ANAHEIM, Calif. -- When a team of specialists cares for patients with congestive heart failure, the costs of treating these patients can be reduced by more than one-third, according to a new cost analysis conducted by Duke University Medical Center.
These savings are realized from shifting the focus of care from costly in-hospital settings to more frequent but inexpensive out-patient visits. Also, since team members interact more often with patients – either in the clinic or by telephone - they can make more effective use of medications, especially newer and more powerful agents that many physicians may not feel comfortable using.
"For patients with chronic diseases like heart failure, we now know how to implement a disease management program that can close the gap between what we know and what is practiced," said cardiologist Dr. David Whellan, fellow at the Duke Clinical Research Institute. Whellan prepared the results of the Duke research for presentation Wednesday at the 49th annual scientific session of the American College of Cardiology.
"By prescribing medications more effectively and reducing hospital stays, we were able to improve the quality of care for these patients," he said. "Overall, we saw a 37 percent decrease in the total cost of treating our patients, mainly through reduced hospitalizations. With our team approach, we were able to keep in touch with our patients more often and more closely monitor their medications. Traditionally, about 80 percent of the cost of caring for CHF (congestive heart failure) patients is related to their hospitalization, and we were able to reduce that effectively."
The analysis was based on a comparison of the costs associated with the care of 117 consecutive patients before and after they enrolled in the Duke Heart Failure Program, a proactive, multi-disciplinary approach to the care of CHF, a costly disease to treat. It is estimated that Medicare spends more than $20 billion a year for the treatment of CHF, more than the treatment for cancer and heart attacks combined, the researchers say.
CHF, which has a host of underlying causes, is characterized by the inability of the heart to pump enough blood to meet the needs of the rest of the body. Patients with the disease tend to tire easily, experience shortness of breath and have swelling in the extremities. More than 3 million Americans suffer from the debilitating effects of CHF, with 400,000 new cases diagnosed each year, especially among the elderly.
The Duke Heart Failure Program is made up of cardiologists, nurse practitioners, nurse specialists, clinical pharmacists, as well as nutritionists and social workers. The nursing staff stays in constant communication with patients by telephone, which helps the team fine-tune a patient's medication regimen and stay abreast of any emerging drug side effects or drug interactions.
One of the most important contributing factors in reducing hospitalizations, Whellan said, was the marked increase in the use of beta-blockers, from 52 percent to 76 percent. Because beta-blockers can slow heart rate and decrease the ability of heart muscle to contract, many physicians will not prescribe these drugs for their patients. However, beta-blockers have been shown to improve the function of the left ventricle, the main chamber that pumps blood to the body.
"New information over the past two or three years has shown that beta-blockers have an important role in the treatment of heart failure," Whellan said. "The use of beta-blockers may seem counter-intuitive, especially for physicians trained in the 1970s and 80s, but studies have clearly shown their beneficial effects. A program like this can help to demonstrate how new types of medication can be incorporated into an overall treatment plan and improve the quality of life for patients.
"We're always looking at what aspects of care we can take out of the hospital and put into the home setting," he continued. "Patients clearly are more comfortable in familiar surroundings."
The study also found that use of ACE inhibitors, which relax blood vessels and allow blood to be pumped with less effort, remained virtually unchanged, and that may not be in the best interest of their patients.
"ACE inhibitors are so well established, and their effects known, so all CHF patients should be on them," Whellan added. "What we did find, however, was that in many cases the dosages were below the target dose. For example, some physicians stop prescribing if their patient's blood pressure rises. However, we have a lot of experience in this area, and we feel confident that we can be aggressive in the use of ACE inhibitors while keeping a close eye on the patient."
Since CHF patients commonly take up to a dozen medications, it is important, Whellan said, that their care be closely monitored and supervised. A key member of the Duke team is a clinical pharmacist, who not only keeps current with the latest in medications, but is also well-versed in interactions between prescribed various medications, as well as over-the-counter agents. Other findings from the study included:
- Patients saw hospital admission rates drop from 1.86 admissions per year to 1.21.
- When they were hospitalized, the length of stay declined from 7.67 to 6.07 days.
- Outpatient visits jumped with general clinic visits rising from 7.8 to 12.9 per year and visits to cardiologists increasing from 1.5 to 7.7.
- Patient costs on average increased 27 percent, while inpatient costs decreased 38 percent.
- For those patients who were hospitalized, their cost-per-discharge decreased 32 percent.
The study was funded by Duke's Office of Science and Technology, which is funding a number of projects investigating the use of evidence-based medicine teams in treating chronic medical conditions.
Joining Whellan in the study, all from Duke, were Dr. Stuart Russell, Dr. Michael Blazing, Dr. Michael Cuffe, Dr. Ruth Ann Greenfield, Robert Taber, Wendy Gattis, Laura Gaulden, Bradi Granger and Dr. Christopher O'Connor.