice. Patients were also offered outpatient visits with doctors at 1
and 4 months after discharge and at the study nurse’s discretion.
Clinical assessment followed a protocol, but no guidelines for evalu-
ation or treatment specific to the study were used. Data on hospital-
ization and outpatient visits were obtained from hospital records and
questionnaires. All patients were followed for 1 year, and final results
were obtained from 135 surviving patients. The 1-year survival rate
did not differ significantly between groups. However, the mean num-
ber of days until readmission was significantly longer in the interven-
tion group (141) than in the control group (106), and the number of
days spent in the hospital by the intervention group tended to be
fewer than those spent by the control group (4.2 vs. 8.2, respective-
ly). There was also a trend toward fewer patients being hospitalized
in the intervention group than in the control group, with a similar
number of outpatient visits in the two groups. The mean cost of the
intervention per patient was $208. Costs for doctors’ outpatient vis-
its tended to be $55 less per patient in the intervention group com-
pared with the control group. In addition, the mean cost per patient
for hospital readmission tended to be lower in the intervention group
($1,628 vs. $3,081), which contributed to a mean annual reduction
in overall costs of $1,300 per patient.
Impact of a guideline-based disease management team on
outcomes of hospitalized patients with congestive heart fail-
ure.
Costantini O, Huck K, Carlson MD, et al.
Archives of Internal Medicine. 2001;161:177-182.
The impact of daily use of new guideline-based recommendations
for treating congestive heart failure (CHF) by a care management
team (a nurse care manager, faculty cardiologist, and physician
representative from the part-time faculty) at a large university-based
medical center was assessed. All participating patients were hospi-
tal inpatients. Care-managed patients were compared with non-
care-managed patients who were not followed by the team and
with baseline patients (i.e., patients hospitalized before implementa-
tion of the new care management approach). National guidelines
were available during the baseline period, but care-managed
patients were monitored daily by the care management team and
recommendations consistent with the guidelines were made.
Clinical measures of quality of care (the use of angiotensin-convert-
ing enzyme inhibitors, documentation of assessment of left ventric-
ular function using echocardiography, and the consistent daily
measurement of body weight) were significantly improved and hos-
pital length of stay and costs were significantly reduced in care-
managed patients compared with non-care-managed patients and
baseline. The median hospital length of stay was 3 days with care
management and 5 days without care management. Care manage-
ment was associated with a $2,204 reduction in hospital costs.
The relationship between hospital readmissions of Medicare
beneficiaries with chronic illnesses and home care nursing
interventions.
Dennis LI, Blue CL, Stahl SM, Benge ME, Shaw CJ.
Home Healthcare Nurse. 1996;14:303-309.
A 12-month retrospective audit of the charts of 62 Medicare
patients with a diagnosis of congestive heart failure (CHF) or chron-
ic obstructive pulmonary disease (COPD) was conducted to evalu-
ate the relationship between various home health care nursing
interventions and hospital readmissions. Criteria for patient selec-
tion included those who were (1) admitted with a primary diagnosis
of CHF or COPD of given severity, (2) under the care of a visiting
home health care nurse within a 1-year interval, (3) Medicare bene-
ficiaries, and (4) receiving services provided by an agency that had
Medicare reimbursement.
Interventions for patients with CHF consisted of assessment of vital
signs; lip, skin, and nail bed color; presence of edema; presence of
chest pain; specific signs/symptoms of CHF; activity tolerance; and
weight measurement. Patient educational interventions included the
signs/symptoms of CHF, prevention of an exacerbation, compo-
nents of a low-sodium diet, medication actions/side effects, and use
of medications. Interventions (assessment and teaching) specific to
COPD were also carried out. A home health care nurse document-
ed each intervention, and the total number of hospital readmissions
was determined in a “convenience” sample of 42 patients.
Interventions were selected from agency nursing care plans and
Medicare regulations appropriate for patients with CHF or COPD.
Fifty-seven percent of the patients (n=24) had CHF versus 43%
(n=18) with COPD. Sixty-four percent of the patients were never
Disease Management for Heart Failure
readmitted to a hospital during the study. Of those who were read-
mitted once (n=15), 20% were readmitted twice and another 29%,
three times. No patients were readmitted more than three times
during the interval studied. As the number of home health care
nursing visits increased, hospital readmissions decreased. Hospital
readmissions also decreased as the total number of assessment
interventions implemented increased. Interventions most strongly
related to readmission rates were assessment of lungs, cough, and
respiratory rate. The teaching interventions were more weakly relat-
ed to the hospitalization rate and were only implemented 29% of
the time.
[15]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Outcomes of an integrated telehealth network demonstra-
tion project.
Dimmick SL, Burgiss SG, Robbins S, Black D, Jarnagin B, Anders
M.
Telemedicine Journal and E-Health. 2003 Spring;9(1):13-23.
A disease management program for congestive heart failure (CHF)
was implemented for residents of a Tennessee county using an
integrated telehealth/telemedicine network with home videoconfer-
encing, telephone conversations, and remote monitoring of blood
pressure, blood oxygen saturation, and pulse. The number of pro-
gram participants varied over time because of deaths and
dropouts.
Weight control (a measure of medication and dietary compliance)
was achieved by more than 50% of patients after program imple-
mentation. Sleep problems (a measure of mood) improved,
although feelings of fatigue, depression, and loss of appetite
increased.
Only 14% of patients were hospitalized in the first 6 months after
program implementation. The hospitalization rate decreased from
1.7 times per patient per year to 0.6 times per patient per year as a
result of program implementation. The hospital length of stay
decreased from a national benchmark of 6.2 days to 4 days.
The cost per patient per year for the program included $2,353 for
nursing labor and $833 for equipment. A reduction in annual costs
for hospital care for CHF from $8 billion to $4.2 billion was project-
ed on a national basis.
Heart failure disease management: impact on hospital care,
length of stay, and reimbursement.
Discher CL, Klein D, Pierce L, Levine AB, Levine TB.
Congestive Heart Failure. 2003 Mar-Apr;9(2):77-83.
A congestive heart failure (CHF) disease management program was
developed for use in an inpatient setting. The program involved a
treatment algorithm/clinical pathway for the time from hospital
admission to discharge and inservice education programs for
Disease Management for for Hear Failure
physicians, nurses, and other health care professionals. Patients
were assigned to a managed group unless the physician objected
or cognitive impairment or inadequate living conditions interfered
with patient participation. Of 593 patients enrolled in the study, 396
patients were assigned to the managed group and 197 patients
were assigned to an unmanaged group. The latter group did not
participate in the program.
Documentation of left ventricular ejection fraction improved signifi-
cantly in the first quarter and throughout the first year after program
implementation in the managed group but not in the unmanaged
group. Documentation of angiotensin converting-enzyme (ACE)
[16]
inhibitor use (or intolerance) increased significantly in both groups in
the first quarter after program implementation, but the improvement
was greater in the managed group than in the unmanaged group
and further improvement in subsequent quarters was observed
only in the managed group.
The average hospital length of stay in the managed group
decreased significantly from 6.1 days before program implementa-
tion to 3.9 days after implementation. There was no significant
change in average length of stay over the course of the study in the
unmanaged group. The average cost per patient after program
implementation was lower for managed patients ($4,404) than
unmanaged patients ($6,828), despite intensified involvement of
nursing staff. Nurse satisfaction was high.
Randomized, controlled trial of integrated heart failure man-
agement: The Auckland Heart Failure Management Study.
Doughty RN, Wright SP, Pearl A, et al.
European Heart Journal. 2002;23:139-146.
The impact of an integrated heart failure (HF) management program
on mortality, hospital readmissions, and quality of life was evaluated
in 197 patients hospitalized with HF. General practitioners were ran-
domized to the intervention group or a control group so that all of
the patients treated by that practitioner were assigned to the same
group as a cluster. The intervention involved clinical review at a
hospital-based clinic shortly after hospital discharge, individual and
group education sessions, a personal diary to record medication
administration and body weight measurements, information book-
lets, and regular clinical follow-up alternating between the general
practitioner and clinic. The control group received usual care.
There was no significant difference between the two groups in the
number of patients who died or were readmitted to the hospital
during 12 months of follow up (68 patients in the intervention group
and 61 patients in the control group). The number of first readmis-
sions for HF and the number of hospital bed days for first readmis-
sions were similar for the two groups. However, fewer subsequent
readmissions for HF and fewer bed days during subsequent read-
missions were associated with the intervention compared with the
control group.
Quality of life was markedly impaired at baseline in both groups.
There was a significantly greater improvement in the physical-func-
tioning component of quality of life in the intervention group than in
the control group.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Effects of an exercise adherence intervention on outcomes
in patients with heart failure.
Duncan K, Pozehl B.
Rehabilitation Nursing. 2003 Jul-Aug;28(4):117-122.
The effectiveness of an intervention designed to facilitate patient
adherence to an exercise regimen was tested in 16 patients with
heart failure (HF). Patients were randomized to the intervention or
an exercise-only (i.e., control) group. Both groups participated in a
12-week supervised exercise program (phase 1), which was fol-
lowed by 12 weeks of unsupervised home exercise (phase 2).
Goals were established for exercise frequency and duration for
both groups. The adherence facilitation intervention involved the
provision of graphic feedback about exercise frequency and dura-
tion, positive feedback when goals were achieved, and help with
problem solving when goals were not achieved. Physiologic out-
comes that were assessed include maximum oxygen consumption
(a measure of exercise capacity), baseline dyspnea index (a meas-
ure of breathlessness), and level of fatigue. Functional status was
evaluated using a 6-minute walk test. A validated questionnaire
was used to assess quality of life.
In phase 1, there was no significant difference between the two
groups in adherence (i.e., the number of exercise sessions com-
pleted). Improvement in all physiologic outcomes and functional
status but not in quality of life was observed in phase 1 in the inter-
vention group. In the control group, improvement was observed
only in functional status and level of fatigue in phase 1. In phase 2,
quality of life and symptoms of dyspnea and fatigue improved and
maximum oxygen consumption decreased in the intervention
group, although all outcomes were better than at baseline at the
end of phase 2. In the control group, maximum oxygen consump-
tion, functional capacity, and qualify of life were worse and dyspnea
and fatigue were improved at the end of phase 2 compared with
baseline. Adherence during phase 2 was significantly higher in the
intervention group than in the control group. Thus, the patient
adherence intervention has the potential to improve physiologic,
functional, and quality of life outcomes in patients with HF.
Impact of a comprehensive heart failure management pro-
gram on hospital readmission and functional status of
patients with advanced heart failure.
Fonarow GC, Stevenson LW, Walden JA, et al.
Journal of the American College of Cardiology. 1997;30:725-732.
The impact of a comprehensive heart failure (HF) management pro-
gram on hospital admissions and functional status was assessed in
214 patients with HF in a nonrandomized observational study
spanning 3 years. Subjects included patients referred to the
Ahmanson-UCLA Cardiomyopathy Center as potential candidates
for heart transplantation who met study inclusion criteria (i.e., can-
didates for transplantation with no contraindications; discharged,
but not “too well”). All patients were initially hospitalized for formal
transplant evaluation, which included invasive testing, medication
evaluation, and a review of all medical records. Intensive medical
therapy was then initiated (or systematically adjusted) to control HF
symptoms, optimize hemodynamics, and address concomitant
conditions (e.g., angina, arrhythmias). Comprehensive patient edu-
cation was also provided to patients and their families in accor-
dance with Heart Failure Practice Guidelines. This included a review
of diet, lifestyle factors, and exercise, as well as symptoms and
signs of worsening HF and complications. This information was
conveyed by a HF clinical nurse specialist and was reinforced with
patient brochures. After discharge, patients were followed by HF
cardiologists in conjunction with referring physicians. This follow-up
included weekly visits to the HF center until the patient was clinical-
ly stable, followed by telephone calls and clinic visits at various
intervals. At each visit, medications were adjusted and patient edu-
cation was reinforced.
Reassessment 6 months after the intervention revealed improved
New York Heart Association functional classification and exercise
tolerance (i.e., improved functional status). Hospitalization rates
were significantly lower, with only 63 admissions for HF during the
6 months following the program compared with 429 admissions
during the 6 months prior to the program (i.e., an 85% reduction).
Ninety-two percent of the patients required hospitalization prior to
the program, compared with 26% after the program. Qualitatively
similar results were obtained when the analysis was confined to the
179 patients who completed 6 months of follow-up without death
or transplantation. For the entire group, the cost of hospital read-
mission after the program was estimated at $578,000 compared
with $3,937,000 prior to the program. After considering the cost of
the initial hospitalization for management and cost of the nurse
specialist’s services during follow-up (estimated at $200 to $400
per patient), the net savings was estimated at about $9,800 per
patient.
Reduction in heart failure events by the addition of a clinical
pharmacist to the heart failure management team: results of
the Pharmacist in Heart Failure Assessment
Recommendation and Monitoring (PHARM) Study.
Gattis WA, Hasselblad V, Whellan DJ, O’Connor CM.
Disease Management for Heart Failure
Archives of Internal Medicine. 1999;159:1939-1945.
The effect of involving a clinical pharmacist in the management of
outpatients with heart failure (HF) was evaluated in a controlled
study. Of 1,568 patients with HF evaluated at a Duke University
cardiology faculty clinic, 181 patients satisfied the enrollment crite-
ria (e.g., presence of signs and symptoms of HF, an ejection frac-
tion less than 45%) and agreed to participate. These patients were
randomized to an intervention (n = 90) or control (n = 91) group. All
patients answered questions about current drug treatment to
assess the regimen, compliance, and any adverse effects.
[17]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Patients in the intervention group underwent evaluation by a clinical
pharmacist, including medication review, therapeutic recommenda-
tions to the attending physician, patient education, and follow-up
telemonitoring. Therapeutic recommendations included increasing
use of angiotensin-converting enzyme (ACE) inhibitors, raising ACE
inhibitor dosages to target levels, and using alternative vasodilators in
ACE-intolerant patients, in accordance with published results from
clinical research. Patient education consisted of detailed information
about the purpose of each drug, importance of adherence to the
prescribed regimen, directions for use, and potential adverse effects.
Patients were encouraged to ask questions and were given the phar-
macist’s telephone number for future contact. The pharmacist also
provided telephone follow-up 2, 12, and 24 weeks after the initial
clinic visit to identify problems, answer questions, and evaluate HF
clinical events (i.e., emergency department visits, hospitalizations for
HF). Pharmacists communicated information to physicians and
referred patients for evaluation when appropriate. Control subjects
received standard care and were assessed and educated by physi-
cians, physician assistants, and/or nurse practitioners. Pharmacists
contacted patients in the control group at 12 and 24 weeks to identi-
fy HF clinical events but provided no recommendations or education.
The median follow-up interval was 6 months. All-cause mortality
and HF events (emergency department visits, hospitalizations) were
significantly lower in the intervention group compared with the con-
trol group (4 events vs. 16 events). At the 6-month follow-up,
patients in the intervention group were also significantly closer to
the target ACE inhibitor dosage, with higher rates of use of other
vasodilators in ACE inhibitor–intolerant patients (75% vs. 26%). No
economic effects were assessed. The authors concluded that
including a clinical pharmacist in the management of HF patients
improved outcomes, possibly because of increased use of ACE
inhibitors and closer follow-up care.
Disease management hits home.
Gilbert JA.
Health Data Management. 1998;6:54-56, 58-60.
Crozer-Keystone Health System, a Springfield, Pennsylvania–based
integrated delivery system, developed a disease management pro-
Disease Management for for Hear Failure
gram for patients with congestive heart failure (CHF). This program,
called Heart Success, was a multidisciplinary program designed to
monitor patients after hospital visits and provide them with educa-
tion and support to keep them as healthy and independent as pos-
sible. Central to the Heart Success program was a personal com-
puter-based, automated patient follow-up system, which made
automatic telephone calls to certain patients to determine their
condition. The system was designed to ask a series of customized
questions when the patient answers the telephone. Patients used
the keypad of their touch-tone telephone to respond to the ques-
tions. The patient also had the option of speaking with a nurse after
answering the last question.
[18]
In 1996, Crozer-Keystone compared hospital readmission rates for
an unspecified number of patients enrolled in the Heart Success
program with readmission rates among patients receiving traditional
home care follow-up. Results of this 9-week pilot study showed
that 76% of the patients receiving home care (home visits by nurs-
es) were readmitted to the hospital within 3 to 4 weeks after dis-
charge. In contrast, only 18% of the patients enrolled in the Heart
Success program were readmitted after 9 weeks of monitoring.
The program director concluded that telemanagement is effective
because it keeps patients in contact with clinicians long after dis-
charge and it also provides a cost-effective way of identifying the
20% of patients who require additional attention.
Does encouraging good compliance improve patients’ clini-
cal condition in heart failure?
Goodyer LI, Miskelly F, Milligan P.
British Journal of Clinical Practice. 1995;49:173-176.
A prospective, randomized controlled trial was conducted to evalu-
ate whether improving medication compliance in elderly patients
with chronic stable heart failure (HF) would influence objective and
subjective measures of HF severity. Patients (age >70 years) at a
London clinic who (1) had a diagnosis of chronic stable HF, (2)
supervised their own medication use, (3) required no medication
changes, and (4) met no physical or mental exclusion criteria were
invited to participate. Fifty elderly patients were randomly assigned
to a 3-month, intensive medication counseling program carried out
by a pharmacist. Instruction about the correct use of medications
proceeded according to a standard written protocol using verbal
communication, medication calendars, and informational
brochures. Another 50 patients constituted a no-counseling (i.e.,
control) group.
Tablet counts and patient questionnaires were completed at the
beginning and end of the study to assess knowledge and compli-
ance. Other measures recorded at the beginning and end of the
study included results on a submaximal 6-minute exercise test,
visual analogue scores of breathlessness, Nottingham Health Profile
scores, and clinical signs of HF. Use of clinical practice guidelines
was not specified.
Baseline measures were similar in the two groups. Compliance
improved significantly (by 32%) in the counseled group but
remained unchanged for the control group. Medication knowledge
improved only for the counseled patients. Results for the 6-minute
exercise test improved by 20 meters for the counseled group but
worsened by 22 meters for the control patients. Distance to breath-
lessness also improved for the counseled patients and worsened
for patients in the control group. In contrast, body weights, jugular
venous pressures, and Nottingham Health Profile scores did not
change significantly for either group. Peripheral and pulmonary
edema scores improved for the counseled group only, along with a
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
small improvement in the visual analogue scores. Associated eco-
nomic effects were not assessed.
The authors concluded that improved compliance attributed to
intensive medication counseling had a small, but measurable, ben-
eficial effect on objective measures of HF. However, the small
nature of this benefit relative to the level of improved compliance
led them to doubt whether improved compliance produces a clini-
cally relevant benefit in older patients with HF.
A disease management program for heart failure: collabora-
tion between a home care agency and a care management
organization.
Gorski LA, Johnson K.
Lippincott’s Case Management. 2003 Nov-Dec;8(6):265-273.
The impact of a disease management program developed through
a collaborative arrangement between a home health care agency
and a care management organization on outcomes was assessed
in 51 patients with heart failure (HF). A nurse employed by the care
management organization coordinated the program, which empha-
sized patient self-management skills (e.g., daily weight measure-
ments, medication management, diet, physical activity, depression
and stress management, regular medical follow-up, and notification
of the physician of changes in condition). The program involved
patient education (e.g., regular telephone calls, mailings) and coor-
dination and promotion of interdisciplinary patient care using com-
munity resources, newsletters, and referrals to a home health care
program.
There was a 35% decrease in the hospitalization rate from 22.6 per
1,000 enrollees to 14.6 per 1,000 enrollees within 9 months after
implementation of the program. Assuming a hospitalization cost of
$5,000, a cost savings of $165,000 from the reduced hospitaliza-
tion of patients participating in the program was projected.
Daily weight measurement was assessed as an outcome repre-
senting self-care behavior. The percentage of patients performing
daily weight measurements increased significantly from less than
10% before program implementation to more than 60% after imple-
mentation. Patient satisfaction was good, very good, or excellent.
Effect of a heart failure program on hospitalization frequency
and exercise tolerance.
Hanumanthu S, Butler J, Chomsky D, Davis S, Wilson JR.
Circulation. 1997;96:2842-2848.
An observational, pre- and post-intervention comparison study
evaluated whether hospitalization rates and functional outcomes
improve when patients with heart failure (HF) are managed by
physicians with special HF expertise, working within a dedicated
HF program. All 187 patients with HF who were referred to the
Vanderbilt Heart Failure and Heart Transplantation Program
between July 1994 and June 1995 were identified. Most (n = 138)
were referred as outpatients, and some (n = 49) were transferred
from other hospitals. The mean patient age was 52 years and the
mean ejection fraction was 26%.
The program consisted of long-term follow-up by three physicians
who work exclusively with HF and heart transplantation patients.
Two nurse coordinators assisted with patient management during
hospitalizations and outpatient care; home health care agencies
were involved in the care of 10% of patients. All patients underwent
echocardiographic evaluation as well as cardiopulmonary exercise
testing, when possible. These tests were performed by program
staff at a nearby outpatient laboratory. Exercise testing was repeat-
ed 3 to 6 months after enrollment to monitor status. A subgroup of
patients also completed the 21-question Minnesota Living with
Heart Failure Questionnaire, which assessed emotional and physi-
cal impairment due to HF. Patient information and outcomes were
maintained in a computerized database, and periodic meetings
were held at the Vanderbilt Home Health Agency and local hospice
care programs to integrate care.
The program was evaluated by comparing annual hospitalization
rates, peak exercise capacity, and medication use before and after
referral among patients followed for more than 30 days. Of the 187
patients referred to the program, 134 (72%) were followed for at
least 30 days. During the year prior to referral, 94% of the patients
had been hospitalized (210 cardiovascular hospitalizations) versus
44% during the year after referral (104 hospitalizations), which is a
53% reduction. Hospitalizations for HF decreased from 164 to 60
for all patients (regardless of follow-up duration) and decreased
from 97 to 30 (a 69% reduction) for patients followed for at least 1
Disease Management for Heart Failure
year after referral. Survival was 83% after the 1-year follow up.
Composite scores on the Minnesota Living with Heart Failure
Questionnaire improved. The authors concluded that patients with
HF have fewer HF-related hospitalizations and significantly better
function when managed by HF specialists working in a dedicated
HF program versus physicians with limited expertise in managing
HF.
[19]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Quality of life of individuals with heart failure: a randomized
trial of the effectiveness of two models of hospital-to-home
transition.
Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, Graham
ID.
Medical Care. 2002;40:271-282.
The impact of a transitional-care intervention designed to facilitate
the transition from hospital to home for patients with congestive
heart failure (CHF) was assessed in a 12-week, randomized con-
trolled trial. The impact of transitional care on health-related quality
of life and rates of hospital readmission and emergency department
use was compared with that of usual care in patients hospitalized
for CHF in one of two large urban teaching hospitals in Canada.
The transitional-care intervention involved telephone outreach within
24 hours after hospital discharge and consultations between hospi-
tal nurses and home care nurses. Patient education and supportive
care for self-management were provided. Patients in both groups
were visited by community nurses twice in the first 2 weeks after
discharge.
After 12 weeks, health-related quality of life was significantly better
in the transitional-care group than in the usual-care group. The
hospital readmission rate was 23% in the transitional-care group
and 31% in the usual-care group, a difference that is not signifi-
cant. The number of emergency department visits was significantly
lower in the transitional-care group than in the usual-care group
(29% vs. 46%).
Effect of a home monitoring system on hospitalization and
resource use for patients with heart failure.
Heidenreich PA, Ruggerio CM, Massie BM.
American Heart Journal. 1999;138:633-640.
The effect of a low-intensity monitoring program on outcomes,
including hospitalizations and cost of care, were assessed in 68
patients with heart failure (HF) in this nonrandomized, matched-
control study. Eligible patients were identified from a claims data-
base and included those with symptomatic HF who were cared for
by one of 31 community physicians within a multidisciplinary med-
Disease Management for for Hear Failure
ical group.
The intervention consisted of patient education, daily self-monitor-
ing, and physician notification of abnormal weight gain, vital signs,
and symptoms. Each patient received weekly educational mailings
describing 52 topics related to HF. These materials were based on
Agency for Health Care Policy and Research (now the Agency for
Healthcare Research and Quality) guidelines for patients with HF
and were reinforced during weekly telephone calls by a nurse.
Patients also received a digital scale and an automatic blood pres-
sure cuff, and were instructed in the use of these items. The
patients were then provided a toll-free number to use daily in trans-
[20]
mitting blood pressure, pulse, weight, and symptom data to a
computer. If data fell outside an established normal range, a nurse
followed up with the patient and faxed the information to the physi-
cian. Patients could also contact the physician directly with any
health concern.
The patients were followed for a mean of 7.4 months. During this
interval, there were 294 physician notifications of abnormal signs or
symptoms in 53 patients; approximately 1 in 8 notifications resulted
in a change in the patient’s medical regimen. The average compli-
ance with call-ins by patients was 85%. Quality-of-life measures did
not change significantly over the course of the study. To further
assess the impact of the intervention, average claims per year
before the intervention were compared with claims per year during
the intervention. In addition, claims by intervention-group patients
were compared with those of a matched control group (n = 86
patients) to control for technological improvements or disease pro-
gression. Compared with the previous year, medical claims per year
decreased in the intervention group ($8,500 to $7,400) but
increased in the control group ($9,200 to $18,800). Similarly, hospi-
tal days per year significantly decreased from 8.6 to 4.8 in interven-
tion patients, while increasing from 8.9 to 17 in control patients.
The number of admissions per year did not differ significantly
between the two groups. The program’s effectiveness was unrelat-
ed to age, sex, or type of left ventricular dysfunction. The average
cost of the program was estimated at $200 per patient per month.
Considering this cost, the cost of care per year for intervention
patients was $9,800 vs. $18,800 for control patients.
Prospective evaluation of an outpatient heart failure man-
agement program.
Hershberger RE, Ni H, Nauman DJ, et al.
Journal of Cardiac Failure. 2001;7:64-74.
The effects of a heart failure outpatient management program on
clinical and cost outcomes of care were assessed in 108 patients
with chronic, symptomatic CHF. The 6-month period before referral
to the program was compared with the 6-month period after refer-
ral. The program involved the use of current practice guidelines for
treating CHF, frequent telephone contact between nurses and
patients, pre-emptive hospitalization (hospitalization for impending
decompensation based on clinical assessment), patient educational
needs assessment, and patient counseling, which were provided
by a team of cardiologists, specially trained and experienced nurs-
es, and a social worker.
Patients’ self-care knowledge (e.g., the warning signs of heart fail-
ure progression, the importance of daily body weight measurement
and dietary salt intake restriction) and the percentage of patients
weighing themselves daily increased significantly after participation
in the program, although patient adherence to the prescribed med-
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
ications and diet did not change (adherence at baseline was good).
The severity of illness (New York Heart Association functional class)
and need for emergency department visits and hospitalization for
cardiovascular causes decreased significantly, and quality of life
improved significantly. The hospitalization rate decreased from 56%
before referral to the program to 27% after participation in the pro-
gram. The corresponding before and after figures for emergency
department use were 54% and 15%, respectively. The average
estimated cost savings associated with reduced hospitalization was
$4,307 per patient.
Disease management: a “smart” way to interact with
patients.
Hinkle AJ.
Health Management Technology. 2000;Apr. 21(4):38.
Blue Cross and Blue Shield of New Hampshire used an Internet-
based disease management program for patients with congestive
heart failure (CHF) identified electronically through claims data. The
Web-based program was designed to assess patients’ willingness
to change, educate patients about CHF, and promote positive
behavioral change.
Enrollment in the program increased 125% over a 4-month period.
Frustration with CHF decreased in more than 90% of patients, and
knowledge of the disease increased in more than 82% of patients.
Quality of life improved in at least half of patients.
[See the summary of Anon. Web-based educational effort for CHF
patients boosts outcomes while cutting costs. Disease
Management Advisor. 2001 Jun;7(6):92-96.]
A randomized trial of telenursing to reduce hospitalization
for heart failure: patient-centered outcomes and nursing
indicators.
Jerant AF, Azari R, Martinez C, Nesbitt TS.
Home Health Care Services Quarterly. 2003;22(1):1-20.
The impact on hospital readmission charges and emergency
department visits of two types of telenursing—(1) home telecare
with real-time video interactions between patients and health care
providers and (2) telephone calls—was compared with usual care
after hospitalization over a 180-day period in 37 patients with con-
gestive heart failure (CHF). In-person visits were made by nurses to
patient homes shortly after hospital discharge and about 60 days
later for all treatment groups. Nurses made recommendations to
primary care providers for changes in therapy as appropriate.
Patient self-care teaching by nurses addressed the disease
process, daily weight monitoring, sodium restriction, smoking ces-
sation, moderation in alcohol intake, weight loss (for obese
patients), aerobic exercise, and medication use and adherence.
CHF-related readmission charges were more than 80% lower in the
telenursing groups (i.e., home telecare group and telephone group)
compared with the usual-care group. The number of emergency
department visits was significantly lower with telenursing than with
usual care.
A randomized trial of the efficacy of multidisciplinary care in
heart failure outpatients at high risk of hospital readmission.
Kasper EK, Gerstenblith G, Hefter G, et al.
Journal of the American College of Cardiology. 2002;39:471-480.
A randomized controlled trial was conducted to compare the
effects of an outpatient management program and usual care on
hospital readmissions and mortality over a 6-month period in 200
patients hospitalized with congestive heart failure (CHF) who were
at increased risk for readmission. Patients were judged at increased
risk for readmission because of age greater than 70 years, left ven-
tricular ejection fraction less than 35%, at least one additional CHF-
related hospital admission in the previous year, ischemic cardiomy-
opathy, peripheral edema at the time of hospital discharge, a
weight loss of less than 3 kg while in the hospital, peripheral vascu-
lar disease, or a low cardiac index or high systolic or diastolic blood
pressure or pulmonary capillary wedge pressure.
The intervention was provided by a multidisciplinary team compris-
ing a cardiologist, CHF nurse, telephone nurse coordinator, and the
patient’s primary physician. The intervention involved periodic fol-
low-up telephone calls by the telephone nurse coordinator; devel-
opment of an individualized treatment plan; patient visits with the
CHF nurse, who followed a treatment algorithm for adjusting med-
ications; and provision of a scale, low-sodium meals, telephone,
and transportation if needed by the patient. Patients receiving usual
care served as controls.
There were significantly fewer hospital readmissions and deaths in
the intervention group (43 readmissions and 7 deaths) than in the
usual-care group (59 readmissions and 13 deaths) during the 6-
month study. At the end of the study, patients were less sympto-
matic and quality of life had improved to a greater extent in the
intervention group compared with the control group.
Disease Management for Heart Failure
There was no significant difference between the intervention group
and the control group in inpatient or outpatient resource use. The
cost per patient was similar with the intervention and usual care.
[21]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Implementing a congestive heart failure disease manage-
ment program to decrease length of stay and cost.
Knox D, Mischke L.
Journal of Cardiovascular Nursing. 1999;14:55-74.
Beginning in 1995, Evanston Northwestern Healthcare (ENH) creat-
ed a multidisciplinary disease management program for congestive
heart failure (CHF) designed to decrease length of stay (LOS),
reduce costs, prevent readmissions, and improve compliance with
treatment. ENH is an integrated delivery system consisting of two
teaching hospitals affiliated with Northwestern University. It has
about 800 admissions for CHF per year.
The program consisted of an integrated program of inpatient con-
sultation and education, patient visits to an outpatient clinic, car-
diac home care, and monitoring of compliance through an auto-
mated telemanagement program. The inpatient component con-
sisted of a 5-day LOS pathway created by members of a multidis-
ciplinary treatment team. This clinical pathway is based on the
Agency for Health Care Policy and Research (now the Agency for
Healthcare Research and Quality) heart failure guidelines and finan-
cial information from the institution. Informational inservice educa-
tional conferences were presented to hospital personnel caring for
CHF patients to ensure successful pathway implementation. The
physician leader of the treatment team also introduced the pathway
to attending physicians, and quarterly reports summarized clinical
and financial outcomes following implementation.
The core of the educational program embodied in the pathway was
individualized patient education. The goal of such education was to
explore reasons for treatment nonadherence, develop strategies for
effective disease management, and encourage health promotion
(i.e., allow patients to become “comanagers” of their disease).
Material was presented to the patients in written and audio form.
The outpatient clinic was designed to optimize medications and
stratify patients by risk to allow more frequent visits for noncompli-
ant and high-risk (end-stage CHF) patients. To reduce emergency
visits, cardiac home care was also available. Lastly, compliance
monitoring, via an automated telemanagement program (CHF Tel-
Assurance program), was used to reinforce education, identify early
warning signs, and reduce the likelihood of hospitalization. Patients
Disease Management for for Hear Failure
called in their daily weights and answered CHF-related questions.
They also received information about exercise and diet, their med-
ical regimen, and the next clinic appointment. Advanced practical
nurses monitored this system and communicated with patients and
physicians as appropriate.
Although this report does not define a specific population, it does
provide some general outcome data for patients participating in the
ENH CHF program. After 18 months, telemanagement participants’
compliance rate averaged 89.5%. Patient satisfaction surveys indi-
cated a high level of satisfaction with the CHF Tel-Assurance pro-
gram. CHF hospitalization rates with the program were 0.6 per
[22]
patient per year at ENH, compared with the national benchmark of
1.7 per patient per year. The 30-day readmission rate for patients
participating in the program was 2.3% (compared with 23% nation-
ally) and the LOS was 4 days (compared with a national average of
6.2 days).
Intensive home-care surveillance prevents hospitalization
and improves morbidity rates among elderly patients with
severe congestive heart failure.
Kornowski R, Zeeli D, Averbuch M, et al.
American Heart Journal. 1995;129:762-766.
A nonrandomized, pre- and post-intervention comparison study
evaluated the impact of intensive home care surveillance on mor-
bidity of elderly patients with severe congestive heart failure (ejec-
tion fraction less than 40%, New York Heart Association functional
class III or IV). Forty-two patients (mean age 78 years and ejection
fraction 27%) who had completed 1 year of home surveillance were
included in the study. All recruited patients had also been hospital-
ized at least once for cardiovascular complications during the year
preceding program enrollment. The outcomes of program partici-
pants at the 12-month follow-up were compared with medical data
for these same patients collected during the year prior to the inter-
vention.
The intervention consisted of weekly home visits by an internist
affiliated with the Tel Aviv Medical Center. The visits included a his-
tory and physical examination, review of medications, laboratory
studies and intravenous medications (as needed), and discussion
of treatment plans for the coming week (i.e., patient education and
planning). In addition, various therapies (e.g., physical therapy, oxy-
gen, extra home visits) were available, and paramedical staff pro-
vided extra patient support.
Evaluation at the end of the first year of home care surveillance
revealed a significant decrease in the mean total hospitalization
rate. The hospital length of stay also significantly decreased, and
similar reductions were seen in cardiovascular admissions. The abil-
ity of patients to perform daily activities (i.e., functional status) also
significantly improved, and drug therapy was modified at least once
in all 42 patients. The authors concluded that an intensive home
care program was associated with a marked decrease in the need
for hospitalization and improved functional status of elderly patients
with severe congestive heart failure. The authors suggested that
such a service might offer a cost-effective advantage and have a
major impact on health expenditures, although costs were not
assessed in the study.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Nonpharmacologic therapy improves functional and emo-
tional status in congestive heart failure.
Kostis JB, Rosen RC, Cosgrove NM, Shindler DM, Wilson AC.
Chest. 1994;106:996-1001.
A 12-week, parallel-design randomized controlled trial was con-
ducted to compare the effects of a multimodal nonpharmacologic
intervention with both digoxin and placebo in patients with conges-
tive heart failure (CHF) who were receiving background therapy with
an angiotensin-converting enzyme (ACE) inhibitor. Twenty patients
with New York Heart Association functional class II or III CHF and
an ejection fraction <40% treated at the University of Medicine and
Dentistry of New Jersey–Robert Wood Johnson Medical School
were randomized to one of three treatment groups: nonpharmaco-
logic treatment (n = 7), digoxin therapy (n = 7), or placebo (n = 6).
The 12-week nonpharmacologic treatment program included (1)
graduated exercise training (e.g., walking, cycling, rowing) three to
five times per week; (2) structured cognitive therapy and stress
management twice weekly for 60 to 90 minutes; and (3) weekly
dietary counseling and interventions aimed at salt reduction and
weight reduction in overweight individuals. All three aspects of the
program were provided in a group setting. Biomedical and behav-
ioral assessments were completed before and after the program.
The treatment with digoxin or matching placebo was initiated at a
starting dose of 0.125 mg, and the digoxin dosage was titrated to
achieve a blood level between 0.8 and 2.0 ng/mL. Placebo and
digoxin were both administered in a randomized, double-blind fash-
ion.
The authors concluded that nonpharmacologic therapy improved
functional capacity, body weight, and mood in patients with CHF. In
contrast, digoxin improved the ejection fraction without correspon-
ding changes in exercise tolerance or quality of life.
Randomized trial of an education and support intervention to
prevent readmission of patients with heart failure.
Krumholz HM, Amatruda J, Smith GL, et al.
Journal of the American College of Cardiology. 2002;39:83-89.
The impact of a targeted education and support intervention on the
rate of hospital readmission or death and hospital costs was
assessed in a 1-year, randomized controlled trial of 88 patients with
congestive heart failure (CHF) who were at least 50 years old.
Patients were randomized to an intervention group or a control
group. In the intervention group, patient knowledge of each of five
care domains for chronic illness (knowledge of the illness, relation-
ship between medications and the illness, relationship between
health behaviors and the illness, knowledge of early signs and
symptoms of decompensation, and where and when to obtain
assistance) was assessed to identify knowledge gaps. An experi-
enced cardiac nurse provided patient education. Telephone calls
were made to patients to reinforce the care domains.
Recommendations for changes in treatment were not part of the
telephone calls, although the nurse made recommendations to the
patient to contact his or her physician as needed if the health sta-
tus deteriorated. The control group received usual care.
The percentage of patients who died or were readmitted to the
hospital during the 1-year study was significantly lower in the inter-
vention group (57%) than in the control group (82%). The total
number of readmissions was 49 in the intervention group and 80 in
the control group, representing a significant 39% reduction.
The total estimated cost of the intervention was $530 per patient.
Average hospital readmission costs were significantly lower in the
intervention group ($14,420) than in the control group ($21,935).
The net cost savings associated with the intervention was $6,985
per patient after taking into consideration the cost of the interven-
tion.
Comparison of Health Buddy with traditional approaches to
heart failure management.
LaFramboise LM, Todero CM, Zimmerman L, Agrawal S.
Family & Community Health. 2003 Oct-Dec;26(4):275-288.
Four strategies for delivery of the education content of a heart fail-
ure (HF) disease management program were compared in a 2-
month pilot study of 90 patients discharged from the hospital with
a primary diagnosis of HF within the previous 6 months. Patients
were randomized to one of four strategies: (1) telephonic case
management, (2) five home visits for patient assessment and edu-
cation (i.e., home care), (3) assessment and education by using a
telehealth communication device (Health Buddy), and (4) a combi-
nation of home visits and the telehealth communication device.
The telehealth communication device had a screen that displayed
questions from the health care provider and allowed patients to
respond. It also provided patients with education according to a
script developed by the health care provider. Patient responses
were automatically transmitted electronically to the health care
provider for review. Follow-up phone calls were made to the patient
if his or her responses suggested an exacerbation of the disease.
Disease Management for Heart Failure
Twenty (30%) of 66 patients assigned to use the telehealth commu-
nication device were unable to use it because of poor health, tech-
nical problems (e.g., lack of electrical outlets or telephone service),
or poor eyesight.
Self-efficacy (i.e., level of confidence in making lifestyle and behav-
ioral changes related to HF management) worsened in the tele-
phonic case management group and improved in the other three
groups. There were no significant differences between the groups
in measures of functional status, mood, or quality of life. At the end
of the 2-month pilot study, functional status (i.e., performance in a
[23]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
6-minute walk test) had improved from baseline to a significant
extent in all four groups. More than half (52%) of patients improved
their walking distance by 10%, and 45% improve their walking dis-
tance by 20%.
At baseline, 29% of participants were depressed. Depression
improved from baseline in all four groups, although the improve-
ment from baseline was not significant. Quality of life improved sig-
nificantly from baseline in all four groups.
[See the summary of Todero CM, LaFramboise LM, Zimmerman
LM. Symptom status and quality-of-life outcomes of home-based
disease management program for heart failure patients. Outcomes
Management. 2002 Oct-Dec;6(4):161-168.]
Case management in a heterogeneous congestive heart fail-
ure population: a randomized controlled trial.
Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P.
Archives of Internal Medicine. 2003;163:809-817.
A randomized controlled trial was conducted to evaluate the effect
of a hospital-based nurse case management program on hospital
readmission rates in 287 patients with congestive heart failure
(CHF). Patients with a primary or secondary diagnosis of CHF and
a left ventricular ejection fraction less than 40% or radiologic evi-
dence of pulmonary edema requiring diuresis (i.e., a heterogeneous
patient population) were randomized to the intervention or a control
group that received usual care. The intervention consisted of early
discharge planning and coordination of care, individualized and
comprehensive patient and family education, 12 weeks of tele-
phone follow-up, and promotion of optimal CHF medications and
doses based on consensus guidelines. A care manager coordinat-
ed these services.
After 90 days there was no difference between the two groups in
the hospital readmission rate (37%). Patients in the intervention
group required fewer days of hospitalization than those in the con-
trol group (6.9 days vs. 9.5 days), but the difference was not signifi-
cant.
Disease Management for for Hear Failure
Patient adherence to the treatment plan was better in the interven-
tion group than in the control group for daily weight measurements,
checks for edema, and a low-salt diet, but both groups took med-
ications as prescribed equally well. Patient satisfaction was signifi-
cantly greater in the intervention group compared with the control
group.
The intervention reduced the total inpatient and outpatient median
cost and the readmission median cost by 14% and 26%, respec-
tively. The differences between the intervention group and control
group were not significant, although the differences might be signifi-
cant if the intervention was used for a larger number of patients.
[24]
The effect of a nurse-managed CHF clinic on patient read-
mission and length of stay.
Lasater M.
Home Healthcare Nurse. 1996;14:351-356.
A 1-year pre- and post-intervention comparison study was con-
ducted to examine the impact of a nurse-managed clinic on hospi-
tal readmission rates for exacerbation of congestive heart failure
(CHF) among 80 patients with CHF or cardiomyopathy managed at
home. Beginning in July 1993, all patients from the tricounty area
surrounding the South Carolina Medical Center with such a diagno-
sis were automatically enrolled in the clinic for care after hospital
discharge. The clinic program focused on precautions to reduce or
detect the signs and symptoms of CHF, including a complete car-
diopulmonary assessment, daily weights, and patient education
(medications, sodium-restricted diet). The expertise of physicians,
dieticians, and social workers was used in collaboration with pri-
mary management by registered nurses. Follow-up care was
scheduled at the nurse’s discretion, and critical-path algorithms
directed this care. Financial assistance was available to facilitate
care and the procurement of medication or supplies.
Prior to program implementation, the medical center observed a
25.6% readmission rate within 6 months among 39 patients with
CHF or cardiomyopathy. The average length of stay (LOS) was 7.3
days. Reanalysis of these measures in a comparable patient popu-
lation (n = 41) 6 months after program implementation showed a
significant drop in the readmission rate to 21.9%; the average LOS
had also significantly decreased to 5.7 days. Comparison of hospi-
talization charges preintervention ($6,898) and 1 year post-interven-
tion ($6,404) further revealed a decrease in charges of almost $500
per patient. The decreased costs were thought to represent
decreased severity of illness upon readmission. Improved patient
knowledge of medications was also observed after the intervention.
Assessment—patients, chronic heart failure, and home care.
Lazarre M, Ax S.
Caring. 1997;16:20-22, 24.
A study assessed the impact of a cardiac specialty program for
home care developed by a private home health care agency (TGC
Home Health Care Inc of Lakeland, FL) on outcomes in patients
with heart failure (HF). In this program, nurses with a critical-care
background provided targeted teaching to patients and families
about disease pathophysiology, risk factors, and management of
symptoms, diet, weight, and medications. Critical pathways were
used to ensure clarity and consistency of information provided.
Each patient was also assigned a cardiac nurse case manager who
planned and delivered care and monitored patients for signs and
symptoms of CHF exacerbation. Other members of the multidisci-
plinary treatment team included a home care aide, social worker,
and physical or occupational therapist. Several types of assess-
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
ment and therapy were available, including comprehensive car-
diopulmonary assessment, electrocardiographic monitoring, pulse
oximetry, intravenous diuretic administration, and inotropic support.
During the 7-month course of this study, 34 patients entered the
program. Study inclusion criteria included admission to home
health care with a primary or secondary diagnosis of HF and a
diagnosis of HF as either an acute exacerbation or new onset. Staff
measured hospital readmission rates in this population 30 and 90
days following enrollment and documented rates of 2.9% and
8.8%, respectively. These rates reflected 7 admissions among 6 of
the 34 patients. The rates were significantly lower than the national
average readmission rates of 16% (30 days) and 32% (90 days), as
reported by the Cardiology Pre-eminenece Roundtable. No attempt
was made to convert outcomes into potential savings. The authors
concluded that a home care program featuring targeted teaching,
close monitoring by cardiac-trained nurses, and early management
of HF exacerbations may reduce hospital readmissions and trans-
late into cost savings.
A study of the relationship between home care services and
hospital readmission of patients with congestive heart fail-
ure.
Martens KH, Mellor SD.
Home Healthcare Nurse. 1997;15:123-129.
A retrospective chart audit was conducted to (1) explore the rela-
tionship between home care nursing services and hospital readmis-
sion rates in patients with a primary diagnosis of congestive heart
failure (CHF) and (2) obtain descriptive information about home
health care nurse interventions provided to patients with CHF by a
specific hospital-based home care agency. The care provided to
patients with CHF was audited because a fiscal report identified
CHF as the most common admission diagnosis.
By using the hospital’s computerized medical records, all patients
with CHF discharged from the hospital to the home over a 1-year
interval were retrospectively identified and evaluated. Of the 1,176
CHF discharges during 1993 and 1994, 924 patients were dis-
charged to home with or without a referral for home care services.
Most discharges (79%) were to the home only, with only 247
patients referred to a home health agency. There were 219 read-
missions to the hospital within 12 months after discharge among
the 924 patients. This figure included admission of 162 patients
who were readmitted between one and six times. Patients receiving
home care services were readmitted to the hospital significantly
less often within 90 days after discharge than the patients not
receiving such services. This relationship approached significance
after 35 days, but no significant relationship was found 14 or 28
days after discharge. Length of stay for the patients readmitted
ranged from 1 to 56 days, with most staying 4-7 days.
Of the 247 discharged patients with referral to a home health care
agency, 120 (48%) patients were referred to the hospital-based
home care agency involved in the study. Most referrals involved
extended care, with an average of 10.74 registered nurse visits per
referral. Fifty-seven patients (48%) were readmitted to the hospital,
with 50 (42%) readmissions occurring within 3 months. A quality
assurance–focused review of care for all patients admitted to home
care with CHF for one quarter of the year (n = 32) revealed that 9
patients (28%) were readmitted to the hospital within 3 months. All
of these readmissions occurred within 26 days, leading the authors
to conclude that hospital readmission was related to the reason for
initial hospitalization.
To elicit possible variables related to hospital readmission, docu-
mentation of care provided to 31 members of a 32-patient sub-
group was analyzed. These data consisted of three categories of
information: areas of assessment (e.g., vital signs, heart and lung
sounds, weight, medication compliance), assessment of findings
(e.g., documentation of edema, weight gain, medical compliance),
and patient teaching (i.e., documentation of instructions to patients
about nutrition, medications, disease management). This focused
review indicated that many areas were always assessed, with the
exception of medication compliance. Most patients also received
instructions, but documentation suggested instructions were not
provided at each visit. Of the nine patients in this subgroup who
were readmitted, the vital signs of four (44%) were outside normal
limits; vital signs were also abnormal in seven (32%) of the 22 not
readmitted. The difference between groups was not significant.
Similarly, no significant difference was found between five patients
readmitted for evidence of fluid overload and 12 patients with fluid
overload who were not readmitted.
Outcomes for patients with congestive heart failure in a
nursing case management model.
Morrison RS, Beckworth V.
Nursing Case Management. 1998;3:108-114.
A retrospective chart review was conducted to evaluate outcomes
in patients with congestive heart failure (CHF) who received care
according to a hospital-based nursing care management model
developed at an acute-care hospital in the southeastern United
Disease Management for Heart Failure
States. The broad theoretical framework for this model was contin-
uous quality improvement (CQI). Multidisciplinary CQI teams were
established for specific case types, including CHF. A physician was
designated team champion, and a case manager was named team
facilitator. The function of each team was to identify the best prac-
tice, develop a critical pathway of care, and spearhead its approval
and implementation. Once a critical pathway was implemented, the
case manager assumed the role of consultant/auditor, including
taking responsibility for patients whose care did not follow the criti-
cal pathway. Patients whose care followed the pathway were typi-
cally managed by the nursing unit registered nurses. CHF was the
[25]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
diagnosis with the highest volume and costs at this institution, so
the critical pathway for CHF was developed first.
The retrospective chart review yielded data for 50 randomly select-
ed CHF patients who received care under the nursing care model
approximately 5 years after it was first introduced. Outcomes
assessed in these patients included length of stay (LOS), costs,
physiologic status, physical functioning, health knowledge, and
family caregiver status.
The mean LOS in 1996 was 5.4 days compared with about 17
days in similar patients hospitalized in 1991, before implementation
of the model. The mean fixed costs, variable costs, and total costs
for the 50 patients were estimated as $2,491, $1,858, and $4,291,
respectively. Whereas several significant correlations existed among
various outcome measures, the only predictor of LOS identified via
regression analysis was number of medications. Only 15 of 28
patients who met the criteria for use of angiotensin-converting
enzyme inhibitor therapy in Agency for Health Care Policy and
Research (now the Agency for Healthcare Research and Quality)
guidelines were taking the medication at the time of discharge from
the hospital. The authors concluded that further attention to com-
pliance with such guidelines is needed, along with collection of
more data about physiologic status during hospitalization, closer
evaluation of a patient’s health knowledge prior to discharge, and
revision and further testing of the data collection instrument.
Telemanagement of heart failure: a diuretic treatment algo-
rithm for advanced practice nurses.
Mueller TM, Vuckovic KM, Knox DA, Williams RE.
Heart Lung. 2002 Sep-Oct;31(5):340-347.
Telemanagement (i.e., telephone contact between patients and
health care providers) and a diuretic treatment algorithm with phar-
macologic and nonpharmacologic interventions were used in an
effort to prevent decompensation in 200 patients with heart failure
(HF). Advanced-practice nurses contacted patients by telephone to
identify problems and provide patient education, with the goal of
reducing morbidity, clinic visits, and hospitalization. The diuretic
treatment algorithm was based on evidence-based medicine and
Disease Management for for Hear Failure
was designed to provide consistent care while allowing for flexibility
in clinical judgment and implementation of an individualized plan of
care.
Patient compliance with the telephone calling program was high
(90%). The 30-day hospital readmission rate decreased from 2.3%
in 1997-1999 to 0.7% in 1999-2001. The hospitalization rate
decreased by 50%, and hospital costs for treating HF decreased
by 52% as a result of the intervention.
[26]
Emerging information management technologies and the
future of disease management.
Nobel JJ, Norman GK.
Disease Management. 2003 Winter;6(4):219-231.
The use of emerging information management technology involving
a remote biometric measuring and monitoring device in the home
setting was studied in patients with congestive heart failure (CHF).
Patient data (body weight and symptoms) were automatically trans-
mitted on a daily basis to a central call station that was monitored
by cardiac nurses who analyzed trends and notified the physician if
the data suggested a change in patient health status. Patients with
a deteriorating condition were called and encouraged to seek
same-day or emergency care. The device also allowed for interac-
tive communication between patients and nurses, which helped
patients adhere to the prescribed health regimen, including medica-
tions and weight management. The nurses assessed patient under-
standing of the disease, treatment, self-care skills, diet, and med-
ication compliance.
Two populations of health maintenance organization members (an
elderly one more than 65 years of age and a younger one 65 years
of age or younger) were compared before and 12 months after
installation and use of the device. Comparisons also were made
with control patients in each age group who did not participate in
the intervention. Data were obtained for 78,038 member-months
for the elderly group (including 66,297 member-months that served
as a control) and 7,477 member-months for the younger group
(including 6,408 member-months that served as a control).
In the elderly population, the bed days per thousand members per
year were reduced by 53% in the intervention group and by 0% in
the control group; costs paid per member per month decreased by
50% in the intervention group and by 0% in the control group. In
the younger group, the bed days per thousand members per year
were reduced by 62% in the intervention group and by 9% in the
control group; the costs paid per member per month were reduced
by 60% in the intervention group and by 9% in the control group.
Heart failure disease management in an indigent population.
O’Connell AM, Crawford MH, Abrams J.
American Heart Journal. 2001;141:254-258.
The effects of a multidisciplinary disease management program for
outpatients on functional status (New York Heart Association func-
tional class, which reflects severity of illness), hospitalization rate,
and costs were assessed in a nonrandomized study of indigent
patients admitted to a university hospital with heart failure. Group A
was comprised of 14 patients with a hospital readmission rate of at
least two times per year and an ejection fraction of 45% or less
who were not candidates for transplantation. Group B was com-
prised of 21 patients referred by their primary care provider or the
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
hospital team at the time of hospital discharge because of a high
likelihood of readmission due to financial, social, or nonadherence
issues. The ejection fraction was 45% or less in group B. Patients
enrolled in the multidisciplinary disease management program were
frequently monitored in an outpatient clinic, with weekly telephone
contact. Written information and individualized counseling about
symptoms, diet, exercise, and medications were provided to
patients. A medication consultation, with assessment for drug inter-
actions, patient education, and medication adjustment in accor-
dance with Agency for Health Care Policy and Research (now the
Agency for Healthcare Research and Quality) guidelines, was per-
formed by a cardiovascular pharmacist. Patients were referred as
needed to a dietitian, diabetes case manager, and cardiac rehabili-
tation team. The intervention was the same for patients in group A
and group B, but the two groups were analyzed separately
because of different characteristics (e.g., greater severity of illness
in group A). The 1-year period before program enrollment was
compared with the 1-year period after enrollment.
After 1 year, functional status improved significantly in both groups,
possibly as a result of improved medication use. The need for hos-
pitalization decreased from 33 and 9 admissions in group A and
group B, respectively, in the year before program enrollment to 3
and 0 admissions, respectively, in the year after enrollment. The
savings in hospital charges associated with the program for group
A and group B were $167,000 and $50,000, respectively. The net
savings when hospital and clinic charges were considered for both
groups combined amounted to $4,600 per patient.
Enhanced access to primary care for patients with conges-
tive heart failure: Veterans Affairs Cooperative Study Group
on Primary Care and Hospital Readmission.
Oddone EZ, Weinberger M, Giobbie-Hurder A, Landsman P,
Henderson W.
Effective Clinical Practice. 1999;2:201-209.
A multisite, randomized controlled trial evaluated whether enhanced
access to primary care affects the diagnostic evaluation, pharma-
cologic management, and health outcomes of patients hospitalized
with congestive heart failure (CHF). Eligible patients included veter-
ans hospitalized at one of nine Veterans Affairs medical centers
with a diagnosis of CHF, among other conditions. These patients
were randomly assigned to receive enhanced access to care (n =
222) or usual care (n = 221) and were followed for 6 months.
The intervention (enhanced care) was delivered by a primary care
physician/registered nurse team. Prior to discharge, the nurse edu-
cated each patient in obtaining daily weights and appropriate use
of diuretics. Educational materials from the American Heart
Association about living with heart failure also were reviewed. The
physician and nurse visited the patient to review medications,
establish a treatment plan, and provide contact information for fol-
low-up outpatient care. Following discharge, the nurse telephoned
the patient within 2 days to assess any problems and arranged fol-
low-up appointments with the nurse and doctor within 1 week. The
frequency of other visits and telephone calls was discretionary.
Control patients received the usual care offered at their facility,
which did not include access to a primary care nurse, supplemental
education, or needs assessment.
Of the 504 patients who entered the study, complete data were
available for 443 patients. About 80% of patients in both groups
underwent recommended evaluation of left ventricular ejection frac-
tion. Among patients for whom an angiotensin-converting enzyme
(ACE) inhibitor was recommended in accordance with Agency for
Health Care Policy and Research (now the Agency for Healthcare
Research and Quality) guidelines (i.e., those with an ejection frac-
tion <40%), three quarters in both the enhanced-access and usual-
care groups received the drug (75% and 73%, respectively).
Enhanced access to primary care did not improve quality of life
(assessed via survey). Patients with enhanced access to care aver-
aged 1.5 readmissions in 6 months of follow-up compared with 1.1
readmissions for patients who received usual care, a difference that
is significant. The authors concluded that compliance with recom-
mended CHF testing and treatment was equally high in both study
groups. They also observed that enhanced access to primary care
did not improve patients’ self-reported health status and was asso-
ciated with more frequent hospitalizations.
Impact of a nurse-managed heart failure clinic: a pilot study.
Paul S.
American Journal of Critical Care. 2000;9:140-146.
The clinical and economic effects of a nurse practitioner-managed,
multidisciplinary outpatient heart failure clinic were evaluated in a
12-month nonrandomized study in which patients served as their
own controls. The clinic was developed in 1995 at a southeastern
university hospital to enhance the follow-up and management of
patients with chronic congestive heart failure (CHF). After initial eval-
uation by a cardiologist at the clinic, patients and their families
received additional evaluation and education from a nurse practi-
tioner (about diet, exercise, body weight, and symptom manage-
ment) and clinical pharmacist (about medications). The nurse prac-
Disease Management for Heart Failure
titioner then followed a protocol to determine the frequency and
need for follow-up telephone calls and clinic visits. These calls and
visits were used to reinforce education, assess patient needs,
arrange tests, and adjust medication. At each clinic visit, the patient
saw the physician, the nurse practitioner, and a clinical pharmacist,
and had access to a dietitian and social worker as needed. The
clinic offered flexibility in allowing the nurse practitioner to see
patients on demand for evaluation and treatment that could reduce
the risk for hospital readmission.
[27]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
The “convenience” study sample consisted of 15 patients with CHF
who were referred to the clinic after admission to an affiliated univer-
sity hospital. Data were retrieved from a computerized medical
record system for the 6 months prior to and the 6 months following
clinic enrollment (i.e., patients served as their own controls). The
patients had a total of 38 hospital admissions (151 hospital days) in
the 6 months before joining the clinic compared with 19 admissions
(72 hospital days) in the 6 months afterward. These decreases in
total number of hospital admissions and hospital days were signifi-
cant. There were also nonsignificant decreases in mean length of
stay (4.3 days vs. 3.8 days) and the number of emergency depart-
ment visits (10 vs. 8). The mean inpatient hospital charges per
patient admission decreased from $10,624 to $5,893, and reim-
bursements were $7,751 (a 73% collection rate) and $5,138 (a 87%
collection rate), respectively. Mean charges for emergency depart-
ment visits decreased from $390 before clinic enrollment to $284
afterward. The authors concluded that participation in the heart fail-
ure clinic appeared beneficial and that early management of CHF
exacerbation may decrease readmissions and improve outcomes.
The results of a randomized trial of a quality improvement
intervention in the care of patients with heart failure.
Philbin EF, Rocco TA, Lindenmuth NW, Ulrich K, McCall M, Jenkins
PL. The MISCHF Study Investigators.
American Journal of Medicine. 2000;109:443-449.
The impact of a multifaceted quality improvement intervention on
quality of care, hospital length of stay and charges, in-hospital and
6-month mortality, hospital readmissions, and quality of life of
patients with heart failure was compared with that of usual care in a
randomized controlled trial. Ten acute-care community hospitals
were randomized to the intervention or usual care, and data were
collected for a 9-month baseline period and a 9-month period after
the intervention, including 6 months after hospital discharge for
each patient. The intervention comprised use of inpatient, emer-
gency department, and home care critical pathways, with diagnos-
tic tests and treatments based on published clinical trial results,
expert guidelines, and widely accepted practices. The emergency
department pathway emphasized rapid diagnosis and initiation of
treatment. Videotaped presentations to the hospital staff and
Disease Management for for Hear Failure
teaching aids for patients and families were used to improve staff
and patient knowledge. The intervention was managed by physi-
cians, nurse leaders, and administrators responsible for quality
management. Markers of quality of care included measurement of
left ventricular systolic function, documentation of the primary
cause of heart failure, proper dietary counseling, and prescribing of
angiotensin-converting enzyme inhibitors.
The changes from baseline in markers of quality of care were mixed
and not significantly different for the intervention compared with
usual care. Average hospital length of stay decreased from baseline
by 1.8 days in the intervention group and by 0.7 days in the control
[28]
group, a difference that is not significant. Hospital charges
decreased slightly in the intervention group and increased slightly in
the control group. The intervention produced small changes in mor-
tality, hospital readmission, and quality of life that were not signifi-
cantly different from those associated with usual care.
A community hospital-based congestive heart failure pro-
gram: impact on length of stay, admission and readmission
rates, and cost.
Rauh RA, Schwabauer NJ, Enger EL, Moran JF.
American Journal of Managed Care. 1999;5:37-43.
The impact of a multidisciplinary inpatient and outpatient conges-
tive heart failure (CHF) program was evaluated in a retrospective
analysis of patients hospitalized at a community-based hospital
with a primary diagnosis of CHF. The control group comprised 407
patients treated during the year prior to program initiation. The
intervention group consisted of 347 patients treated in the program
for 1 year. A subset of the intervention group (n = 81) received out-
patient inotropic therapy designed to address signs of CHF decom-
pensation and avoid the need for hospital readmission.
The program (intervention) used a multidisciplinary team approach
based on Agency for Health Care Policy and Research (now the
Agency for Healthcare Research and Quality) guidelines. Patients
were managed in accordance with inpatient and outpatient treat-
ment protocols established and implemented by team members. A
4-day inpatient heart failure clinical path addressed necessary con-
sultations/tests, treatment, diet, activity, patient education, and dis-
charge planning. Patients at high risk for decompensation upon
discharge were referred to an outpatient, hospital-based CHF clinic
for follow-up management, including the intermittent administration
of intravenous inotropes. Team members were educated about the
protocols, clinical paths, services for CHF patients, and patient
education materials at the individual and group level. Patients and
their families learned how to manage CHF via a nurse-directed
educational program focusing on diet, compliance, and symptom
recognition. After hospital discharge, patients received regular fol-
low-up telephone calls to address problems and encourage com-
pliance with the home CHF management regimen.
The primary endpoint for the analysis was length of stay (LOS) for
all CHF-related hospital admissions. Secondary endpoints were the
primary admission rate for CHF management, the readmission rate
within 90 days after discharge, and the per-case cost to the patient
and provider for all CHF admissions. Compared with the control
group, patients in the intervention group had a significantly reduced
LOS (5.7 days vs. 7.3 days), significantly fewer admissions for CHF
management (404 vs. 503), and a lower 90-day readmission rate
(13% vs. 18%). The mean cost per admission was $6,719 in the
control group and $5,601 in the program group, representing a
17% reduction in cost per admission. A 77% net reduction in non-
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
reimbursed (lost) hospital revenue ($718,468) was also noted after
program implementation. The cost of operating the outpatient heart
clinic was approximately $104,000, and revenue generated from
the program was about $211,000. Data regarding the effectiveness
of the outpatient inotropic therapy in avoiding readmission were not
included in the report.
Prevention of readmission in elderly patients with congestive
heart failure: results of a prospective, randomized pilot
study.
Rich MW, Vinson JM, Sperry JC, et al.
Journal of General Internal Medicine. 1993;8:585-590.
The impact of a nurse-directed, nonpharmacologic, multidiscipli-
nary intervention on hospital readmissions in elderly patients with
congestive heart failure (CHF) was evaluated in a prospective, ran-
domized controlled trial. Patients at least 70 years of age who were
admitted to a secondary and tertiary teaching hospital over a 1-
year interval were screened for CHF. Ninety-eight patients (mean
age 79 years) who were considered at moderate-to-high risk for
early hospital readmission were enrolled. The patients were strati-
fied by risk and randomly assigned to receive conventional physi-
cian-directed care supplemented by a nurse-directed multidiscipli-
nary team (n = 63) or conventional care by their usual physician (n
= 35).
The intervention consisted of (1) comprehensive education by an
experienced geriatric cardiovascular nurse, (2) a detailed medica-
tion review with specific recommendations designed to improve
compliance and reduce side effects, (3) social service consultations
to facilitate discharge planning and the transition back to home, (4)
individualized dietary teaching by a registered dietitian, and (5)
enhanced follow-up care through home care and telephone con-
tacts. The follow-up care consisted of regular home visits, in accor-
dance with federal home care guidelines, and nurse-initiated tele-
phone calls. Patients also received educational materials (including
a patient guide to CHF), charts, and medication cards to facilitate
appropriate dietary modification, medication compliance, and daily
self-monitoring of weight. Patients in the control group received
conventional care that could include social service evaluation,
dietary and medication teaching, and home care; but this care was
considered lower in intensity than the care provided to the interven-
tion group.
All patients were followed for 90 days after initial hospital discharge.
The primary endpoints were rehospitalization within 90 days and
the cumulative number of days hospitalized during follow-up. The
90-day readmission rate was 33% for the patients in the interven-
tion group compared with 46% for the patients in the control
group, a difference that is not significant. The mean number of hos-
pital days was not significantly different in the two groups; it was
4.3 for the intervention group versus 5.7 for the control group. In a
subgroup of 61 patients at intermediate risk for readmission, the
intervention reduced readmissions by 42% (from 48% to 28%), and
there was a trend toward reduction in the average number of hos-
pital days (a change from 6.7 days to 3.2 days). The authors con-
cluded that a comprehensive, multidisciplinary approach to reduc-
ing repetitive hospitalizations in elderly patients with CHF might lead
to a reduction in readmissions and hospital days, particularly in
patients at moderate risk for early rehospitalization. They felt that
further evaluation of this treatment strategy in a larger trial, includ-
ing an assessment of the cost-effectiveness, was warranted.
Extrapolation of these data to all CHF patients discharged after
short-stay hospitalization suggests a potential cost savings of
$262.5 million per year, although no cost data were analyzed in the
study.
A multidisciplinary intervention to prevent the readmission of
elderly patients with congestive heart failure.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE,
Carney RM.
New England Journal of Medicine. 1995;333:1190-1195.
The effects of a nurse-directed, multidisciplinary intervention on
rates of readmission, quality of life, and costs of care for high-risk
elderly patients with congestive heart failure (CHF) were evaluated
in a prospective, randomized controlled trial. Patients at least 70
years of age who were admitted to the Washington University
Medical Center because of CHF were eligible to participate if they
had at least one risk factor for early readmission. Of 282 eligible
patients, 142 were randomly assigned to an intervention group and
140 were assigned to a control group. The intervention consisted
of nurse-directed education about CHF for the patient and family,
individualized dietary assessment and instruction, social-service
consultation for discharge planning, medication review by a geri-
atric cardiologist, and intensive follow-up. The follow-up consisted
of home care services supplemented by individualized home visits
and telephone contact with members of the multidisciplinary treat-
ment team. The goal of this follow-up was to reinforce education,
ensure dietary and medication compliance, and identify CHF symp-
toms amenable to outpatient treatment. Patients in the control
group received standard treatment and services ordered by their
physicians.
Disease Management for Heart Failure
All patients were followed for 1 year, although the primary study
endpoint was readmission-free survival after 90 days. That status
was achieved in 91 patients (64%) in the intervention group com-
pared with 75 patients (55%) in the control group, a difference that
is not significant. However, when the analysis was limited to sur-
vivors of the first hospitalization, the difference between the two
groups was significant. There were significantly fewer readmissions
within 90 days for any reason in the intervention group (53 vs. 94
readmissions, which is a 44% reduction). Readmission for CHF
was less frequent in the intervention group (24 vs. 54 readmissions,
[29]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
which is a 56% reduction). The total hospital days per patient also
was reduced in the intervention group (3.9 vs. 6.2 days, which is a
37% reduction). The proportion of patients readmitted more than
once in the 90-day follow-up interval was also significantly less (6%
vs. 16%).
In a subgroup of 126 patients who completed the Chronic Heart
Failure Questionnaire, quality-of-life scores after 90 days were
improved from baseline to a significantly greater extent in patients
in the intervention group than in patients in the control group. The
average cost of the intervention was $216 per patient. Caregiver
costs and nonhospital costs did not differ significantly between the
two groups, although the cost of hospital readmission was signifi-
cantly higher in the control group ($3,236 vs. $2,178). The overall
cost of care was estimated to be $460 less per patient in the inter-
vention group because of the reduction in hospital admissions.
Effect of a multidisciplinary intervention on medication com-
pliance in elderly with congestive heart failure.
Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P.
American Journal of Medicine. 1996;101:270-276.
Medication compliance was evaluated in elderly patients with con-
gestive heart failure (CHF) to identify factors associated with
reduced compliance and to assess the effect of a multidisciplinary
treatment approach on medication adherence. Patients in this
prospective randomized controlled trial were a subset of patients at
least 70 years old enrolled in a previous trial conducted at the
Washington University Medical Center. The patients had been
admitted to the hospital with CHF and satisfied study entry criteria.
Prior to discharge, 156 eligible patients were randomly assigned to
the intervention (n = 80) or conventional care (n = 76).
The intervention began while the patients were still hospitalized.
Patient education about CHF management was provided using a
15-page teaching guide prepared by the study team. A study nurse
visited each patient daily to emphasize the importance of compli-
ance with medications and diet. Each patient also received dietary
instruction from a dietitian and discharge planning from a social
service representative. Shortly prior to discharge, a geriatric cardiol-
Disease Management for for Hear Failure
ogist made specific recommendations regarding each patient’s
medication regimen. Following discharge, patients were visited by
the hospital’s home care department and were contacted regularly
by the study nurse. Patients in the control group received conven-
tional medical care including standard hospital services (i.e., dietary
teaching, medication instructions).
Detailed data on all prescribed medications were collected at the
time of hospital discharge, and medication compliance was
assessed by pill counts performed at the patient’s home roughly 30
days later. The overall compliance rate during the first 30 days after
discharge was 85%. Compliance was 88% for patients in the inter-
[30]
vention group compared with 81% for patients in the control group,
a difference that is significant. Eighty-five percent of patients in the
intervention group achieved a compliance rate of 80% or greater
versus 70% of patients in the control group. The difference is signif-
icant. Multivariate analysis showed that assignment to the interven-
tion group was the strongest independent predictor of compliance,
although Caucasian race and not living alone were also predictive
of compliance.
Hospital readmission rates were determined for the first 90 days
following hospital discharge. During this interval, 22 control-group
patients (29%) and 18 intervention-group patients (23%) were read-
mitted to the hospital 31 and 22 times, respectively. Total days of
rehospitalization were 258 days for the control group and 188 days
for the intervention group. Thus, readmissions per patient were
reduced by 33% and hospital days were reduced by 31% in
patients randomized to the intervention group. Independent predic-
tors of readmission were low systolic blood pressure and high
blood urea nitrogen concentration. There was a trend toward fewer
readmissions in patients who were more than 90% compliant. The
authors concluded that such a multidisciplinary treatment strategy
appears to improve medication compliance in elderly CHF patients
and may improve outcomes.
Effect of a standardized nurse case-management telephone
intervention on resource use in patients with chronic heart
failure.
Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A.
Archives of Internal Medicine. 2002;162:705-712.
A randomized controlled trial was conducted to assess the effects
of a telephone congestive heart failure (CHF) case management
intervention on resource use. Physicians were randomized to an
intervention group or a usual-care control group so that the same
approach was used for all patients treated by a particular physician.
Patients were identified at the time of hospitalization and were fol-
lowed for 6 months after discharge from the hospital. The interven-
tion was based on a decision support software program designed
to emphasize factors known to predict hospitalization in patients
with CHF (i.e., patient nonadherence to medications and diet, lack
of knowledge of the signs and symptoms of worsening illness).
Printed education materials were mailed to patients in the interven-
tion group monthly. Physicians in the intervention group received
patient progress reports produced automatically by the software,
using data collected by telephone. Physicians also received phone
calls from case managers (registered nurses) about specific patient
concerns as needed. Care for patients in the usual-care group was
not standardized and presumably involved patient education before
hospital discharge.
After 6 months, the heart failure hospitalization rate in the interven-
tion group was 48% lower than that in the usual-care group. The
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
average number of hospital days for CHF was 46% lower and the
percentage of patients with multiple admissions was 43% lower in
the intervention group compared with the usual-care group.
Inpatient heart failure costs were 46% lower in the intervention
group. All of these differences were significant. The intervention
yielded cost savings even after the costs of the intervention were
taken into consideration. There was no evidence of cost shifting
from the inpatient setting to the outpatient setting. Patient satisfac-
tion was greater in the intervention group than in the usual-care
group.
Disease management interventions to improve outcomes in
congestive heart failure.
Roglieri JL, Futterman R, McDonough KL, et al.
American Journal of Managed Care. 1997;3:1831-1839.
The impact of selected disease management interventions (e.g.,
post-hospitalization follow-up) on outcomes in patients with con-
gestive heart failure (CHF) or a CHF-related diagnosis were studied
in a managed care setting. The analysis was part of a 24-month,
multicenter, longitudinal comparison study of a comprehensive CHF
disease management program. Study subjects consisted of 149
patients enrolled in the CHF disease management program and all
members of a managed care plan. The program participants were
enrolled in the CHF program following physician or social worker
referral or identification by review of medical claims. The larger pop-
ulation of health plan members corresponded to plan membership
for the third quarters of 1995 (n = 139,922) and 1996 (n =
161,267).
The program consisted of patient education, nurse-initiated tele-
phone calls to patients (telemonitoring), a home visit by a nurse
(post-hospitalization discharge intervention), and physician educa-
tion (mailings and telephone calls to raise program awareness.) The
telemonitoring and education-oriented interventions were available
only to patients enrolled in the program, although all members of
the health plan were eligible for the guideline-based clinical inter-
ventions. Guidelines directing treatment for patients with CHF and
CHF-related diagnoses included those from the American Heart
Association, the Agency for Health Care Policy and Research (now
the Agency for Healthcare Research and Quality), and NYLCare
Health Plans.
Review of hospital and emergency department utilization data pro-
vided information about utilization events, which were categorized
as attributable to pure CHF or a CHF-related diagnosis. The effects
of the program were then analyzed for pure CHF and CHF-related
diagnoses, with outcomes for the third quarter of 1996 (post-inter-
vention follow-up) compared with those for the third quarter of
1995 (pre-intervention baseline).
Overall, the data demonstrated significantly reduced admission and
readmission rates for patients with a pure CHF diagnosis. Among
the entire CHF patient population, the third quarter admission rate
declined 63%, and the 30-day and 90-day readmission rates
declined 75% and 74%, respectively. Among program participants
with a pure CHF diagnosis, the 30-day readmission rate was
reduced to 0, and an 83% reduction occurred for both the third-
quarter admission and 90-day readmission rates. In addition, the
average length of stay for patients with CHF-related diagnoses was
significantly reduced among both plan participants and program
participants. Reductions were seen in total hospital days and emer-
gency department utilization. The authors concluded that a com-
prehensive disease management program can reduce health care
utilization not only among CHF patients in the program, but also
among an entire managed care plan population.
A medication discharge planning program: measuring the
effect on readmissions.
Schneider JK, Hornberger S, Booker J, Davis A, Kralicek R.
Clinical Nursing Research. 1993;2:41-53.
The effect of a medication discharge-planning program on hospital
readmissions among patients with congestive heart failure (CHF) in
a quasi-experimental, after-only, randomized controlled study. Five
nurses implemented the program for 54 patients with CHF who
were admitted to a 600-bed nonprofit, Midwestern medical facility
over a 5-month interval. All enrolled patients had the cognitive
capability to self-administer medications and were taking one or
more medications at the time of discharge from the hospital. These
patients were randomly assigned to a control (n = 28) or an experi-
mental group (n = 26). The experimental group participated in the
medication discharge-planning program, and the control group
received the usual informal discharge planning provided on the
nursing unit.
Five nurse investigators were trained by the principal investigator to
follow a specific format for medical discharge planning based on
Orem’s theory of self-care. Training involved a review and practice
of the discharge-planning format. Discharge planning was conduct-
ed prior to hospital discharge. It involved oral presentation of infor-
mation about the prescribed medication by the nurse investigator.
Disease Management for Heart Failure
This information was consistent with printed medical information
cards provided to the patient. The cards listed the purpose of each
medication, side effects, whom and when to call with questions,
and any medication-specific instructions. The nurse investigator
also reinforced information and corrected any patient misunder-
standings about medications. Family members, if present, were
included in the program.
The nurse investigator next inquired about the patient’s daily routine
and assisted him or her in scheduling medication administration
times. Patients were then queried about problems with taking med-
[31]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
ications at home. If the patient identified no problems, the nurse
investigator posed two potential problems (forgetfulness and limited
budget) and discussed solutions to these problems. Finally, the
nurse briefly reviewed the medication schedule and purpose of
each medication. Subsequent reinforcement and instruction were
provided as appropriate. Patients also were given a physician tele-
phone number for any questions once they had left the medical
center. The entire interaction took about 20 minutes.
The two groups were similar with respect to all demographic data.
The total number of medications at the time of hospital discharge
ranged from 1 to 11. Eight (29%) of the 28 patients in the control
group were readmitted within 31 days after discharge compared
with 2 (8%) of the 26 patients in the experimental group. The differ-
ence is significant. The authors concluded that these findings con-
firm the importance of a medication discharge-planning program.
Congestive Heart Failure Disease Management Study: a
patient education intervention.
Serxner S, Miyaji M, Jeffords J.
Congestive Heart Failure. 1998;4:23-28.
The effects of educational mailings and compliance aides on hospi-
tal readmissions, quality of life, and compliance were evaluated in a
6-month randomized controlled trial of 109 elderly patients hospi-
talized with congestive heart failure (CHF). The subjects were identi-
fied by selecting all patients with a diagnosis of CHF discharged
from Columbia Good Samaritan Hospital and Columbia San Jose
Medical Center within a 1-year interval. Study exclusion criteria
consisted of CHF of noncardiac origin, inability to speak English, no
telephone or residence, and discharge to a skilled nursing facility
outside of the Columbia Hospital system.
Patients were randomized to an education intervention (n = 55) or
standard care (n = 54). The intervention consisted of mailings at 3-
to 4-week intervals of a personalized letter and a wide range of
educational materials (booklets, brochures, fact sheets, resource
guide, video). These materials were accompanied by compliance
aides (medication sheets and a weight chart). Patients in the con-
trol group received the customary hospital education but no special
Disease Management for for Hear Failure
information after discharge. Trained nurse interviewers conducted
telephone surveys before and after the intervention for all patients.
The survey used was a unique instrument designed by a multidisci-
plinary CHF patient education task force that assessed CHF knowl-
edge, attitudes, self-efficacy, and key outcome behaviors. The
medical staff was informed about the study by mail to raise pro-
gram awareness. Hospital records were used to monitor patient
health care utilization related to CHF admissions and costs. No
data were collected on admissions or emergency department visits
to hospitals not within the system.
[32]
Compliance, quality of life, and hospital readmissions were moni-
tored for 6 months. In the control group, 27 (50%) of the patients
were admitted at least once during this interval compared with 15
(27%) of the patients in the intervention group. The 44% reduction
in readmissions was significant. Multiple readmissions were more
common among patients in the control group than in the interven-
tion group. Compared with the control group, the intervention
group had a significantly lower (by 51%) total number of readmis-
sions (21 vs. 43 in the control group). Post-test analysis revealed
significant differences between the control and intervention groups
on key behavioral and attitudinal measures (reduction in salt intake,
change in cooking habits, weight monitoring). There also were sig-
nificant differences between the two groups on frequency of forget-
ting medications (i.e., medication compliance), self-efficacy scores,
and ratings of personal health. Compared with the control group,
the intervention group reported better overall health status, greater
confidence in self-management, and enhanced compliance with
diet, medications, and weight monitoring. The cost of the educa-
tional program was $50 for patients, and the average cost of a
CHF admission to the study medical facility at that time was
$6,000. Based on the reduced readmission rate, the investigators
estimated that the intervention reduced overall costs. A net return
on the investment of $8:$1 for the hospital and $19:$1 for third-
party payers was projected.
Prevention of hospitalizations for heart failure with an inter-
active home monitoring program.
Shah NB, Der E, Ruggerio C, Heidenreich PA, Massie BM.
American Heart Journal. 1998;135:373-378.
A 1-year observational pre- and post-intervention comparison study
was conducted to determine whether a program less rigorous than
some intensive multidisciplinary interventions could reduce hospital-
izations in patients with moderate or severe congestive heart failure
(CHF). A secondary aim of the study was to ascertain whether ben-
efits associated with some inpatient programs directed at elderly
patients with CHF would extend to younger individuals with the dis-
ease treated as outpatients. Twenty-seven patients (mean age 62
years) with class II–IV CHF satisfied enrollment criteria and entered
the study. These patients included patients referred to the Heart
Failure Clinic at the San Francisco Veteran Affairs Medical Center
after a recent hospitalization or while treated as stable outpatients.
The intervention featured patient education and self-monitoring,
automated reminders to improve compliance, and telephone com-
munication with a nurse monitor. Educational materials relating to
symptoms, medications, and management of CHF were mailed to
participants weekly for the first 8 weeks of the study. Patients also
received devices and instruction in obtaining daily weights and vital
signs, and were given a pager through which they received
reminders regarding medications and measurements. Patient clini-
cal status was assessed and physiologic data were collected in
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
weekly telemonitoring phone calls by study nurses. Patients were
also provided with 24-hour telephone access to a nurse to report
changes in their condition, weight gain, or medical emergencies.
Cardiologists reviewed physiologic data weekly and received imme-
diate notification of patient changes in status. Nurses followed up
any such notifications with the patient, and physicians reported any
actions taken to the nurse.
The primary endpoints were numbers of hospitalizations and hospi-
tal days during the mean follow-up period of 8.5 months compared
with values during an equivalent period before the intervention.
Overall, the number of hospitalizations per patient-year of follow-up
after enrollment (0.4) did not differ significantly from the number
prior to enrollment (0.8). However, cardiovascular hospitalization
significantly decreased from 0.6 per patient-year to 0.2 per patient-
year. All-cause and cardiovascular hospital days also decreased
significantly from 9.5 to 0.8 per patient-year and 7.8 to 0.7 per
patient-year, respectively. During the study, there were 52 physician
notifications by the monitoring system for 65 reported problems
(e.g., weight gain, shortness of breath, edema). This notification
resulted in 19 physician interventions, 50% of which were to
increase the dosage of diuretics or change other cardiac medica-
tions. Patient acceptance of the program was high, with 82% rating
the program as useful or very useful. The treating physicians also
found the program helpful in permitting medication adjustments by
phone. No associated economic effects were reported.
Effects of a home-based intervention among patients with
congestive heart failure discharged from acute hospital care.
Stewart S, Pearson S, Horowitz JD.
Archives of Internal Medicine. 1998;158:1067-1072.
The effect of a home-based intervention (HBI) on readmission and
death among “high-risk” patients with congestive heart failure (CHF)
was evaluated in a randomized controlled trial conducted at a terti-
ary referral hospital in Australia. Hospitalized patients with CHF/sys-
tolic dysfunction, exercise intolerance, and recurrent hospital
admissions for acute CHF were eligible to participate. Ninety-seven
patients were randomized to receive usual care (n = 48) or the HBI
(n = 49).
Before hospital discharge, HBI patients were visited by the study
nurse and counseled about compliance with the treatment regimen
and the need to report any signs of clinical deterioration. One week
after discharge, these patients received a home visit by a nurse and
pharmacist. The pharmacist assessed patient medication knowl-
edge by questionnaire and medication compliance by pill count.
Patients who demonstrated poor medication knowledge or non-
compliance received remedial counseling, a daily medication
reminder, a weekly medication container, incremental monitoring by
caregivers, medical information/reminder cards, and referral to a
community pharmacist. The nurse also evaluated patients for evi-
dence of clinical deterioration or adverse effects from medications;
patients were referred to their primary care physician as appropri-
ate. The nurse also contacted patients’ primary care physicians to
discuss the visit and arrange more intensive follow-up, as appropri-
ate. Patients in the usual-care group received normal levels of post-
discharge care, including follow-up physician appointments within 2
weeks after hospital discharge and home support in some cases
(27%).
Seven patients (14%) assigned to the HBI group received no home
visit because of early readmission or study withdrawal. The home
visit to the remaining patients revealed that 22 (52%) patients were
noncompliant with medications and 38 (90%) patients had inade-
quate knowledge of the treatment regimen. Therefore, most HBI
patients required remedial measures, including referral of nine
patients to community pharmacists. In addition, 14 patients
showed signs of clinical deterioration, prompting referral to the pri-
mary care physician. Patients were followed for 6 months after the
intervention to evaluate the primary composite study endpoint
(unplanned readmissions plus out-of-hospital deaths) and second-
ary endpoints (time until first endpoint, rate of unplanned readmis-
sion, total hospital days, emergency department visits, overall mor-
tality, and costs).
During follow-up, HBI patients had significantly fewer unplanned
readmissions (36 vs. 63) and a trend toward fewer out-of-hospital
deaths (1 vs. 5) than control patients. The composite primary end-
point was 0.8 vs. 1.4 events per patient assigned to HBI and usual
care, respectively. The difference is significant. There were no signif-
icant differences between the two groups in time until primary end-
point, percentage of patients with unplanned admissions, or overall
mortality. However, HBI patients had fewer days of hospitalization
(261 vs. 452) and significantly fewer visits to the emergency depart-
ment (48 vs. 87) than the control group. The mean cost of hospital-
based care for the HBI group averaged $3,200 versus $5,400 for
the usual-care group. The estimated cost of the intervention was
$190 (Australian dollars) per patient; outpatient costs for the two
groups did not differ.
Effects of a multidisciplinary, home-based intervention on
unplanned readmissions and survival among patients with
Disease Management for Heart Failure
chronic congestive heart failure: a randomised controlled
study.
Stewart S, Marley JE, Horowitz JD.
The Lancet. 1999;354:1077-1083.
In a 6-month randomized controlled trial, 200 patients with chronic
congestive heart failure (CHF) who were discharged home after
acute hospital admission were randomly assigned to usual care (n
= 100) or a multidisciplinary, home-based intervention (n = 100).
Eligible patients included those who had been admitted to a tertiary
referral hospital in Australia and (1) were 55 years old or older, (2)
[33]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
had New York Heart Association functional class II, III, or IV CHF, (3)
had at least one prior hospital admission for acute CHF, and (4)
met no study exclusion criteria.
The study began with assessment of all patients immediately prior
to discharge to obtain baseline demographic, clinical, and psy-
chosocial data. Patients were then randomized to the intervention
group or usual-care group, and existing norms for discharge plan-
ning were applied to all patients (including follow-up appointments
within 2 weeks after discharge at an outpatient cardiac clinic).
Patients assigned to the home-based intervention group then
received a structured home visit by a cardiac nurse within 7 to 14
days after discharge. Nurse assessments included a physical
examination, review of medication compliance, and evaluation of
the patient’s understanding of appropriate treatment for CHF (e.g.,
appropriate diet, exercise, symptom recognition). Based on this
assessment, patients and their families (if appropriate) received a
combination of remedial counseling, introduction of strategies to
improve treatment compliance and response, incremental monitor-
ing by caregivers, and referral to a primary care physician for urgent
care, if appropriate. The nurse then sent a report to the patient’s
primary care physician and cardiologist detailing results of the
assessment and any remedial actions. The nurse then arranged
any changes in pharmacologic therapy and additional home visits,
as appropriate, as well as follow-up telephone contacts after 3 and
6 months.
The patients were followed for 6 months (the effective intervention
duration). The primary composite study endpoint was frequency of
unplanned readmissions plus out-of-hospital deaths within 6
months. Secondary endpoints included time to first endpoint
(event-free survival), frequency of unplanned admissions alone, fre-
quency of out-of-hospital deaths alone, days of unplanned read-
missions, functional status and quality of life, and hospital and
community-based health care costs. During 6 months of follow-up,
there were 129 primary-endpoint events in the usual-care group
and 77 events in the intervention group, a difference that is signifi-
cant. Significantly more intervention-group patients than usual-care
patients remained event free (51 vs. 38). There were also signifi-
cantly fewer unplanned readmissions (68 vs. 118) and associated
days in the hospital (460 vs. 1,173) among intervention-group
Disease Management for for Hear Failure
patients. Whereas intervention-group patients had superior quality-
of-life scores after 3 months of follow-up, scores did not differ sig-
nificantly between the two groups after 6 months. Hospital-based
costs amounted to $490,300 (Australian) for the intervention group
and $922,600 for the usual-care group. Community-based health
care costs were similar for the two groups. The mean cost of the
intervention was $350 per patient.
[34]
Home-based intervention in congestive heart failure: long-
term implications on readmission and survival.
Stewart S, Horowitz JD.
Circulation. 2002;105:2861-2866.
The long-term effects of a multidisciplinary, post-discharge, home-
based intervention were evaluated in participants in two previously
published studies (see the summaries of Stewart S, Pearson S, et
al. Archives of Internal Medicine. 1998;158:1067-1072 and Stewart
S, Marley JE, et al. Lancet. 1999;354:1077-1083), involving a total
of 297 patients with congestive heart failure (CHF). The intervention
involved home visits by nurses to optimize medication manage-
ment, provide patient education, identify early signs of clinical dete-
rioration, and intensify medical follow-up as appropriate. Patients
were randomized to the intervention or usual care.
After a median follow-up time of 4.2 years, there were significantly
fewer unplanned hospital readmissions and deaths in the interven-
tion group (0.21 events per patient per month) than in the usual-
care group (0.37 events per patient per month). The median event-
free survival time was significantly longer in the intervention group
(7 months) than in the usual-care group (3 months). The median
cost (in Australian dollars) of unplanned readmissions was signifi-
cantly lower in the intervention group ($325 per month per patient)
than in the usual-care group ($660 per month per patient).
Nurse-led heart failure clinics improve survival and self-care
behaviour in patients with heart failure: results from a
prospective, randomised trial.
Stromberg A, Martensson J, Fridlund B, Levin LA, Karlsson JE,
Dahlstrom U.
European Heart Journal. 2003;24:1014-1023.
The impact of a nurse-led heart failure (HF) clinic on morbidity, mor-
tality, and self-care behavior was studied in a 12-month, random-
ized controlled study of 106 patients who were admitted to the
hospital for HF. The intervention involved follow-up after hospitaliza-
tion by trained cardiac nurses who made changes in medications
according to protocol and provided education and social support
to the patient and his or her family. The control group received
usual care.
The intervention group had significantly fewer deaths and hospital
admissions and days, and scored significantly higher on a ques-
tionnaire about self-care behaviors (a high score reflects better
behavior) than the control group. A 55% decrease in admissions
per patient per month was associated with the intervention.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Symptom status and quality-of-life outcomes of home-based
disease management program for heart failure patients.
Todero CM, LaFramboise LM, Zimmerman LM.
Outcomes Management. 2002 Oct-Dec;6(4):161-168.
Changes in CHF symptom occurrence and characteristics and
quality of life were evaluated over a 2-month period in 93 patients
with CHF who had recently been discharged from the hospital and
were referred by their physician to a home disease management
program. Nurses visited the patients at home at baseline (approxi-
mately 1 month after hospital discharge) and again 2 months later
to assess symptoms and collect data. The program included rou-
tine reminders to monitor symptoms and suggestions for symptom
management. A patient education videotape explaining the disease
and its management was shown, and patients were given an edu-
cational manual for reference.
Patients were randomized to one of four strategies for delivery of
the educational component of the program: (1) telephonic case
management, (2) five home visits for patient assessment and edu-
cation (i.e., home care), (3) assessment and education by using a
telehealth communication device (Health Buddy), and (4) a combi-
nation of home visits and the telehealth communication device.
However, because a preliminary analysis revealed that symptom
status did not differ at baseline or the end of the study based on
which group the patient was assigned to, the data for the four
groups were combined.
The most common symptoms at baseline were fatigue (86%) and
shortness of breath (78%). The percentage of patients experiencing
these and each of nine other symptoms was decreased from base-
line at the end of the study. Shortness of breath was the most
common symptom at the end of the study, affecting 75% of
patients. Fatigue was the second most common symptom at the
end of the study, affecting 70% of patients.
The frequency, severity, amount of interference with physical activi-
ty, and the interference with enjoyment of life from shortness of
breath improved over the 2-month study. Similarly, the frequency,
severity, amount of interference with physical activity, and the inter-
ference with enjoyment of life from fatigue improved during this
period. Improvements in quality of life also were reported.
[See the summary of LaFramboise LM, Todero CM, Zimmerman L,
Agrawal S. Comparison of Health Buddy with traditional approach-
es to heart failure management. Family & Community Health. 2003
Oct-Dec;26(4):275-288.]
Heart failure collaborative care: an integrated partnership to
manage quality and outcomes.
Urden LD.
Outcomes Management for Nursing Practice. 1998;2:64-70.
Preliminary outcome information is reported about an integrated
disease case management program for heart failure (HF) that was
established at a hospital in response to the complexity and difficulty
of treating patients with HF. First, an interdisciplinary team created
an inpatient HF clinical pathway with the goals of decreasing length
of stay (LOS) of hospitalized HF patients and eliminating or minimiz-
ing unnecessary readmissions and emergency department visits.
Work was then begun to integrate this inpatient HF pathway with a
home care HF pathway. The net result was the development of a
HF service consisting of five overlapping components: (1) inpatient
consultation with a nurse practitioner (NP) and cardiologist, path-
way care, and comprehensive discharge planning and teaching; (2)
regular outpatient follow up at a HF clinic with an NP, cardiologist,
and nurse clinician; (3) intermittent outpatient intravenous infusion
therapy, managed by a nurse clinician who was supervised by an
NP and cardiologist; (4) ongoing outpatient telemanagement by a
nurse clinician; and (5) linkage with appropriate community, home
health, and referral services.
Preliminary outcome data gathered for 108 patients seen on the
service indicate that patients have been satisfied with the service,
accessibility, timely response, and personalized care. However,
because no baseline data about satisfaction with care were
obtained, no conclusions about changes in satisfaction with care
can be drawn. Early assessment also showed an increase in con-
sultations (e.g., dietician and social service referrals) by more than
20%. Patient education (about HF medication, diet, and symptom
management) was thought to be considerably improved. Significant
improvements were noted in overall quality of life, emotional func-
tioning, and physical functioning after 3 months of follow-up. The
LOS for hospitalized HF patients decreased by 1.1 days since
implementation of the HF inpatient pathway. Readmissions within
30 days after discharge decreased from 17% to 4%. The decrease
in overall LOS resulted in $2,700 in cost savings per patient hospi-
talization. These emerging trends suggest that the HF service inter-
ventions will have additional positive fiscal outcomes.
Disease Management for Heart Failure
Pharmaceutical care of patients with congestive heart fail-
ure: interventions and outcomes.
Varma S, McElnay JC, Hughes CM, Passmore AP, Varma M.
Pharmacotherapy. 1999;19:860-869.
The effects of a structured pharmaceutical care program for
patients with congestive heart failure (CHF) on disease control,
quality of life, and health care facility utilization were evaluated in a
longitudinal, prospective, randomized controlled trial. Elderly
patients who were hospitalized or attended an outpatient clinic in
[35]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
one of three study sites in Northern Ireland were recruited. Eighty-
three patients with a confirmed diagnosis of CHF who (1) were
more than 65 years old, (2) had an adequate cognitive status, and
(3) met no exclusion criteria were restrictively randomized to an
intervention group (n = 42) or a control group (n = 41). Groups
were matched as well as possible for CHF severity, renal function,
concomitant illness, and cognitive status.
The intervention group received algorithm-based education from a
research pharmacist about CHF, its treatment, and lifestyle changes
for symptom control. Educational material was provided in written
and oral form. Patients were also encouraged to monitor their
symptoms and comply with prescribed drug therapy. This was rein-
forced by providing patients with monitoring diary cards that they
were to show to their physicians and community pharmacists.
Instructions for an extra dose of diuretic were provided in the event
of a defined weight gain or symptoms. If necessary, dosage regi-
mens were simplified in liaison with hospital physicians. The
research pharmacist discussed the project with physicians and
community pharmacists, and obtained information from community
pharmacists about dispensed medications for evaluating medica-
tion compliance. The 41 patients in the control group received
standard care, excluding education and counseling by the pharma-
cist, self-monitoring, or liaison among physicians and community
pharmacists. The following outcome measures were assessed in all
patients at baseline as well as after 3, 6, 9, and 12 months: 2-
minute walk test, blood pressure, body weight, pulse, forced vital
capacity (FVC), quality of life, knowledge of symptoms and drugs,
compliance with therapy, and health care utilization.
Body weight, pulse, and FVC did not differ between the two groups
after the intervention. Patients in the intervention group tended to
have higher blood pressures, with a significant difference between
the two groups in diastolic pressures noted after 12 months.
Patients in the intervention group showed improved compliance
with drug therapy on some measures (drug use profile data but not
self-reported data), which in turn improved aspects of their exercise
capacity (distance walked) compared with patients in the control
group. Education on management of symptoms, lifestyle changes,
and dietary recommendations also benefited patients in the inter-
vention group, as suggested by superior scores on quality-of-life,
Disease Management for for Hear Failure
physical functioning, and emotional health assessments. Drug ther-
apy knowledge improved significantly in the intervention group dur-
ing the 12-month study compared with the control group. There
were significantly fewer hospital admissions in the intervention
group (14 vs. 27 in the control group). Although intervention-group
patients tended to have more emergency department visits (15 vs.
7) and doctor emergency visits (38 vs. 35), there were no signifi-
cant differences between the two groups in these measures.
Specific costs were not determined.
[36]
Does increased access to primary care reduce hospital
readmissions? Veterans Affairs Cooperative Study Group on
Primary Care and Hospital Readmission.
Weinberger M, Oddone EZ, Henderson WG.
New England Journal of Medicine. 1996;334:1441-1447.
In a multicenter, randomized controlled trial conducted at nine
Veterans Affairs (VA) Medical Centers, 1,396 veterans hospitalized
with diabetes (n = 751), chronic obstructive pulmonary disease (n =
583), or congestive heart failure (n = 504) were randomized to a
customary post-discharge care group or an intensive, primary care
intervention group. Exclusion criteria included certain concomitant
illnesses, plans for care from a skilled nursing facility, inability to
speak English, lack of a telephone, and poor cognitive status.
Baseline assessment showed that the patients were severely ill;
two thirds were considered at medium or high risk for readmission.
Half of those with congestive heart failure had New York Heart
Association functional class III or IV disease. Baseline quality-of-life
scores were poor.
The intervention was delivered by a team consisting of a registered
nurse and a primary care physician. The intervention was designed
to increase access to primary care after hospital discharge, with
the goals of reducing readmissions and emergency department vis-
its and increasing patients’ quality of life and satisfaction with care.
It involved close follow-up by the team, beginning before discharge
and continuing for 6 months. Prior to discharge, patients in the
intervention group were assessed by a primary care nurse and
were given educational materials and a card with team member
names and beeper numbers. The primary care physician also visit-
ed patients to review the hospital course, discharge plans, and
medication regimens. The nurse then scheduled a follow-up clinic
appointment within 1 week after discharge. The nurse telephoned
patients within 2 days after discharge to assess potential problems
and remind patients about their appointments. Additional reminders
and protocols for missed appointments were implemented as nec-
essary. Patients in the control group received customary post-dis-
charge care, without primary care nurse access, supplemental edu-
cation, or needs assessment.
Patients were followed for 180 days after hospital discharge using
a national database of VA hospitalization information and computer
systems at local hospitals. Although patients in the intervention
group received more intensive care, they had a significantly higher
monthly readmission rate (0.19 vs 0.14) and more days of rehospi-
talization (10.2 vs. 8.8) than patients in the control group. Patients
in the intervention group were more likely to be readmitted than
patients in the control group (49% vs. 44%, respectively), and the
readmission tended to occur sooner in intervention-group patients
than in control-group patients. Intervention-group patients were sig-
nificantly more satisfied with their care than were control-group
patients, although quality-of-life scores did not differ between the
two groups. The study lacked adequate power to permit subgroup
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
analysis, but no significant differences in outcomes were noted
between the three disease strata. The authors concluded that the
primary care intervention increased rather than decreased the rate
of rehospitalization among patients discharged from VA hospitals,
although the intervention was associated with greater patient satis-
faction with care.
A comprehensive management system for heart failure
improves clinical outcomes and reduces medical resource
utilization.
West JA, Miller NH, Parker KM, et al.
American Journal of Cardiology. 1997;79:58-63.
The feasibility and safety of a physician-supervised, nurse-mediat-
ed, home-based system for heart failure (HF) management was
evaluated in an observational study involving 51 patients with HF.
This MULTIFIT system was designed to effectively implement con-
sensus guidelines for pharmacologic and dietary therapy using a
nurse manager to enhance compliance and monitor patient clinical
status by telemonitoring. Patients recently hospitalized with HF at a
Kaiser-Permanente medical center and outpatients referred by
physicians with a diagnosis of HF were recruited for the study.
Nurse case managers, who worked in conjunction with primary
physicians, were primarily responsible for implementing the MULTI-
FIT intervention. It consisted of an initial comprehensive nurse visit
to the patient’s home followed by regularly scheduled, nurse-initiat-
ed telephone calls. The frequency of these calls was predetermined
but could be increased if symptoms progressed or after a recent
event (e.g., emergency department visit, hospitalization). Nurse
managers also educated patients about HF-related issues, includ-
ing sodium restriction, pharmacotherapy, and symptom recognition.
Behavioral techniques were introduced to improve compliance and
foster self-monitoring skills. Physician consultation was available on
an as-needed basis, and a primary physician retained overall
responsibility for patient management.
Patient management was directed by locally adapted guidelines
consistent with the American College of Cardiology/American Heart
Association consensus report, as well as Agency for Health Care
Policy and Research (now the Agency for Healthcare Research and
Quality) clinical practice guidelines. One specific goal of implement-
ing the guidelines was to optimize use of vasodilator therapy (i.e.,
angiotensin-converting enzyme [ACE] inhibitors, hydralazine). Local
cardiologists assisted with developing guideline implementation
goals consistent with the local environment. Monitoring of care by
the nurse manager provided information about guideline compli-
ance.
Fifty-one patients with the clinical diagnosis of HF were followed for
a mean of 138 days after program enrollment. Compared with the
6 months before program enrollment, medical resource utilization
declined significantly after enrollment. For example, utilization rates
for general medical visits, cardiology visits, HF-related emergency
department visits, and total emergency department visits
decreased by 23%, 31%, 67%, and 53%, respectively. Compared
with the 12 months before enrollment, hospitalizations for HF
decreased significantly (by 87% from 1.12 to 0.15 per year) and the
total hospitalization rate decreased significantly (by 74% from 1.61
to 0.42 per year). Functional status, symptomatic status, and
health-related quality of life also improved during the intervention as
determined by the Duke Activity Status Index, New York Heart
Association functional class, and the Short Form-36. The program
also achieved pre-established pharmacologic and dietary goals,
with significant increases in dosages of ACE inhibitors and
hydralazine. For example, the percentage of patients taking target
dosages of the ACE inhibitor lisinopril increased from 45% to 83%.
For hydralazine, the percentage of patients taking target dosages
increased from 10% to 70%. Self-reported use of dietary sodium
significantly decreased. The total contact time between nurse man-
agers and patients (including the initial 2-hour visit) averaged 7.0
hours. The authors concluded that the MULTIFIT system enhanced
the effectiveness of pharmacologic and dietary therapy for HF in
clinical practice, improving outcomes and compliance and reducing
medical resource utilization.
The benefit of implementing a heart failure disease manage-
ment program.
Whellan DJ, Gaulden L, Gattis WA, et al.
Archives of Internal Medicine. 2001;161:2223-2228.
The effects of a congestive heart failure (CHF) disease management
program on medication use, hospitalization rate, number of clinic
visits, and costs were evaluated in a randomized, prospective study
of 117 patients with a recent hospitalization for CHF, an ejection
fraction less than 20%, or symptoms consistent with New York
Heart Association functional class III or IV. The program involved
the use of treatment protocols, follow-up clinic visits and telephone
calls, and a patient education manual.
The mean enrollment time was 4.7 months. The use of angiotensin
converting-enzyme inhibitors was high at baseline (78%) and did
not change significantly as a result of the intervention (79%). The
Disease Management for Heart Failure
use of beta-blockers increased significantly from baseline (52%) to
the end of enrollment (76%).
As a result of the intervention, the hospitalization rate decreased
significantly from 1.5 hospitalizations per patient-year to none, and
the number of clinic visits increased significantly from 4.3 clinic vis-
its per patient-year to 9.8 clinic visits per patient-year. The outpa-
tient cost per patient-year increased by $659, and the inpatient
cost per patient-year decreased by $6,963. The cost per discharge
also decreased. A total cost savings of $8,571 per patient-year
was associated with the intervention.
[37]
 Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Congestive Heart Failure (continued)
Uptake of self-management strategies in a heart failure
management programme.
Wright SP, Walsh H, Ingley KM, et al.
The European Journal of Heart Failure. 2003 Jun;5(3):371-380.
The effectiveness of an integrated outpatient heart failure (HF) man-
agement program was evaluated in a 12-month, randomized con-
trolled trial involving 197 patients with a first diagnosis or exacerba-
tion of HF who were admitted to a New Zealand hospital. The inter-
vention entailed HF clinic visits every 6 weeks, with counseling by a
nurse specialist and optimization of drug therapy; patient education
sessions; telephone follow-up as required; provision of diaries for
recording daily weights; and instructions on performing daily weight
measurements. A control group received usual care without struc-
tured patient education, provision of a diary, or advice on self-man-
agement. Patients were encouraged to purchase scales for home
use; the clinic did not purchase scales for use by patients.
Disease Management for for Hear Failure
The intervention had no effect on deaths or hospital readmissions,
but it decreased total bed days and multiple readmissions, and
improved quality of life. Seventy-six of the 100 patients randomized
to the intervention group used the diaries, and these patients tend-
ed to receive more medications, were more likely to attend patient
education sessions and make clinic visits, and were less likely to
die during the study than patients who did not use the diaries. Of
the 76 patients who used the diaries, 51 patients weighed them-
selves regularly; these patients tended to own scales at home,
attend education sessions, and experience fewer hospital admis-
sions than patients who did not weigh themselves regularly. At the
end of the study, knowledge of self-management was greater in the
intervention group than in the control group.

[38]
 [39]
Disease Management for Heart Failure
 Appendix C.
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Anon, 1998 Nearly 5,000 Not specified Home visit by Yes, Agency for Patients Cardiac nurses
patients with home health Health Care Policy
CHF agency nurse to and Research
assess patient (now the Agency
status, diet, for Healthcare
medication Research and
compliance; Quality), American
patient workbook Heart Association
for assistance guidelines
with disease
management;
nurse visits and
telephone contact

Anon, 2000 95 patients Not specified Telephone case Not specified Patients Cardiac care
with CHF management nurses
system (patient
education)

Anon, 2001 69 elderly Claims data and Computer-based Not specified Patients Nurse
(Disease patients with physician referrals (Internet) or
Management moderate to telephone
Advisor. 2001; severe CHF (interactive voice
7[7]:103-106) response)
reporting by
patients of self-
measured blood
pressure, pulse,
weight, and CHF
symptoms

Anon, 2001 159 patients Monthly automated Patient education Not specified Patients Program
(Disease with CHF review of claims primarily by coordinator
Management data using an telephone
Advisor. 2001; algorithm
7[6]:92-96)
Disease Management for Heart Failure

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[40]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Hospital admissions, 2 years Not specified, but no Inpatient health Health plan The intervention reduced
inpatient costs, control group identified care costs members both hospital admissions
hospital days, decreased 61% receiving home and hospital days by 58%
ED visits care from and ED visits by 49%.
contracted home
health care
agency

New York Heart 6 months before Controlled pre-and Hospital and total Patient homes Functional class
Association and after post-intervention costs decreased by quality of life improved.
functional class, comparison 64% and 68%, The hospitalization
quality of life, respectively rate decreased by 49%.
hospital and ED ED use did not change.
use, costs

Hospitalizations, 1 year RCT Cardiac costs per Patient homes There were 20
hospital days, cardiac patient per month hospitalizations for a total
costs decreased by $247 of 149 days in the
in the computer computer group and 39
group and $265 in hospitalizations for 258
the interactive voice days in the interactive
response group, voice response group.
and increased by
$135 in the usual-
care (control) group

Self-reported 18 months Pre- and post- Overall costs Patient homes Disease knowledge and
disease knowledge intervention decreased by ~35% functional status
and functional health; comparison due to decreases improved in 93% and 56%
ACE inhibitor use; in ED use and of patients, respectively.
ED use; hospital hospital admissions ACE inhibitor use increased
admissions and LOS and LOS by more than 20% to 65%.
Disease Management for Heart Failure

[41]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Anon, 2001 117 patients Hospitalization for Planning before Not specified Patients Attending physicians,
(Clinical Resource with CHF CHF within past 6 hospital discharge; nurse practitioners,
Management) months, New York clinic and nurse specialist,
Heart Association telephone pharmacist, social
functional class III follow-up; and worker, and
or IV, and ejection patient education nutritionist
fraction <20% about medications,
diet, and care plan

Anon, 2001 Not specified Not specified Software program Not specified Patients with CHF Nurse case managers
(Data Strategies & and appliance for
Benchmarks) use at home by
patients to
transmit health
data to nurse
case managers

Anon, 2002 10 patients Inpatients judged Use of a home- Not specified Patients Nurse practitioner
with CHF in need of extra based device to
support and measure and
reinforcement and electronically
outpatients with transmit weight,
poor understanding blood pressure,
of disease and heart rate, oxygen
frequent physician saturation, and
or ED visits temperature to
a central location
on a daily basis

Bertel O, 25 patients with Consecutive Special CHF Not specified Patients and Not specified
Conen D, 1987 severe CHF patients referred to program focused physicians
institution because on:
of severe CHF (1) individualized
refractory to medical therapy
treatment for CHF,
(2) antiarrhythmic
Disease Management for Heart Failure

treatment and
close follow-up
visits, and
(3) continuous
education of
patients and
physicians to
improve treatment
compliance and
early management
of complications
ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[42]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Use of target Not specified Pre- and post- Outpatient costs University Use of target dosages of
dosages of ACE intervention increased by 27%, medical center ACE inhibitors and beta-
inhibitors and comparison inpatient costs blockers increased.
beta-blockers, clinic decreased by 38%, Hospitalization rate
visits, hospitalization and total cost of decreased from 1.86 to
rate and LOS care decreased by 1.21 times per patient per
37% year. Average LOS
decreased from 7.67 to
6.07 days. Rate of clinic
visits increased from 7.8 to
12.9 visits per patient year.

Hospitalizations, Not specified Pre- and post- The savings in Patient homes Hospitalizations and ED
ED visits, bed days intervention direct costs was visits decreased by 23%.
comparison $1,266 per patient Total number of bed days
per year decreased by 50%.

Hospitalizations, 3 months Pilot study None Inpatient and Hospitalizations and ED

ED visits, patient outpatient visits were eliminated and
sense of well-being patient well-being and
and understanding of understanding of the
the disease disease were significantly
improved.

Survival, outcomes Not specified, but Nonrandomized None University-based The 1-year survival in the
of medical treatment 1-year and 2-year observational with hospital in intervention group (92%)
for CHF, outcomes survival rates were comparison with Switzerland was significantly higher
of medical treatment provided for the pre-existing “control” than that in the control
for arrhythmias intervention group group group (43%). The 2-year
survival rate for the
intervention group (83%)
Disease Management for Heart Failure

compares favorably with

previously reported
survival rates.

[43]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Bouvy ML, 152 patients Patients admitted Patient interviews Not specified Patients Pharmacist
Heerdink ER, with CHF to the hospital or about medication
et al., 2003 attending a compliance with
specialist monthly follow-up
outpatient CHF contact
clinic

Capomolla S, 234 patients Referral through an Cardiovascular Yes, American Patients Multidisciplinary
Febo O, et al., 2002 with HF unspecified risk stratification, College of
process creation of an Cardiology/American
individualized Heart Association
plan of care, and
health care
education and
counseling

Cardozo L, 290 elderly Random selection Implementation of Yes, internally Health care Clinical nurse
Aherns S, 1999 patients with of patients (age internally developed clinical providers manager
CHF >65 years) developed clinical pathway for CHF monitoring
presenting to a pathway for CHF management processes of care;
tertiary-care intended to variances in care
teaching hospital improve care for reported to
for CHF elderly patients attending physician
management over and improve for corrective
a 1-year interval resource utilization action

Chapman DB, 67 patients Not specified Comprehensive Yes, internal Patients (education, Registered nurse
Torpy J, 1997 with CHF outpatient protocols support, home with CHF
program offering established by the health care); training (nurse
standardized care, Heart Failure physicians coordinator) in
patient education, Center based on (education about conjunction with
outpatient infusion both the 1994 program and physician medical
of inotropic agents, Cardiology protocols used) director and
electronic linkages Preeminence administrator
between clinic Report on CHF
Disease Management for Heart Failure

and ED, and and a 2-day

home health care cardiology
nurse visits roundtable meeting

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[44]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Medication 6 months RCT None Outpatient clinic, Medication compliance

compliance, hospital, and was greater in the
rehospitalization, home intervention group than in
mortality, and qualify the control (usual-care)
of life group. There were no
significant differences
between the two groups in
rehospitalization, mortality,
or quality of life.

Cardiac deaths, 12 months RCT There was a cost Day hospital and Cardiac deaths and
hospital readmissions, savings of $1,068 community readmissions were
New York Heart for each quality- significantly lower and
Association functional adjusted life-year New York Heart Association
class gained by using the functional class was more
intervention instead likely to improve in the
of usual care intervention group than in
the control (usual-care)
group.

LOS, cost of care, 12 months Randomized Significant reduction Tertiary-care LOS decreased from 6.36
mortality, readmission retrospective pilot in variable cost of teaching hospital days (for controls) to 5.25
statistics, and study $776 per patient in metropolitan days (with pathway).
performance rates of attributed to Detroit Performance of three of
processes of care shorter LOS six processes of care
improved. However, rate
of readmission increased
from 9.25% (in controls) to
13.5% (with pathway).

Hospital admissions, 12 months before Observational pre- and Potential for Hospital at Hospital admissions,
number of hospital and 16 months post-intervention decreased costs tertiary-care hospital days, and average
days, average LOS after enrollment comparison due to less medical center LOS decreased by 30%,
frequent followed by 42%, and 17%,
hospitalization outpatient clinic respectively.
(estimated cost of and home care
1 year of clinic
treatment was
$2,000 vs. $9,000
Disease Management for Heart Failure

for average cost of

single admission)

[45]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Civitarese LA, 20 physicians All patients of a Internally Yes, internally Physicians; Physicians
DeGregorio N, in private private community developed clinical developed clinical patients as
1999 community medical group practice guideline practice guideline secondary
medical group; admitted to the integrated with for treatment recipients
275 patients hospital during the monthly quality of CHF
with CHF study interval with improvement
a confirmed meetings
discharge diagnosis
of CHF (ICD-9
code 428)

Cline CM, 190 adults Recruited from Education None for evaluation Patients and Registered nurses
Israelsson BY, with HF patients admitted about HF or treatment families with experience
et al., 1998 to university (pathophysiology, specific to the treating patients
hospital for HF over treatment); study; patients with HF
2-year interval guidelines for received self-
self-management management
of diuretic therapy; guidelines for
follow-up at diuretic therapy
nurse-directed
outpatient clinic

Costantini O, 582 inpatients Hospital Care management, Care Patients Nurse care
Huck K, et al., 2001 with CHF inpatients with daily use of recommendations manager, faculty
new care were based on cardiologist, and
guidelines national guidelines physician
representative from
part-time faculty

Dennis LI, 24 Medicare “Convenience” Assessment and Use of agency Patients who were Home health
Blue CL, et al., patients with sample drawn from patient teaching nursing care plans Medicare care nurses
1996 CHF and pool of Medicare interventions and Medicare beneficiaries
18 Medicare beneficiaries administered to regulations
patients with receiving home patients by home appropriate for
COPD health care for health care nurses patients with CHF
Disease Management for Heart Failure

CHF or COPD or COPD

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[46]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Rates of classifying 21 months Prospective None Patients Rates of classifying systolic

systolic and diastolic hospitalized at and diastolic dysfunction
dysfunction, use of Pittsburgh medical remained unchanged.
ACE inhibitors, groups’ primary ACE inhibitor use
hospitalization rates, community-based increased by 39%.
documentation of hospital Quarterly admissions for
discharge instructions systolic dysfunction-based
CHF decreased by 49%.
Documentation of
patient discharge
instructions was
suboptimal.

1-year survival rates, 1 year Prospective, Mean cost of Swedish university The intervention did not
time until randomized trial intervention: $208 hospital clinic and affect 1-year survival rate,
readmission, days in per patient (US); patient homes but it increased the number
hospital, health care Mean annual of days until readmission
costs reduction in overall (141 vs. 106 in control
cost: $1,300 per group), and decreased the
patient number of days in
hospital (4.2 vs. 8.2).

Quality of care 1 year Controlled pre- and Care management Large university Care management
(use of inhibitors, post-intervention was associated with medical center improved quality of care
documentation of comparison a $2,204 reduction and reduced median
echocardiography, in hospital costs hospital LOS from 5 days
daily weight to 3 days.
measurement) and
hospital LOS and
costs

Hospital readmission 12 months Retrospective chart None Patient homes A significant relationship
rates review (nonexperimental was found between certain
research design) interventions implemented
by home health care
nurses and hospital
readmission rates among
Disease Management for Heart Failure

Medicare patients with CHF

or COPD. Hospitalization
readmission rates
significantly decreased as
the number of nurse visits
and assessment-based
interventions increased.

[47]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Dimmick SL, Not specified Recruited from Telehealth disease Not specified Patients Registered nurses
Burgiss SG, et al., county residents management
2003 (videoconferencing,
telephone
conversations,
and remote
monitoring of
blood pressure,
blood oxygen
saturation, and
pulse)

Discher CL, 593 patients Patients admitted Treatment Yes, Agency for Patients and health Nurse case
Klein D, et al., 2003 with CHF to the hospital who algorithm/clinical Health Care Policy care professionals manager
had physician pathway and and Research (now
support, and education of the Agency for
adequate cognitive health care Healthcare
ability and living professionals and Research and
conditions for patients Quality)
program
participation

Doughty RN, 197 patients Patients admitted Clinical review at Yes, Agency for Patients Nurse
Wright SP, et al., with HF to a hospital with a clinic, individual Health Care Policy
2002 a primary diagnosis and group and Research
of HF education (now the Agency
sessions, a for Healthcare
personal diary to Research and
record medication Quality)
administration and
body weight
measurements,
information
booklets, and
Disease Management for Heart Failure

regular clinical
follow-up

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[48]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Weight control (a 13 months Not randomized or A reduction in cost Homes and Weight control was
measure of controlled of care for CHF clinics achieved by more than 50%
medication and hospitalizations of patients as a result of
dietary compliance), from $8 billion the intervention. Sleep
mood (sleep problems, to $4.2 billion was problems improved,
fatigue, depression, projected annually although feelings of
and appetite), and on a national basis fatigue, depression, and
hospitalization rate loss of appetite increased.
and costs The hospitalization rate
decreased from 1.7 times
per patient per year to 0.6
per patient per year, and
the hospital LOS decreased
from a national benchmark
of 6.2 days to 4 days.

Average hospital 1 year Pre- and post- There was a Community The intervention led to a
LOS and costs, intervention significant reduction hospital significant reduction in
documentation of left comparison in cost per patient average LOS from 6.1
ventricular ejection from $6,828 to days to 3.9 days,
fraction and ACE $4,404 improvement in
inhibitor use, and documentation of left
nurse satisfaction ventricular ejection
fraction and ACE inhibitor
use, and high nurse
satisfaction.

Number of patients 12 months RCT None Hospital-based There was no significant

who died or were clinic difference between the
readmitted to the intervention group and the
hospital, number of control (usual-care) group
bed days, and quality in the number of patients
of life who died or were
readmitted to the hospital.
The intervention was
associated with fewer
multiple readmissions
and bed days, and greater
improvement in the
Disease Management for Heart Failure

physical-functioning
component of quality of life
than usual care.

[49]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Duncan K, 16 patients Recruited from an Exercise plus Not specified Patients Research nurse
Pozehl B, 2003 with HF HF clinic adherence
involving
individualized
goal setting,
graphic feedback
on goals, and
problem-solving
support

Fonarow GC, 214 heart Patients with HF Comprehensive Patients educated Patients and their Education by HF
Stevenson LW, transplant presenting for heart management in accordance with families clinical nurse
et al., 1997 candidates transplantation program by HF Heart Failure specialist; follow-up
evaluation who met transplant team Practice Guidelines; care provided by
eligibility featuring a systematic HF cardiologists
requirements (i.e., systematic adjustment of
stable for hospital approach to drug medications
discharge; no therapy; patient described, but no
contraindications; education (diet, specific guidelines
not “too well”) exercise, self- identified
monitoring); and
regular telephone
and clinic follow-up
with HF team
after discharge

Gattis WA, 181 adults with Patients with HF Evaluation by a Target dosages of Patients Clinical pharmacist
Hasselblad V, et al., HF and left and left ventricular clinical pharmacist, ACE inhibitors
1999 ventricular dysfunction including used were in
dysfunction (ejection fraction medication accordance with
<45%) undergoing evaluation, those established
evaluation at therapeutic by randomized
university-affiliated recommendations controlled trial
clinic to physician,
patient education,
and follow-up
telemonitoring

Gilbert JA, 1998 Unidentified Not specified Telephone-based Not specified Patients Not specified, but
Disease Management for Heart Failure

number of disease multidisciplinary

patients with management team mentioned
CHF system, designed
to monitor patients
after hospital visits
and provide
education and
support

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[50]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Maximum oxygen 24 weeks RCT None Cardiac All outcomes were better
uptake (a measure of (12 weeks rehabilitation than at baseline in the
exercise capacity), supervised and facility and home intervention group.
dyspnea, fatigue, 12 weeks Adherence to the exercise
walk-test unsupervised) regimen during the
performance, unsupervised weeks was
quality of life significantly better in the
intervention group than in
the control group.

Functional status, 6 months before Nonrandomized, Estimated savings in Heart Functional status improved
hospital readmissions, and at least observational (pre- hospital readmission transplantation and hospital readmission
management costs 6 months after and post-intervention costs of $9,800 per center rate decreased by 85%
intervention comparison) patient; estimated with the intervention.
(3-year interval) cost of intervention:
$200-$400 per patient

Primary endpoints: 6 months (median Double-blind None Duke University, All-cause mortality and HF
all-cause mortality patient follow-up randomized general cardiology clinical events decreased
and nonfatal HF interval) controlled trial faculty clinic and ACE inhibitor use and
clinical events (ED dosage improved with the
visits or hospitalization intervention.
for HF); secondary
endpoints: ACE
inhibitor use and
dosage

Hospital readmission 9 weeks Observational (pilot) None Patient homes Hospital readmission rates
Disease Management for Heart Failure

rates study (telemanagement decreased from 76% to

through Crozer- 18% with the intervention.
Keystone Health
System, a
Springfield, PA-
based integrated
delivery system)

[51]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Goodyer LI, 100 elderly All elderly patients 3 months of Patient instruction Patients Pharmacist
Miskelly F, et al., patients with at a London clinic intensive based on protocol,
1995 chronic, stable who met inclusion medication but no specific
HF criteria counseling by a guidelines were
pharmacist identified

Gorski LA, 51 patients Claims analysis, Education (regular Yes, American Patients Nurse
Johnson K, 2003 with HF health risk telephone calls, College of
assessment, and mailings) and Cardiology/American
referrals from coordination and Heart Association
utilization managers, promotion of
case managers, interdisciplinary
physicians, and patient care
patients using community
resources,
newsletters, and
referrals to a
home health
care program

Hanumanthu S, 134 patients All patients Comprehensive Not specified Patients and Physicians who
Butler J, et al., 1997 with HF referred to Heart management by providers (providers work exclusively
Failure and Heart HF specialists/ participated in with HF and heart
Transplantation transplant team, periodic meetings transplant patients;
Program (by including medical with affiliated home assisted by nurse
cardiologists) management, health agency and coordinators and
during a 1-year cardiovascular hospice to home health care
Disease Management for Heart Failure

interval testing, and integrate patient agencies

medication care)
adjustments

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[52]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Medication knowledge, 3 months Prospective RCT None Outpatient clinic Medication compliance
medication compliance, for the elderly at increased by 32% and
results on submaximal Charing Cross knowledge improved with
6-minute exercise Hospital, London the intervention. Results
test, visual analogue for the 6-minute exercise
scores of test improved by 20
breathlessness, meters for the intervention
Nottingham Health group and worsened by
Profile scores, 22 meters for the control
clinical signs of HF patients. Nottingham
(e.g., edema) Health Profile scores did
not change for either group.
Distance to breathlessness
and peripheral and pul-
monary edema scores
improved only in the inter-
vention group.

Hospitalization rate, 9 months Pre- and post- A cost savings of Home The intervention led to a
self-care behaviors, intervention $165,000 was substantial decrease in
and patient satisfaction comparison projected hospitalization rate and an
increase in self-care
behavior, and patient
satisfaction was good,
very good, or excellent.

Annual hospitalization Follow-up intervals Nonrandomized, None Vanderbilt Heart The intervention reduced
rates, peak exercise ranging from observational pre- and Failure and Heart cardiovascular- and HF-
capacity, and 30 days to 1 year post-intervention Transplantation related admissions by 53%
medication use compared with comparison Program and 69%, respectively, and
similar period improved functional status
before intervention compared with earlier
care.
Disease Management for Heart Failure

[53]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Harrison MB, 200 patients Patients screened Transitional care Yes, Agency for Patients Nurses
Browne GB, with CHF during (telephone Health Care Policy
et al., 2002 hospitalization outreach within and Research
24 hours after (now the Agency
discharge, for Healthcare
consultations Research and
between hospital Quality) guidelines
and home care
nurses, patient
education, and
supportive care
for self-
management)

Heidenreich PA, 68 patients Use of medical Multidisciplinary Patient educational Patients Nurses
Ruggerio CM, with HF claims database program consisting materials based (education, self-
et al., 1999 to identify patients of patient on Agency for monitoring
with an HF claim education, daily Health Care techniques);
>$50, a self-monitoring and Policy and physicians
hospitalization for telephone Research (now (notification of
HF, or recent ED transmission of the Agency for problems based
visit for HF, with data, and Healthcare on results of
subsequent contact physician Research and patient self-
of patient’s notification of Quality) monitoring)
physician abnormal weight guidelines for
gain, vital signs, patients with HF
and symptoms

Hershberger RE, 108 outpatients Referred because Use of current Yes, Agency for Patients Cardiologists,
Ni H, et al., 2001 with CHF of chronic, practice guidelines Health Care Policy specially trained,
symptomatic CHF for treating CHF, and Research experienced
frequent telephone (now the Agency nurses, and a
contact between for Healthcare social worker
nurses and patients, Research and
pre-emptive Quality) and
hospitalization, American Heart
patient education Association/
American College
of Cardiology
Disease Management for Heart Failure

guidelines

Hinkle AJ, 2000 Not specified Electronically Internet-based Not specified Patients Not specified
identified from disease
claims data management
(assesses
willingness to
change, educates
about CHF,
promotes positive
behavioral change)
ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[54]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Health-related quality 12 weeks RCT None Hospital and Health-related quality

of life, rates of hospital patient homes of life was significantly
readmission and better in the transitional-
ED visits care group than in the
usual-care group. The
hospital readmission rate
did not differ significantly
(23% vs. 31%). ED visits
were significantly lower in
the transitional-care group
(29% vs. 46%).

Primary endpoints: Approximately Nonrandomized, Estimated cost of Community setting Hospital days per year
total claims (costs) 1 year (mean matched-control study program was $200 (patient homes) significantly decreased
per year, admissions follow-up 7.4 per patient per from 8.6 (in previous year)
per year, hospital months) month; estimated to 4.8 in intervention
days; secondary mean savings per patients, while increasing
endpoints: patient year was $9,000 from 8.9 to 17 in control
compliance with (difference in cost patients. Number of
self-monitoring, between groups) admissions per year did
number of physician not differ significantly
notifications, between the two groups.
quality of life

Patient self-care 6 months before Pre- and post- Average estimated Outpatient setting Patient self-care
knowledge and daily and 6 months intervention cost savings knowledge, daily weight
weight measurement, after referral comparison associated with measurement, and quality
severity of illness, ED reduced of life increased, and
use, hospitalization, hospitalization was severity of illness
and quality of life $4,307 per patient decreased. Hospitalization
rate and ED use decreased
from 56% and 54%,
respectively, before referral
to 27% and 15%,
respectively, after the
Disease Management for Heart Failure

program.

Frustration with CHF, Not specified Not applicable None Third-party Decreased frustration
knowledge of CHF, insurer with CHF in >90% of
quality of life patients, increased
knowledge of CHF in
>82% of patients, improved
quality of life in >50% of
patients.

[55]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Jerant AF, Azari R, 37 patients Patients admitted In-person nurse Yes, Visiting Patients Nurse
et al., 2003 with CHF to a university visits shortly after Nurses
hospital with a hospital discharge Association and
primary diagnosis and after 60 days, Advisory Council
of CHF plus telenursing to Improve
(video-based Outcomes
home telecare or Nationwide in
telephone calls) Heart Failure

Kasper EK, 200 patients Patients Outpatient Not specified Patients Multidisciplinary
Gerstenblith G, with CHF hospitalized with program with
et al., 2002 CHF who were periodic follow-up
at increased risk telephone calls
for readmission and visits, an
individualized
treatment plan,
a treatment
algorithm, and
provision of a
scale, low-sodium
meals, telephone,
and transportation
if needed

Knox D, Not specified Not specified Integrated Clinical pathway Patients and Multidisciplinary
Mischke L, 1999 multidisciplinary for LOS based on providers team, with
program of Agency for Health advanced
inpatient Care Policy and practical nurse
consultation and Research (now coordinating and
education, patient the Agency for supervising
outpatient clinic Healthcare compliance
visits, cardiac Research and monitoring
home care, and Quality) guidelines
monitoring of
compliance
through automated
telemanagement
program
Disease Management for Heart Failure

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[56]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

CHF-related hospital 180 days Pre- and post- CHF-related Home The number of ED visits
readmissions and intervention readmission was significantly lower with
ED visits comparison charges were telenursing than with
>80% lower with usual care.
telenursing than with
usual care

Hospital 6 months RCT The cost per patient Home There were significantly
readmissions, was similar with the fewer hospital
mortality, symptoms, intervention and readmissions and deaths,
and quality of life usual-care groups patients were less
symptomatic, and quality
of life improved to a
greater extent in the
intervention group
compared with the
usual-care group.

Patient satisfaction, 18 months for Outcome data None Evanston Satisfaction was high and
compliance with compliance; other presented, but not a Northwestern compliance rate averaged
automated periods of tracking defined study Healthcare 89.5%. CHF
telemanagement not indicated hospital and clinic, hospitalization rate was
program, and patient 0.6 per patient per year
hospitalization homes vs. national benchmark
rate, 30-day of 1.7 per patient per
readmission rate, year. The 30-day
LOS readmission rate was
2.3% (vs. 23%
nationally). LOS was
4 days (vs. national
average of 6.2 days).
Disease Management for Heart Failure

[57]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Kornowski R, 42 elderly Individuals Home Not specified Patients Internal medicine

Zeeli D, et al., 1995 patients with participating in surveillance physicians;
severe CHF home surveillance program collaboration with
program for ≥1 year involving paramedical personnel
who met other home visits by
inclusion criteria internists and
(history of paramedical
hospitalization in personnel for
preceding year, evaluation,
ejection fraction recommendations
<40%) to patient (i.e.,
education), and
treatment

Kostis JB, 20 patients Not specified Nonpharmacologic Not specified Patients Treatment team,
Rosen RC, et al., with CHF treatment program, including physicians,
1994 consisting of psychotherapist,
exercise, dietary dietician, and staff
counseling, at cardiovascular
cognitive therapy, rehabilitation facility
and stress
management

Krumholz HM, 88 patients Patients at least Targeted education Not specified Patients Experienced
Amatruda J, et al., with HF 50 years old who and support cardiac nurse
2002 were hospitalized intervention with
with HF telephone
follow-up

LaFramboise LM, 90 patients Patients discharged Home visits, Yes, Agency for Patients Research nurse
Disease Management for Heart Failure

Todero CM, et al., with HF from the hospital telehealth Health Care Policy
2003 within the previous communication and Research
6 months with a device, or both (now the Agency
primary diagnosis compared with for Healthcare
of HF telephonic case Research and
management Quality)

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[58]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Total and 12 months before Nonrandomized, pre- None Home care A home surveillance
cardiovascular-related and after and post-intervention surveillance program significantly
hospital admissions, intervention comparison program in decreased total and
hospital LOS, Tel Aviv cardiovascular-related
functional status, hospital admissions and
medication use hospital LOS in elderly
patients with severe CHF,
and significantly
improved self-reported
functional status.

Ejection fraction, 12 weeks Randomized, None University of Compared with digoxin

exercise tolerance, controlled, Medicine and therapy and placebo, the
anxiety and parallel design Dentistry of nonpharmacologic
depression scores New Jersey— intervention resulted in
(mood), weight loss Robert Wood significant improvements
Johnson Medical in exercise tolerance,
School weight control, and
mood. In contrast, digoxin
significantly improved ejec-
tion fraction but not exer-
cise capacity or quality of
life.

Rate of hospital 1 year RCT The intervention Home The percentage of patients
readmission or death reduced hospital who died or were
readmission costs by readmitted to the hospital
$6,985 per patient was significantly lower in
the intervention group
(57%) than in the control
group (82%). The interven-
tion reduced the total num-
ber of readmissions by
39%.

Self-efficacy (i.e., 2 months Pilot RCT None Home Self-efficacy worsened in

Disease Management for Heart Failure

level of confidence in the telephonic case

making lifestyle and management group and
behavioral changes increased in the other
related to HF three groups. Functional
management), status, mood, and quality
functional status, of life improved from
mood, and quality baseline in all four groups;
of life there were no significant
differences between the
groups in these measures.

[59]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Laramee AS, 287 patients Patients admitted Early discharge Yes, Agency for Patients Nurses
Levinsky SK, with CHF to the hospital planning, patient Health Care Policy
et al., 2003 with a primary or and family and Research
secondary education, (now the Agency
diagnosis of CHF 12 weeks for Healthcare
and a left of telephone Research and
ventricular ejection follow-up, and Quality),
fraction <40% or promotion of American
radiologic evidence optimal CHF College of
of pulmonary medications Cardiology/American
edema requiring Heart Association,
diuresis Heart Failure
Society of America

Lasater M, 1996 80 patients All patients Program at Unidentified Patients Registered nurses;
with CHF or hospitalized at nurse-managed critical-path collaboration by
cardiomyopathy local medical CHF clinic algorithms directed physicians
center for CHF emphasizing nurse-provided care (cardiologists),
or cardiomyopathy precautions to dieticians, social
were automatically reduce risk of workers
enrolled in CHF hospital
precautions clinic readmission
for follow-up after (patient education,
hospital discharge cardiopulmonary
assessment, daily
weights,
assessment of
medication
compliance)

Lazarre M, 34 patients All patients who Cardiac care Unidentified Patients and Nurses with a
Ax S, 1997 with HF entered cardiac program for home critical pathways families critical-care
care program care featuring used to guide background
during 7-month targeted teaching, targeted teaching contracted by
course of study close monitoring home health
who also met by cardiac-trained care agency;
inclusion criteria nurses, collaboration
cardiovascular with
assessment, and multidisciplinary
Disease Management for Heart Failure

early team
management of
HF exacerbations

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[60]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

90-day hospital 90 days RCT The total inpatient Hospital and The 90-day readmission
readmission rate, and outpatient home rate was the same (37%)
costs, and patient median cost and for both groups.
adherence the readmission Adherence to the
median cost were treatment plan was
reduced by 14% and significantly better in the
26%, respectively intervention group than in
the control group.

Patient knowledge 1 year (6 months Nonrandomized, Comparison of Nurse-managed The intervention decreased
of medications, before and after observational hospitalization CHF precautions hospital readmissions
hospital readmission intervention) (pre- and post- charges after clinic associated (22% vs. 26%) and LOS
rates, hospitalization intervention intervention ($6,404) with South (5.7 days vs. 7.3 days),
costs comparison) vs. before Carolina Medical and improved patient
intervention ($6,898) Center knowledge of medications.
revealed a savings
of almost $500 per
patient

Hospital readmission 7 months Nonrandomized, None Patients 30-day and 90-day

rates 30 and 90 days partially controlled receiving home readmission rates
after program (results compared with care according (2.9% and 8.8%,
enrollment national averages) to a home health respectively) were lower
care agency- than national averages
sponsored (16% for 30 days and 32%
cardiac program for 90 days).
Disease Management for Heart Failure

[61]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Martens KH, 924 patients Use of Home health care Not specified Patients Home health
Mellor SD, 1997 with CHF computerized nursing care nurses
discharged to medical records to interventions
home (study identify all CHF focused on patient
aim #1); 120 patients in hospital assessment and
patients with system who were teaching
CHF and discharged to home,
referral to with or without
specific home referral to home
health care health care, over
agency (study a given interval
aim #2)

Morrison RS, 50 patients Random selection Hospital-based, Yes, institutional Care providers Nurse case
Beckworth V, 1998 with CHF from patients nursing care critical pathways manager
hospitalized within management developed by a
a 6-month interval model involving continuous quality
with a primary the development improvement team
diagnosis of CHF and implementation
(ICD-9 code 428) of a critical
pathway for CHF
care

Mueller TM, 200 patients Not specified Telemanagement Yes, Heart Failure Patients Advanced-practice
Vuckovic KM, with HF and a diuretic Society of America nurses
et al., 2002 treatment and others
algorithm

Nobel JJ, 78,038 member Members of a Remote biometric Not specified Patients Cardiac nurses
Norman GK, 2003 months with health maintenance measuring and
age >65 years organization monitoring device,
and 7,477 and interactive
Disease Management for Heart Failure

member months communication

with age between nurses
<65 years and patients

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[62]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Hospital readmissions 3 months (follow-up Retrospective chart None Patient homes Patients who received
within various 90 days after audit home health care nursing
intervals, compliance intervention) services were readmitted
with intervention to the hospital
implementation significantly less often
(28% vs. 42%) within
90 days after hospital
discharge than patients
not receiving such
services.

Hospital LOS, costs Calendar year Retrospective chart The estimated Acute-care Mean LOS in 1996 with
(fixed, variable, 1996 review mean fixed, variable, hospital in the implementation of the
total), physiologic and total costs for southeastern nursing care management
status, physical 50 patients treated United States model was 5.4 days vs.
functioning, health according to this ~17 days in 1991 before
knowledge, and model were $2,491, implementation.
family caregiver $1,858, and $4,291, Regression analysis
status respectively identified number of
medications as the only
predictor of LOS. Guideline
compliance was
suboptimal.

Patient compliance 2 years Not randomized or Hospital costs for Home Patient compliance was
with telephone calling controlled treating HF high (90%). The 30-day
program, 30-day decreased by 52% readmission rate
hospital readmission decreased from 2.3% in
rate, hospitalization 1997-1999 to 0.7% in
rate, and costs 1999-2001. The
hospitalization rate
decreased by 50%.

Hospital days per 12 months Controlled but not The intervention Home The intervention reduced
thousand members randomized reduced the costs hospital days per thousand
per year paid per member members per year by 53%
per month by 50% in patients >65 years old
Disease Management for Heart Failure

in patients >65 and by 62% in patients

years old and by <65 years old.
60% in patients
<65 years old

[63]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

O’Connell AM, 35 indigent Patients admitted Multidisciplinary Yes, Agency for Patients Cardiologists,
Crawford MH, patients with to university disease Health Care Policy nurse practitioner
et al., 2001 CHF not hospital with high management and Research with specialized
eligible for hospitalization rate program (monitoring (now the Agency training and
transplantation or referred by at clinic, telephone for Healthcare experience caring
primary care contact, patient Research and for cardiac
physician because education, Quality) guidelines patients, social
of high risk of medication for medications worker, pharmacist,
hospitalization consultation, dietitian, cardiac
due to financial, referral to rehabilitation team
social, or dietitians and
nonadherence other specialists)
issues

Oddone EZ, 443 patients Random invitation Enhanced access Appropriate Patients Primary care
Weinberger M, with CHF of CHF patients to primary care, utilization of ACE physician/registered
et al., 1999 treated at one of including inhibitors assessed nurse team
nine Veterans assignment to using Agency for
Affairs medical primary care Health Care
center study sites nurse and Policy and
physician team, Research (now
patient education, the Agency for
increased Healthcare
telephone contact, Research and
and additional Quality) guidelines
outpatient visits (guideline
implementation
not described);
American Heart
Association
materials used for
patient education

Paul S, 2000 15 patients A “convenience” Nurse practitioner- Nurse practitioner Patients and their Nurse practitioner
with CHF sample of patients managed, provided care in families in collaboration
who were admitted multidisciplinary accordance with with multidisciplinary
to a university- outpatient clinic unidentified clinic team
affiliated clinic offering patient protocols
education,
Disease Management for Heart Failure

assessment and
treatment by a
multidisciplinary
team, frequent
monitoring via
nurse telephone
calls and visits,
and on-demand
clinic visits for
worsening signs
of CHF
ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[64]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Functional status 1 year before and Nonrandomized, There was a net Clinic Functional status improved
(severity of illness), year after pre- and post- savings of $4,600 and the need for
hospitalization rate, 1enrollment intervention per patient hospitalization decreased.
and hospital and comparison
clinic costs

Diagnostic evaluation, 6 months of Multisite RCT None Nine Veterans Compliance with
pharmacologic follow-up after Affairs medical recommended CHF
management, randomization centers (inpatient testing and treatment was
health-related and clinic care) similar among the
quality of life, and patient homes intervention and control
hospital readmission groups. Enhanced access
rates to primary care did not
improve patients’
self-reported health
status and was
associated with more
frequent hospitalizations
(1.5 readmissions in
6 months vs. 1.1 in the
control group).

Total hospital 6 months before Nonrandomized Mean inpatient Nurse practitioner- Clinic enrollment
readmissions, total and after selection with hospital charges managed, decreased hospital
hospital days, mean intervention subjects serving as decreased from multidisciplinary admissions (and days)
LOS, ED visits, (clinic enrollment) own controls $10,624 per patient outpatient clinic from 38 (151 hospital
charges, and admission to $5,893; affiliated with days) to 19 (72 hospital
reimbursement mean ED visit university hospital days). It also decreased
Disease Management for Heart Failure

charges decreased mean LOS (4.3 days vs.

from $390 to $284 3.8 days) and number of
ED visits (10 vs. 8).

[65]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Philbin EF, 1,504 patients Selected based on Multifaceted quality Critical pathways Patients and health Physicians, nurse
Rocco TA, et al., with HF at diagnosis-related improvement were based on care staff leaders,
2000 acute-care grouping (inpatient, ED, and expert guidelines administrators
community home care critical responsible for
hospitals pathways with quality
recommended management
diagnostic tests
and treatments;
staff and patient
education)

Rauh RA, 754 patients Patients at a Physician-directed, Yes, Agency for Patients and Nurses in
Schwabauer NJ, with CHF community-based nurse-managed Health Care Policy families received collaborations
et al., 1999 hospital with a inpatient and and Research patient education; with physicians,
discharge diagnosis outpatient CHF (now the Agency members of dieticians, and
of CHF (diagnosis- program, featuring for Healthcare multidisciplinary social workers
related grouping intensive patient Research and treatment team
127) education, Quality) guidelines were educated
treatment in for CHF about CHF
accordance with management and
protocols, and protocols at the
aggressive individual and
outpatient group level
pharmacologic
management

Rich MW, 98 elderly Patients at least Comprehensive, Home visits were Patients Nurses working
Vinson JM, et al., patients with 70 years of age nurse-directed in accordance with with a
1993 CHF admitted to a multidisciplinary federal home-care multidisciplinary
secondary and approach to guidelines treatment team
tertiary teaching reducing repeated
hospital over a hospitalizations
1-year interval were including teaching,
screened for CHF; medication and
CHF patients at dietary intervention,
moderate-to-high discharge planning,
risk for early and enhanced
hospital readmission, follow-up care
who met no study
Disease Management for Heart Failure

exclusion criteria,
were enrolled

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[66]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Quality of care 9-month baseline RCT A slight reduction Hospital and The intervention had small
(e.g., measurement and post- in hospital patient homes effects on outcomes that
of left ventricular intervention periods, charges was were not significantly
systolic function), including 6 months observed different from the effects
hospital LOS and after hospital of usual care. Average
charges, mortality, discharge hospital LOS decreased
hospital readmissions, from baseline by 1.8 days
quality of life in the intervention
group and by 0.7 days
in the control group.

Primary endpoint: 1 year prior to Retrospective chart 17% ($1,118) Community-based Compared with control
LOS for all CHF- program review reduction in cost per Illinois hospital group, intervention group
related hospital implementation for admission; 77% (inpatient setting) had a significantly reduced
admissions; controls; 1 year ($718,468) net and associated LOS (5.7 days vs. 7.3
secondary after program reduction in physician-directed, days), fewer admissions
endpoints: primary implementation nonreimbursed nurse-managed for CHF management
CHF admission for intervention hospital revenue; outpatient CHF (404 vs. 503), and a
rate, readmission group cost of operating clinic (outpatient lower 90-day
rate within 90 days outpatient heart setting) readmission rate (13%
of discharge, per- clinic was about vs. 18%).
case cost (to $104,000, and
patient and program revenue
provider) for all generated was
CHF admissions $211,000

All-cause admissions 90-day Prospective RCT No actual cost data 550-bed The intervention did not
and cumulative post-intervention were provided; secondary and significantly reduce
number of hospital follow-up however, potential tertiary care readmissions or hospital
days during 90-day annual savings university teaching days. The 90-day
follow-up interval were estimated at hospital followed readmission rate was 33%
$262.5 million if by patient homes for the intervention group
data were vs. 46% for the control
extrapolated to all group. The mean number
patients with CHF of hospital days was 4.3
discharged from for the intervention group
short-stay hospitals vs. 5.7 for the control
group.
Disease Management for Heart Failure

[67]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Rich MW, 282 elderly Patients A nurse-directed Not specified Patients and Nurses
Beckman V, et al., patients with hospitalized at multidisciplinary their families collaborating with
1995 CHF treatment site intervention, multidisciplinary
were invited to offering team
participate if they comprehensive
had risk factors for education, a
readmission and prescribed diet,
met no exclusion medication review,
criteria social service
support, and
intensive follow-up
(telephone contact
and home visits)

Rich MW, 156 elderly Subset of Comprehensive Not specified Patients Study nurse in
Gray DB, et al., patients with patients in previous patient education, collaboration with
1996 CHF trial who had a dietary and social multidisciplinary
diagnosis of CHF service team (physician,
and who did not consultations, pharmacist,
meet any exclusion medication review, dietician, social
criteria and intensive worker, home
postdischarge care workers)
follow-up

Riegel B, 358 patients Patients screened Telephone case Yes, Agency for Patients Case managers
Carlson B, with CHF for eligibility when management to Health Care (registered nurses)
et al., 2002 hospitalized provide patient Policy and
education and Research (now
collect and the Agency for
document patient Healthcare
progress data after Research and
discharge Quality) and others
Disease Management for Heart Failure

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[68]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Primary outcome 4-year study with Prospective RCT Average cost of Hospital at Elderly patients with CHF
measure: survival 1-year follow-up intervention was university medical participating in a
for 90 days without (90 days during $216 per patient; center followed by nurse-directed
hospital readmission; intervention and the cost of hospital patient homes multidisciplinary
secondary endpoints: 9 months after readmission was intervention experienced
all-cause readmissions, intervention $2,178 in the improved quality of life,
CHF-related discontinuation) intervention group 44% fewer readmissions
readmissions, vs. $3,236 in the within 90 days, 56% fewer
cumulative days of control group hospital admissions for
hospitalization after (P = .03); CHF, 37% fewer hospital
follow-up, quality of estimated savings days, and lower medical
life, medical costs of $460 per costs compared with
patient control patients receiving
standard care.

Medication Medication Prospective RCT None Washington Compared with controls,

compliance (by pill compliance University Medical overall compliance
count), hospital assessed for Center improved and
readmission rates 30 days, hospital (hospitalization) readmissions and hospital
readmission rates followed by days decreased by 33%
assessed for patient homes and 31%, respectively, in
90 days elderly patients with CHF
who underwent a
multidisciplinary treatment
intervention aimed at
improving medication
compliance.

HF hospitalization 6 months RCT Inpatient HF costs Hospital and The HF hospitalization rate,
rate, number of HF were 46% lower in patient homes number of HF hospital
hospital days, and the intervention days, and percentage of
percentage of patients group patients with multiple
with multiple readmissions were 48%,
readmissions 46%, and 43% lower
in the intervention group
than in the usual-care
control group.
Disease Management for Heart Failure

[69]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Roglieri JL, All participants Referral by Patient education, Yes, American Patients Nurse for
Futterman R, in a managed attending physician telemonitoring, Heart Association, (educational and telemonitoring
et al., 1997 care plan, or hospital case post-hospitalization Agency for Health clinical interventions and patient
including a manager, or discharge Care Policy and and telemonitoring) education; not
subset of identified in review intervention Research (now and physicians specified who
149 patients of medical claims (home visit by the Agency for (education about managed
who participated (ICD-9 codes) nurse), and Healthcare program, including physician
in a CHF physician Research and review of CHF education
disease education (practice Quality), and treatment
management guidelines) NYLCare guidelines)
program HealthPlans

Schneider JK, 54 patients with Patients admitted Nurse-directed The medication Patients and Nurse
Hornberger S, et al., CHF to medical facility medication discharge- families (when investigators
1993 over 5-month discharge planning planning program present)
interval for CHF was based
who met other on Orem’s theory
inclusion criteria of self-care; no
(ability to specific guidelines
self-administer were identified
medications, taking
one or more
medications at
discharge)

Serxner S, 109 elderly CHF patients Low-cost Not specified Patients; providers Trained nurse
Miyaji M, et al., patients with discharged from a educational also received interviewers
1998 CHF hospital system materials and mailed information
over the course of compliance aids to raise program
a year who had a mailed to awareness
telephone, spoke patients at
English, and had regular intervals
Disease Management for Heart Failure

CHF of cardiac (home-based

origin educational
intervention)

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[70]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Third-quarter 24 months Longitudinal None Managed care Third-quarter admission

admission rates, (12 months before comparison study health plan and rate and 30- and 90-day
30- and 90-day and after patient homes readmission rates declined
readmission rates, intervention) 63%, 75%, and 74%,
LOS, total hospital respectively, in patients
days, and ED with any CHF-related
utilization among diagnosis. In patients with
patients with (1) a a pure CHF diagnosis,
pure CHF 30-day readmission rate
diagnosis and (2) decreased to 0, and
any CHF-related third-quarter admission
diagnosis and 90-day readmission
rates both decreased 83%.
Health care utilization
(admissions, readmissions,
LOS) also decreased in
entire managed care plan
population.

Hospital readmission 1 month of Quasi-experimental, None A 600-bed, Participants in the

rate 31 days after follow-up after after-only, randomized nonprofit medication discharge-
discharge intervention controlled study Midwestern planning program had
medical facility significantly lower
readmission rates 31 days
after discharge than
patients who underwent
standard discharge
planning (8% vs. 29%).

Quality of life, 6 months (3-month RCT Cost of program Patient homes The intervention reduced
hospital intervention, with was $50 per patient; (recipients of hospital readmissions by
readmissions, 6-month follow-up estimated net return home-based 51% and improved overall
associated costs, after enrollment) on the investment program offered patient health status,
compliance with of $8:$1 for the by Columbia confidence in
medications, diet, hospital and $19: hospital system) self-management, and
and daily weights $1 for third-party compliance with diet,
Disease Management for Heart Failure

payers medications, and weight

monitoring among
patients with CHF.

[71]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Shah NB, Der E, 27 patients with Patients referred to Mailed patient Not specified Patients; Nurses with
et al., 1998 moderate or CHF clinic at education materials, physicians notified access to
severe CHF Veterans Affairs automated of problems cardiologists
medical center reminders for detected by patient
during 6-month medication self-monitoring
enrollment period compliance, self-
who met inclusion monitoring of
criteria weights and vital
signs, and
facilitated telephone
communication
with a nurse
monitor

Stewart S, 97 patients Patients at tertiary Home visit by a Not specified Patients Home-based,
Pearson S, et al., with CHF referral hospital nurse and nurse-pharmacist
1998 who had pharmacist to team
CHF/systolic optimize medication
dysfunction, management,
exercise provide education
intolerance, and (and remedial
recurrent hospital counseling) about
admissions for medications and
acute CHF; who medication
met no exclusion compliance,
criteria; and who identify early
agreed to clinical
participate deterioration, and
intensify medical
follow-up, as
appropriate

Stewart S, 200 patients Patients Home visit and Not specified Patients and Home-based
Marley JE, et al., with chronic discharged from telemonitoring by families cardiac nurse
1999 CHF a tertiary referral a cardiac nurse
hospital in to optimize
Disease Management for Heart Failure

Australia with medication and

(1) age ≥55 years, disease
(2) New York Heart management,
Association identify early
functional class II, clinical deterioration,
III, or IV CHF, and intensify medical
(3) at least one follow-up, and
prior hospital provide remedial
admission for counseling
acute CHF (patient teaching),
as appropriate
ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[72]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Hospitalizations (all 1 year (mean Observational (pre- and None Patient homes No significant difference
cause and follow-up interval post-intervention in number of
cardiovascular), was 8.5 months comparison) hospitalizations per
hospital days after intervention) patient-year before and
(all cause and after the intervention (0.8
cardiovascular), and 0.4, respectively).
physician notifications, Cardiovascular
patient acceptance hospitalizations decreased
from 0.6 per patient-year
to 0.2 per patient-year.
All-cause and
cardiovascular hospital
days decreased from 9.5 to
0.8 per patient-year and
from 7.8 to 0.7 per patient-
year, respectively.

Primary endpoint: 6 months of RCT The mean cost Tertiary referral The intervention reduced
frequency of follow-up after of hospital-based hospital in southern primary-endpoint events
unplanned enrollment care for the Australia followed (0.8 vs. 1.4 per patient),
readmissions plus (duration of intervention group by patient homes unplanned readmissions
out-of-hospital intervention) averaged $3,200 (36 vs. 63), out-of-hospital
deaths; secondary vs. $5,400 for the deaths (1 vs. 5), days of
endpoints: event-free usual-care group hospitalization
survival, percentage (not significant); (261 vs. 452), and visits
of patients with the estimated to the ED (48 vs. 87).
unplanned cost of the
readmissions, total intervention was
hospital days, number $190 (Australian)
of ED visits, overall per patient;
mortality, cost of outpatient costs
hospital-based did not differ
care between groups

Primary endpoint: 6 months of RCT Hospital-based Tertiary referral The intervention reduced
frequency of follow-up after costs were hospital in primary endpoint events
unplanned enrollment Australian $490,300 Australia followed from 129 to 77,
readmissions (duration of for the intervention by patient homes unplanned readmissions
Disease Management for Heart Failure

plus out-of-hospital intervention) group and Australian (118 vs. 68), and
deaths; secondary $922,600 for the associated hospital days
endpoints: event-free usual-care group (1,173 vs. 460) and
survival, days of (P = 0.16); increased the number
unplanned community-based of patients remaining
readmissions, health care costs event-free (51 vs. 38).
functional status were similar for both Quality-of-life scores did
and quality of life, groups; mean cost not differ significantly
hospital and of the intervention between the two groups
community-based was Australian $350 after 6 months.
health care costs per patient

[73]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Stewart S, 297 patients Screening of Postdischarge Not specified Patients and Multidisciplinary
Horowitz JD, 2002 with CHF patients admitted home-based families
to the cardiology intervention
unit of a hospital (see the
and active summaries of
consultation with Stewart S,
the admitting Pearson S, et al.
physician Archives of
Internal Medicine.
1998;158:1067-
1072 and Stewart
S, Marley JE,
et al. Lancet.
1999;354:1077-
1083)

Stromberg A, 106 patients Patients Follow-up HF Not specified Patients Cardiac nurses
Martensson J, with HF hospitalized for HF clinic where
et al., 2003 medication
changes were
made by protocol,
and patients and
family members
received education
and social support

Todero CM, 93 patients Referred by CHF disease Yes, Agency for Patients Nurses
LaFramboise LM, with CHF physician to home management Health Care Policy
et al., 2002 disease program with and Research
management routine reminders (now the Agency
program after to monitor for Healthcare
hospital discharge symptoms, Research and
for acute suggestions for Quality)
exacerbation of symptom
CHF management, and
patient education
Disease Management for Heart Failure

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[74]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Unplanned hospital Median of 4.2 RCT The median cost of Tertiary referral There were significantly
readmissions, years unplanned hospital in fewer unplanned
deaths, and event- readmissions was Australia followed readmissions and deaths,
free survival significantly lower by patient homes and the median event-free
in the intervention survival was significantly
group than in a longer in the intervention
control group group than in the control
receiving usual care group.

Mortality, hospital 12 months RCT None Clinic The intervention group had
admissions and significantly fewer deaths
days, and self-care and hospital admissions
behavior and days, and exhibited
better self-care behavior
than the control group.

The percentage of 2 months Not randomized or None Home The percentage of patients
patients with specific controlled with each CHF symptom
HF symptoms; the decreased as a result of
frequency, severity, the intervention. The
and amount of frequency, severity,
interference with amount of interference
physical activity with physical activity,
from the symptoms; and interference with
and the interference enjoyment of life from
with enjoyment of shortness of breath
life from the and fatigue (the two
symptoms most common symptoms)
improved.
Disease Management for Heart Failure

[75]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

Urden LD, 1998 108 patients Not specified Integrated disease Inpatient CHF Patients and Team consisting
with CHF case management clinical pathway providers (clinical of a cardiologist
program (service) developed pathway) medical director,
for CHF featuring internally by team nurse practitioner,
inpatient and and nurse clinician
outpatient
consultation,
comprehensive
education,
outpatient
treatment, and
intensive home
telephone contact,
including monitoring
and home
intervention

Varma S, 83 elderly Patients hospitalized Structured Use of previously Patients Research

McElnay JC, et al., patients with or attending an pharmaceutical published pharmacist in
1999 CHF outpatient clinic in care program algorithm for liaison with
one of three study for elderly CHF pharmaceutical community
sites with: patients education, but no physicians and
(1) confirmed specific practice community
diagnosis of CHF, guidelines identified pharmacists
(2) age >65 years,
and (3) adequate
cognitive score

Weinberger M, 1,396 patients Patients Intensive Not specified Patients Primary care
Oddone EZ, et al., with diabetes hospitalized at outpatient teams, consisting
1996 (n = 751), one of nine primary care by of one primary
COPD (n = 583), Veterans Affairs a dedicated care nurse and
or CHF (n = 504) hospitals with physician-nurse one primary
CHF, COPD, or team following care physician
diabetes inpatient
assessment and
provision of patient
educational
Disease Management for Heart Failure

materials

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[76]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Hospital LOS, Not specified, but Observational Decreased LOS Inpatient LOS decreased by
30-day readmission <1 year after resulted in $2,700 (community 1.1 days and 30-day
rate, costs, program in savings per hospital in readmissions decreased
patient satisfaction, implementation patient Michigan); from 17% to 4% after
consultations, quality hospitalization outpatient (patient program implementation.
of life, emotional and homes) Consultations increased
physical functioning by >20%. Patient
education, overall quality
of life, emotional
functioning, and
physical functioning
improved.

2-minute walk test, 12 months Longitudinal, Average cost of Three study sites Compared with controls,
blood pressure, body prospective RCT medical ward (hospitals, clinics) program participants had
weight, pulse, forced admission was in Northern Ireland better quality of life,
vital capacity, £175.4 vs. £35.2 for physical functioning,
quality of life, ED visit and emotional health;
knowledge of medication compliance;
symptoms and and medication
medications, knowledge; and fewer
compliance with hospital admissions
therapy, and use of (14 vs. 27).
health care facilities

Hospital 6 months after Multicenter RCT None Hospitals and Patients in the intervention
readmissions, intervention clinics at nine group had a higher
days of Veterans Affairs monthly readmission rate
hospitalization, Medical Centers (0.19 vs. 0.14) and more
quality of life, days of rehospitalization
satisfaction with (10.2 vs. 8.8) despite
care greater satisfaction
than patients in the
control group.
Disease Management for Heart Failure

[77]
 Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention

West JA, 51 patients Recruitment of Physician- Management Patients and Nurse case
Miller NH, et al., with HF patients hospitalized supervised, nurse- guidelines providers managers with
1997 at managed care mediated, home- adapted from and access to
medical center for based HF consistent with supervising
HF within past management American College physician
12 months, as well system (MULTIFIT) of Cardiology/
as referral of that implements American Heart
outpatients by consensus practice Association
physicians guidelines for consensus
pharmacologic report and the
and dietary Agency for Health
therapy, and uses Care Policy and
a nurse manager Research (now
to promote the Agency for
adherence and Healthcare
carry out patient Research and
telemonitoring Quality) clinical
practice guidelines
for CHF

Whellan DJ, 117 patients Patients with a Disease Not specified Patients Nurse practitioner
Gaulden L, et al., with CHF hospitalization for management or nurse specialist
2001 CHF, an ejection program with and pharmacist
fraction <20%, or treatment
symptoms protocols,
consistent with follow-up clinic
New York Heart visits and
Association class telephone calls,
III or IV and a patient
education manual

Wright SP, 197 patients Patients with first Clinic visits, Not specified Patients Nurse specialist
Walsh H, et al., with HF diagnosis or patient education
2003 exacerbation of sessions, telephone
HF admitted to the follow-up, and use
hospital of diaries for
recording daily
weight
measurements
Disease Management for Heart Failure

ACE = angiotensin-converting enzyme; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department;
HF = heart failure; ICD-9 = International Classification of Diseases, Ninth Revision; LOS = length of stay; RCT = randomized controlled trial.

[78]
 Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results

Death, 10 months (mean Nonrandomized, pre- None Patient Quality of life, functional
hospitalizations, patient follow-up and post-intervention homes (home- status, and compliance
ED visits, clinic interval of 138 ± comparison based care with guidelines improved.
visits, functional 44 days) system sponsored Medical visits, cardiology
status, exercise by managed visits, HF-related ED
capacity, self- care organization) visits, and total ED visits
reported data decreased by 23%, 31%,
(weights, dietary 67%, and 53%,
compliance), respectively.
functional status, Hospitalizations for HF
health-related decreased by 87% from
quality of life, 1.12 to 0.15/year, and
compliance with total hospitalization rate
guidelines decreased by 74%
from 1.61 to 0.42/year.

Medication use, Mean enrollment Randomized Outpatient costs Clinic Beta-blocker use and clinic
hospitalization rate, time of 4.7 months prospective pre- and increased, but the visits increased
and number of clinic postintervention cost per discharge significantly. The
visits comparison and inpatient and hospitalization rate
total costs per decreased significantly.
patient-year
decreased, resulting
in a net savings of
$8,571 per
patient-year.

Mortality, hospital 12 months RCT None Hospital, clinic, The intervention had no
readmissions, bed and home effect on deaths or hospital
days, quality of life, readmissions, but it
and knowledge of decreased total bed days
self-management and multiple
readmissions, and
improved quality of life.
Knowledge of self-
Disease Management for Heart Failure

management was greater

in the intervention group
than in a control group.

[79]
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