Heart failure results in substantial morbidity, mortality, and health care expenditures. There are 5.8 million people in the United States with heart failure, and this condition has one of the highest rates of hospitalization and rehospitalization. There are, fortunately, several therapies that are based on evidence and recommended by professional societies and that can reduce morbidity, mortality, and costs.
For example, a 2009 study in the Journal of the American Medical Association of 12,565 patients with HF investigated whether guidelines were being adhered to. It found that fewer than one third of patients who were eligible for aldosterone antagonist therapy were actually given these guideline-recommended drugs. At discharge, some hospitals prescribed them to no patients at all. Meanwhile, the rate of documented contraindication in the medical record was only 0.5 percent.
Yet for heart failure patients these drugs are proven to lower mortality, hospitalization, and rehospitalization rates.
“These heart failure therapies are highly cost effective,” says Gregg C. Fonarow, MD, professor of cardiovascular medicine at UCLA.
There is compelling evidence supporting the efficacy and effectiveness of the therapy. The 2009 update of the American College of Cardiology Foundation/American Heart Association’s heart failure guidelines recommends low-dose aldosterone antagonists for appropriate heart failure patients, and documents “strong data demonstrating reduced death and rehospitalization in two clinical trial populations.”
Furthermore, a 1999 New England Journal of Medicine study of 1,663 patients with severe heart failure found that with spironolactone “the frequency of hospitalization for worsening heart failure was 35 percent lower” and risk of death 30 percent lower, while symptoms of heart failure showed “significant improvement” and might result in fewer clinic visits and cost moderation.
In a 2011 NEJM study of 2,737 patients with systolic heart failure and mild symptoms, the number of hospitalizations — including second and subsequent hospitalizations — was consistently lower for patients receiving eplerenone. Compared with the control group, there was a 24 percent reduction in total hospitalizations, a 29 percent reduction in hospitalizations for cardiovascular reasons, and a 38 percent reduction in hospitalizations for heart failure.
Room for improvement
There is a lot of room for care improvement here. This is just the sort of clear, unambiguous, focused opportunity that medical directors like, Fonarow says.
“By providing quality feedback and encouraging participation in performance improvement systems, managed care can provide highly effective but less costly care for heart failure” compared with current practice.
Importantly, the 2009 JAMA study found aldosterone antagonist use significantly higher in patients who were also prescribed other evidence–based heart failure therapies. These other therapies were also associated with reduced hospitalization.
You might think the situation would be different for drugs that have been around longer. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers have also been proven to lower the risk of hospitalization, rehospitalization, and death in heart failure patients, Fonarow says. Yet, as he and colleagues report in Archives of Internal Medicine, prescriptions for these drugs were not given to 28 percent of eligible patients.
Similarly, “evidence–based beta blockers have been shown to lower the rates of death and rehospitalization in the 30 days after hospital discharge for heart failure,” Fonarow says. “This therapy provides early, intermediate, and long-term benefits.”
Other beta blockers have not been shown to provide such benefit, yet many physicians prescribe these other beta blockers for heart failure and not those proven to improve survival, Fonarow and colleagues reported in a 2007 study in Archives of Internal Medicine.
The pattern of underuse with clear consequences for both health and costs extends beyond the limits of pharmacotherapy. Cardiac resynchronization therapy for appropriate patients lowers mortality and hospitalization rates, but not rehospitalization. “Heart failure hospitalization rates were lowered by 50 percent in the CARE HF study,” Fonarow says, citing studies by Cleland and colleagues. “Yet only one third of ideal candidates for cardiac resynchronization therapy have received this therapy in cardiology practices.” It is clear that we are not taking sufficient advantage of guideline-recommended therapies and the substantial opportunity to improve outcomes for patients with heart failure.
Certain management strategies have been shown to provide benefits for both health and finances. Ample evidence demonstrates that certain forms of disease management are effective for heart failure, says Marvin A. Konstam, MD, past president of the Heart Failure Society and professor of medicine at Tufts University School of Medicine. The 2004 randomized study he led of heart failure management in a diverse provider network tracked 200 patients with high baseline use of approved heart failure pharmacotherapy.
At 90 days, patients randomized to disease management experienced half the hospitalizations for heart failure as controls. Furthermore, intervention patients had reduced hospital days related to a primary diagnosis of heart failure.
Overall, days in hospital per patient-year for cardiovascular cause were vastly reduced in the intervention group, but when the program was ended, much of the gain in positive outcomes was lost.
Not all configurations of heart failure disease management reduce hospitalization equally. In a recent editorial in the Journal of the American College of Cardiology, Konstam and a colleague recommend better use of pharmaceuticals and good diet. They also push educating patients and families for the sake of better adherence, self-monitoring, and responses to changes in clinical status. “Patients who show the greatest improvement in adherence also show the greatest reductions in heart failure hospitalizations.”
Heart failure clinics
A heart failure clinic led by heart failure specialists, together with advance practice nurses and physician assistants, has also been proven to be effective. These achieve “very substantial reductions in hospitalization,” Fonarow says, referring to studies he published in 1997 and 2010. Encountering patients during hospitalization and following patients during the ensuing period, such centers achieve improved compliance in the use of guideline-recommended drugs and devices, and better outcomes. Of course, Fonarow says, “Not every geographic region has access to such centers.”
Another approach uses telemedicine. Important questions regarding telemedicine include: Who conducts it (nurses? other staff members?), which patients receive it (only those with the highest likelihood of adverse events?), and how long does each category of patient receive it?
Recently, a study by Harlan M. Krumholz in NEJM found that telemonitoring reduced neither rates of death nor rates of rehospitalization in heart failure patients. Whether a different approach to telemonitoring or targeting of a different patient mix would be effective is not known. Meanwhile, this may not be the best place for managed care to expend resources for heart failure patients.
Should participation in performance improvement programs be encouraged?
Health plan medical directors use several approaches to monitoring successes in reducing hospitalization and extending life for patients with heart failure. “None of these replace hospital and outpatient participation in performance improvement programs for heart failure patients, such as the American Heart Association’s ‘Get With the Guidelines’ program,” Fonarow says.
“Hospitals participating in Get With the Guidelines have been shown to provide higher quality of care and have lower 30-day rehospitalization rates, compared to other hospitals,” he says.
That bears repeating: The Heart Association’s program achieves not only better quality of care but, in addition, fewer expensive rehospitalizations.
“Performance improvement programs can also be effective in improving care and outcomes for heart failure in the outpatient practice setting,” Fonarow says.
A 2010 prospective study of a registry including 34,810 patients with left ventricular ejection fraction of 35 percent or less and chronic heart failure or previous myocardial infarction achieved “substantial improvements in the use of guideline-recommended therapies in eligible patients with heart failure in outpatient cardiology practices.” The study was conducted at 167 outpatient cardiology and multispecialty practices.
At 24 months the use of beta blockers had increased from 86 percent to 92.2 percent, of aldosterone antagonists from 34.5 percent to 60.3 percent, of cardiac resynchronization therapy from 37.3 percent to 66.3 percent, of implantable cardioverter-defibrillators from 50.1 percent to 77.5 percent, and of education about heart failure from 59.5 percent to 72.1 percent.
“As these therapies are highly effective in reducing hospitalization rates and have been shown to be cost-effective, the expected benefits in terms of lives saved, hospitalizations prevented, and health care expenditures reduced would be expected to be substantial,” Fonarow says.
“Heart failure [is] perhaps the best example of a chronic disease for which care could be optimized by a medical home approach,” write Konstam and Barry H. Greenberg, MD, in the Journal of Cardiac Failure, while acknowledging that certain aspects of the approach have not yet been worked out adequately.
“The medical home is appealing in part because these are patients with lots of comorbidities,” says Greenberg, professor of medicine at the University of California–San Diego Medical Center.
It “offers the best opportunity to succeed in both driving quality and outcomes and controlling health care costs, while maintaining provider discretion to individualize care in the best interest of the patient,” the authors state.
The approach provides incentives for continuity of care, aligns multidisciplinary teams of providers to weigh the range of options appropriate for each patient, encourages competition with other systems, and avoids payer micromanagement.
Providing incentives for continuity of care means patients “have access to the health care system” and can be “educated in such a way as to improve adherence to prescribed medications, to dietary recommendations, to daily monitoring of weight, and similar steps,” Konstam says.
In contrast, such metrics as 30-day rehospitalization might lead to no more than deferral of a needed rehospitalization beyond 30 days to avoid penalty, he points out.
If managed care wishes to reduce hospitalization and rehospitalization, then these payers should attempt to alter the payment model, Konstam suggests.
“Managed care organizations should work with provider systems to develop models of reimbursement that change the approach to managing patients longitudinally and that align incentives to keeping patients out of the hospital,” he states.
Overall, we need to get to where patients monitor themselves and are monitored by health care professionals and medical devices “in a more systematic way than their showing up at the emergency department after they have gained 30 pounds,” Konstam says.
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Early diagnosis and prevention
Early diagnosis and treatment of heart failure is a slam-dunk to save lots of money while preserving quality of life, says Barry H. Greenberg, MD, professor of medicine at University of California–San Diego Medical Center.
Clearly, getting to these patients early and then treating them adequately — not partially or incompletely — will prevent hospitalizations and procedures down the road, he says.
All too frequently, “there is delay in recognizing and diagnosing heart failure and getting appropriate therapy on board,” Greenberg says. “We need to close the gap.”
Medical directors can play a key role. “Sometimes the presentation is subtle, but we know the risk factors. We need providers to have a heightened awareness with patients with hypertension, coronary artery disease, diabetes, and additional relevant conditions,” Greenberg says. “With certain risk factors, we need providers to ask themselves if certain symptoms might be because of heart failure, to have appropriate suspicions.”
Diagnosing heart failure can be challenging. There can be uncertainty about whether some symptoms are caused by heart failure. “For patients with appropriate risk factors, medical directors should encourage providers to perform appropriate clinical evaluations and order an echo and/or biomarker test,” Greenberg says. That will not only improve quality but also save money in the long run.
Crucially, if heart failure is present, therapy must not be suboptimal. Otherwise, there may be consequences — expensive consequences. This is a point medical directors can hammer home.
Suboptimal therapy in patients with early heart failure is common, Greenberg says.
For difficult-to-manage patients, such as those with tolerance problems, early referral to a heart failure specialist may be effective and may save money over the long run. The American Board of Internal Medicine now certifies advanced heart failure specialists. Alternately, a heart failure disease management program can help, he says.
Of course, prevention of heart failure is, itself, perhaps the best possible route in all this. Prevention, Gregg C. Fonarow, MD, of UCLA, points out, is an effective way “to reduce the costs associated with heart failure, by preventing heart failure from developing in the first place.”
This provides, he says, further motivation for medical directors to focus on attacking hypertension, diabetes, and smoking, and on improving outpatient management of coronary artery disease and acute myocardial infarction.
Proven to reduce readmissions
Heart failure patients with outpatient follow-up within seven days of discharge from a heart failure hospitalization have a lower risk of 30-day readmission than do other patients.
A study by Gregg C. Fonarow, MD, professor of medicine at UCLA, and colleagues, enrolled 30,136 patients from 225 hospitals with median length of stay of four days. The majority were without early follow-up. The median percentage of patients who had early follow-up after discharge was 38.3 percent.
Overall, 21.3 percent of patients were readmitted within 30 days, as reported in 2010 in the Journal of the American Medical Association. The 30-day readmission rates were 23.3 percent for hospitals in the first quartile of early follow-up (that is, within seven days), 20.5 percent for the second quartile, 20.5 percent for the third quartile, and 20.9 percent for the fourth quartile.
Notably, the median age of patients enrolled was 79. However, Fonarow says that “the benefits of early physician follow-up would be expected to benefit younger heart failure patients, as well.”
In the study, most early follow-up care was handled by general internists and not by cardiologists. “Interestingly, 30-day mortality rates were lower in hospitals with the highest rate of early follow-up with cardiologists,” Fonarow comments. So here is another place where health plans might identify the potential for long-term cost savings.
The authors speculate that while achieving early follow-up may be difficult for some physician practices, “models of care that include nurse practitioners or physician assistants under physician supervision may result in increased access to and timeliness of care.”
Better payment methodologies would do a lot to improve outcomes in the heart failure population, says Marvin A. Konstam, MD, past president of the Heart Failure Society.