Heart Failure Management Hinges on Care Collaboration

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With increasing numbers of Americans affected by heart failure, the healthcare system’s mantra for care is “teamwork.”

CVB_0306_04Acute heart failure accounts for more than one million primary hospitalizations annually, and more than three million contributing hospitalizations. It is the leading cause of hospitalization in patients over the age of 65—which will grow as the population ages. 

In September, the Agency for Healthcare Research and Quality (AHRQ) reported that hospitalizations for congestive heart failure increased by 3 percent during the last decade, rising to the second most common disease treated in hospitals in 2007.

Another AHRQ report released in May found that the “potentially preventable hospitalizations” associated with heart failure total $7.2 billion annually. The average hospital stay for a heart failure patient costs $6,000 to $12,000, according to the New England Healthcare Institute. As a result, the high rate of hospitalization has led to cost estimates for 2009 of more than $37 billion for heart failure care in the U.S. (Circulation 2009;119(3):480-6).

The leading causes of hospitalization include a failure to recognize worsening symptoms, patient noncompliance with medications and weight management, and a lack of cohesion between caregivers. “Even as we increase our compliance with beta blocker and ACE [angiotensin-converting enzyme] inhibitor recommendations, we are still seeing the readmission rates increase,” says William E. Chavey, MD, a practicing primary care physician and family medicine faculty member at the University of Michigan in Ann Arbor. “We also know that the single, biggest factor predicting admission for heart failure is prior admission. We’re attempting to manage a progressive condition that we cannot cure.” 

Statistics from the Veterans Administration suggest that readmission for heart failure occurs within 30 days following 20 percent of discharges, with similar rates in the Medicare system. This issue will continue to garner attention as third-party payors, including the Centers for Medicare & Medicaid Services (CMS), are becoming unwilling to reimburse for readmissions that occur within 30 days of discharge.

Initial Rx management

The care for early stage heart failure/pre-heart failure is well orchestrated by the guidelines, according to Clyde W. Yancy, MD, president of the American Heart Association (AHA). Asymptomatic patients with a reduced ejection fraction (EF) should adhere to ACE inhibitors or angiotensin receptor blockers (ARBs) and a beta blocker. “The earlier the intervention occurs with evidence-based therapy, the better,” says Yancy, medical director and chief of cardiothoracic transplantation at the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas. If a low EF (less than 30 percent) is due to ischemic heart disease, an implantable defibrillator might be warranted, along with standard drug therapy (ACE inhibitors/ARBs and beta blockers). “The benefit [of ICDs] appears to be strongest in those with mild or moderate disease, as opposed to advanced disease,” he says.

If the disease progresses to the development of symptoms, diuretics begin to play an important role in controlling a patient’s volume, especially in early-stage depressed left ventricular EF, says Marc Jay Semigran, MD, director of the heart failure program at Massachusetts General Hospital in Boston. Aldosetrone antagonists should be added if symptoms progress, and multiple diuretics may eventually be needed to control volume overload.

But early-stage patients tend to be managed by primary care physicians and it’s not clearly defined when a heart failure specialist should intervene, Chavey says. He acknowledges that some confusion may exist among primary care physicians about the management of heart failure—with a reduced or preserved EF. The growing consensus, voiced by Yancy, is that the “best care for heart failure patients seems to emanate from a team approach, led by a physician leader. That physician needs to be supported by physician extenders, such as nurses or physician assistants. Most importantly, this team needs to engage in an interactive, longitudinal patient-centric experience.”

Disease progression

Practitioners have multiple clinical trial results to guide drug dosages for progressing heart failure. One caveat, however, is the sensitivity for ACE inhibitors versus beta blockers. “To the best of our knowledge, the response to beta blockers is dose related,” Yancy says. “Therefore, the more beta blocker on board, the better the response—response is measured by the recovery of heart muscle and survival. However, we are not as convinced that the same applies to ACE inhibitors.”

Semigran concurs that benefits of higher doses of beta blockers are clearer than maximizing dose for ACE inhibitors or ARBs, adding that primary care physicians can be particularly helpful in tailoring doses. He also says that there is a concern that patients could become symptomatic if doses are too high.

Chavey says that the side effects of beta blockers can reduce  patients’ quality of life, even while working to prolong their lives. However, if beta blockers are going to be withheld from a patient with worsening heart failure due to lack of tolerance, it needs to be part of an “informed consent” with the patient and his/her family, he says. 

If beta blockers are administered, the current ACC/AHA guidelines only recommend three as evidence-based adjuncts to standard ACE inhibitor and diuretic therapy in congestive heart failure: bisoprolol (Zebeta; Wyeth), carvedilol (Coreg; GlaxoSmithKline) and long-acting metoprolol (Lopressor; Novartis). “It is only appropriate to use an evidence-based beta blocker for heart failure, as all beta blockers are not created equal,” Yancy stresses. “With these agents, we know how to prescribe, how much to prescribe and how to dose with other drugs.”

Meanwhile, more evidence has emerged contraindicating the combination use of ACE inhibitors and ARBs as a treatment for congestive heart failure. Most recently, at the 2009 European Society of Cardiology meeting, Kuenzli et al reported that the combination treatment reduced hospitalizations but did not affect mortality and was associated with adverse events, after evaluating eight randomized controlled trials with a total of 18,061 patients.

Yancy says the ideal approach is an ACE inhibitor preferentially, but ARB if the patient is ACE inhibitor-intolerant. “The two should only be used together if there is some compelling reason, like blood pressure control,” he says, adding that the combination therapy receives a Class IIb, the lowest recommendation, in the current guidelines.

In cases of acute decompensated heart failure, Semigran recommends increasing the use of vasodilators, an “underappreciated” therapy “as opposed to continuing with IV diuretics and oral vasodilators or using inotropes.” For future treatments, Semigran suggests that relaxin, among other novel drugs being developed, could be an “interesting agent for improving cardiac performance, as well as having improved renal effects.” In October, Corthera received fast-track designation for relaxin from the FDA. There also are large-scale trials of nesiritide (Natrecor; Scios) for acute decompensated heart failure currently underway. 

IT’s future role

Over the past year, there has been an increased emphasis on reducing heart failure readmissions. The discussion has entered the healthcare reform debate via government legislators and payors, as well as private insurance payors. CMS launched a pilot project earlier this year, for example, testing the use of bundled payments, which allow hospitals one-lump sum to share among all providers in an episode of care. Experts agree that it’s only a matter of time before CMS will not pay for heart failure readmissions within 30 days. Studies looking at reducing heart failure have concluded that a multidisciplinary approach and health IT monitoring systems are ways to coordinate care and achieve better outcomes.

In a real-world clinical practice study, Roughead et al found that a collaborative medication review—including physician referral, a pharmacist home visit to identify medication-related problems and a pharmacist report with follow-up undertaken by the physician—cut hospitalization by 45 percent in its first year (Circ Heart Fail 2009;2:424-428). An important finding of the study is that medication-related problems contribute to poorer health outcomes for heart failure patients, and these can be prevented or improved even in the very old (population averaged 80 years), says Elizabeth E. Roughead, PhD, from the Quality Use of Medicines and Pharmacy Research Centre at the University of South Australia in Adelaide. She adds that their successful results came from “doctors and pharmacists collaboratively caring for their patients.”

Likewise, a meta-analysis of 10 clinical trials found that implementing programs using team-based care and in-person communication could result in a 3 percent reduction in hospital heart failure readmissions per month (Health Affairs 2009;28(1):179-89). Yancy says these types of improved results require a longitudinal model of care that can be driven by a cardiologist and a dedicated heart failure clinic, a hospital-based program, or a community center with a primary care physician champion.

Semigran concurs that third-party payors or primary care physicians, unrelated to the hospitalization, can organize “effective heart failure disease management programs, especially if the heart failure specialist is kept abreast of medicinal and therapeutic changes.”

The processes might require “integrated systems of care or IT-based resources, particularly for education and adherence. The health IT solutions may not be widely available yet, but that will be the future of the field,” Yancy says.

A 2009 New England Healthcare Institute report found that using remote patient monitoring for heart failure reduces readmission rates by 32 percent, compared to standard outpatient care for the six months following hospitalization. Applying this standard to a population of 100 advanced heart failure patients averages in 24 fewer hospitalizations, each of which cost about $9,700 and involves 5.5 days in the hospital. 

“If you can keep patients out of the hospital by monitoring them at home, and intervening prior to the decompensation progressing to the need for hospitalization, the provider saves the cost of admission and readmission, and it’s good for patients,” Semigran notes.

“Disease management, as opposed to a single pharmaceutical treatment, is effective; specifically an integrated approach that optimizes the best care and therapies during hospitalization and transitions that high quality of care to a provider of record in relatively short order after hospitalization,” Yancy concludes.