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ORIGINAL ARTICLE

Improved Cost-effectiveness for Management of Chronic Heart Failure by Combined Home-based Intervention with Clinical Nursing Specialists Yi-Lwun Ho,1,2 Tse-Pin Hsu,3 Chiou-Ping Chen,3 Chu-Yuan Lee,3 Yen-Hung Lin,2 Ron-Bin Hsu,4 Yen-Wen Wu,5 Nai-Kuan Chou,4 Chi-Ming Lee,2 Shoei-Shen Wang,4 Hsiu-Tzu Ting,3 Ming-Fong Chen2* Background/Purpose: The influence of home- and clinic-based caring system on the economic burden off heart failure remains unknown. Methods: Between January 2004 and December 2004, chronic heart failure patients who were followed up by specialist nurse-led telephone visiting regularly were enrolled. Clinical and economic data half a year before enrollment were collected as control. Results: A total of 247 patients (168 males, 79 females; mean age, 60 ± 17 years) were enrolled. The mean follow-up period was 139 ± 96 days. The mean left ventricular ejection fraction was 35%. There were 1618 times of specialist nurse-led telephone visiting (average 8 ± 6 times/patient). The mortality rate was 5.7%. Before enrollment, the total hospitalization fees were US$624,020. After enrollment, the cost was reduced to US$362,722 (41.8% reduction). The mean functional class (New York Heart Association) also improved from 2.27 ± 0.80 to 1.96 ± 0.90 (p < 0.001). The mean duration of hospital stay due to heart failure was reduced by 5.3 days (26.2% decrement). The total numbers of admission were reduced to 36 times (33.0% decrement). The readmission rate due to etiologies other than heart failure (such as infection, gastrointestinal bleeding, etc.) was reduced from 15.9% to 7.7%. The total fees of visiting emergency station were reduced from US$6528 to US$6101 (6.5% decrement). On the other hand, the frequency of visiting the outpatient department (OPD) increased from 5.2 ± 3.2 to 6.6 ± 4.1 times/patient (p < 0.001). The total fees of visiting OPD increased from US$90,783 to US$94,855 (4.4% increment). Conclusion: The home- and clinic-based caring system is capable of decreasing adverse outcomes, mostt notably hospitalization and length of stay, and could trigger significant cost savings in the management off heart failure. [J Formos Med Assoc 2007;106(4):313–319] Key Words: economic burden, heart failure, home- and clinic-based caring system

The prognosis of heart failure due to left ventricular dysfunction is poor, with a 5-year survival of 50% and 10-year survival of only 20%.1 Specialist heart failure nurse-led home-based management

not only improves quality of life and reduces readmissions in patients with congestive heart failure, but also reduces costs and improves the efficiency of the health care system.2–7 A combination

©2007 Elsevier & Formosan Medical Association .

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Graduate Institute of Clinical Medicine, 2Division of Cardiology, Department of Internal Medicine, and Departments of 3Nursing, 4Surgery and 5Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.

Received: March 2, 2006 Revised: November 8, 2006 Accepted: December 5, 2006

*Correspondence to: Dr Ming-Fong Chen, Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. E-mail: [email protected]

J Formos Med Assoc | 2007 • Vol 106 • No 4

313

Y.L. Ho, et al

of clinic- and home-based intervention has also been reported to reduce recurrent readmission and improve event-free survival.8 The economic effect of such a system remains unknown, so this prospective study was conducted to assess this issue.

Methods

of heart failure (exerted breathing sensation, shortness of breath, leg edema, fluid retention) or fluid retention up to 1.5–2 kg/week developed, then the specialist nurse would arrange for the patient to visit the ES or be admitted after discussion with the physician. The patient could communicate with the specialist nurse any time when their condition changed. After discharge from the hospital, the specialist nurse would communicate with the patient within 48–72 hours.

Patients Patients with heart failure manifestations (exerted breathing sensation, shortness of breath, leg edema, fluid retention) and impaired left ventricular contractility (left ventricular ejection fraction ≤ 40% by echocardiography or Tc99m left ventriculography) were enrolled in this study. Gender, age, medications, serum biochemical data, and etiologies of heart failure were recorded. Patients were initially followed up at outpatient department (OPD) at 4-week intervals. The management of these heart failure patients was according to ACC/AHA guidelines for heart failure management.9 Specialist nurse-led telephone visiting was done at 2-week intervals. After their conditions stabilized, patients were followed up at OPD at 2- or 3-month intervals and received telephone visiting at 3- or 4-week intervals. If the patient was admitted to ward or visited the emergency station (ES), the specialist nurse would care for the patient and inform the attending visiting staff. After discharge from the hospital, the patient would be scheduled to visit the OPD within 1 week.

Role of specialist nurse and telephone visiting The specialist nurse did the history taking and physical examination when the patient visited the OPD. They recorded the vital signs and body weight. The specialist nurse also gave the patient health education about the pathophysiology of heart failure, diet therapy, and limitation of fluid intake. The specialist nurse-led telephone visiting included body weight status, urine output, compliance of medication, fluid intake, and side effects of medication. If the symptoms and signs 314

Economic analysis of management for heart failure The economic analysis was based on three divisions including OPD, ES, and ward. The frequency of visiting OPD and insurance paymentt for visiting OPD were calculated. The frequencies of visiting ES and insurance payment for visitingg ES were calculated. The frequency of admission to intensive care unit (ICU) and duration of ICU stay were calculated. The admission rate, duration of admission, and insurance payment forr admission were calculated. The readmission rate (caused by either heart failure or other etiologies) and mortality rate were also calculated. These data were calculated half a year before enrollment as control group. The exchange rate between New Taiwan dollar (NT$) and United States dollar on September 30, 2005 was US$1 = NT$33.21.

Statistical analysis Data were expressed as mean ± standard deviation. Comparisons between groups for continuous data were made using pair t test. Differences between proportions were assessed by χ2 test. Multiple regression analysis was conducted for the mean duration of hospital stay, admission rate, and readmission rate due to etiologies other than heartt failure (such as infection, gastrointestinal bleeding, etc.). All other variables, including enrollmentt to this program, age, gender, different comorbidities, and initial functional class (New York Heartt Association) were used as the covariates. A value of p < 0.05 was considered to indicate statistical significance. J Formos Med Assoc | 2007 • Vol 106 • No 4

Clinic- and home-based intervention off heart failure f

Results

Economic burden of admission and ES

Patient characteristics A total of 247 patients (168 males, 79 females; mean age, 60 ± 17 years) were enrolled. The etiologies for heart failure and medications are listed in Table 1. The comorbidities are listed in Table 2. The mean follow-up period was 139 ± 96 days. The mean left ventricular ejection fraction was 35%. Mortality during the follow-up period was 5.7%. The mean functional class improved from 2.27 ± 0.80 to 1.96 ± 0.90 (Table 3, p < 0.001). There were 10 patients (48%) with initial functional class IV that improved to functional class I (one patient), functional class II (six patients), and functional class III (three patients).

Specialist nurse-led telephone visiting There were 1618 times of specialist nurse-led telephone visiting (average 8 ± 6 times/patient). Average time spent on each telephone visit was 4.3 ± 3.0 minutes. The telephone numbers for patient consultation were 266 times. The compliance for patient follow-up was 97.4%.

Table 1. Patient characteristics Sex (male/female), n

Before enrollment, the total admission fees were US$624,020 (Table 4). After enrollment, the costt was reduced to US$362,722 (41.8% reduction). The total numbers of admission were reduced 36 times (33.0% decrement). The reduction of each admission cost was US$8166. The mean duration of hospital stay due to heart failure was reduced from 19.5 ± 21.7 to 14.3 ± 17.7 days (p = 0.039; Figure 1). The readmission rate due to heart failure was 16.5% (before enrollment) and 17.0% (afterr enrollment). After enrollment, the readmission

Table 2. Concomitant associated diseases Concomitant associated disease Hypertension

92 (37)

Diabetes mellitus

79 (32)

Atrial fibrillation

72 (29)

Hyperlipidemia

52 (21)

ASD

3 (1)

VSD

3 (1)

Stroke

20 (8)

Chronic renal insufficiency

36 (15)

Uremia

14 (6)

Liver cirrhosis 169/78

Age (yr)

60 ± 17

Mean left ventricular ejection fraction (%)

35

Medications, n (%) Digoxin β-blocker ACEI and/or ARB Diuretics Anti-arrhythmic agent

144 (63) 108 (47) 115 (61) 203 (89) 69 (30)

Etiologies for heart failure, n (%) Coronary artery disease Dilated cardiomyopathy Valvular heart disease Myocarditis Others*

120 (48.6) 70 (28.3) 37 (15.0) 10 (4.0) 14 (5.7)

*Including congenital heart disease and cardiomyopathy other than dilated or ischemic types. ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker.

J Formos Med Assoc | 2007 • Vol 106 • No 4

n (%)

5 (2)

COPD

17 (7)

Multiple comorbidities 1 disease 2 diseases 3 diseases 4 diseases 5 diseases 6 diseases

66 (26.7) 63 (25.5) 42 (17.0) 16 (6.5) 2 (0.8) 1 (0.4)

ASD = atrial septal defect; VSD = ventricular septal defect; COPD = chronic obstructive pulmonary disease.

Table 3. New York Heart Association functional class Functional Before enrollment, After enrollment, classification n (%) n (%) Class I Class II Class III Class IV

34 (14) 132 (53) 60 (24) 21 (9)

82 (33) 112 (45) 31 (13) 22 (9)

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Y.L. Ho, et al

Table 4. Changes of heart failure patients before and after enrollment (n = 247) Before enrollment

After enrollment

Change (%)

Cost (US$) Total admission Non-heart failure admission ES OPD

624,020 541,800 6528 90,783

362,722 184,136 6101 94,855

−41.8 −66.0 −6.5 4.4

Duration (d) Total admission Non-heart failure admission ES ICU

2127 1729 66 327

1042 556 45 160

−51.0 −67.8 −31.8 −51.1

Numbers Total admission Non-heart failure admission ES ICU OPD

109 82 43 35 1085

73 26 27 12 1352

−33.0 −68.3 −37.2 −65.7 24.6

Insurance payment for ES (congestive heart failure)

0

00 >6

60

0 50

1– 50

0 1– 40

40

0 1– 30

30

0

00

20

1–

Figure i 1. Duration off h hospitall stay (all ( ll cause)) was significantly f l reduced after enrollment (p ( = 0.039).

10

1–2 2–3 3–4 4–8 8–12 > 12 Admission duration (wk)

Before enrollment After enrollment

–1

10

Insurance payment for OPD

C

0–1

1–2

2–3

3–4 Week

Before enrollment

4–8

8–12

> 12

After enrollment

Figure i 3. After f enrollment, ll ((A)) the h fr f equency off visiting outpatient department (OPD) was increased and (B) the interval between visiting OPD was shortened. (C) The cost off visiting OPD was significantly increased after enrollment.

600 500 OPD number

Interval of visiting OPD

B

OPD number

Patient number

A

400 300

p= 0.00018

200 100

0

0

40 >

40

0 1– 30

0

30

25

1– 25

0 1– 20

0

20 1–

15

15

00

1– 10

0 –5

–1 51

–2

25

5

0

US dollars

Economic burden of OPD (Figure 3) The frequency of visiting OPD increased from 5.2 ± 3.2 to 6.6 ± 4.1 times/patient (p < 0.001). The total numbers of visiting OPD also increased from 1085 to 1352 times (24.6% increment). The mean fee of visiting OPD was reduced from US$84 ± 84 to US$70 ± 62 (p < 0.001). The total fees of visiting OPD increased from US$90,783 to US$94,855 (4.4% increment).

Discussion The management of heart failure consumes 1–2% of health care expenditure in European countries,10,11 with around 75% relating to inpatient care. In 2000, 1.5% of total health care expenditure was attributed to chronic heart failure in the United States, and 65% of heart failure expenditure was related to hospitalization.12 About 45% of patients hospitalized with acute heart J Formos Med Assoc | 2007 • Vol 106 • No 4

failure will be rehospitalized at least once (and 15% at least twice) within 12 months.13,14 Therefore, reduction of admission also reduces the economic burden of heart failure. In this study, the admission cost was reduced 41.8% by a clinicand home-based intervention of heart failure. This is similar to the 40.3% reduction in recurrentt bed utilization reported by Stewart et al.2 The reduction of each admission cost was US$8166. This is also similar to the report of estimated savings in hospital readmission costs of $9800/ patient.6 In this study, the mean duration of hospital stay due to heart failure and unplanned admission was also reduced. The data were similarr to the report of Thompson et al.8 Via bidirectional communication between medical staff and patients, a clinic- and home-based intervention program can improve survival and self-care behavior in patients with heart failure as well as reduce the number of events, readmissions, and days in hospital. 317

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There are several possible reasons for the favorable economic outcome of such management. This clinic- and home-based intervention of heart failure patients was associated with good compliance of β-blocker therapy (47%) during follow-up.8 A similar finding was reported by Thompson et al and there was 56% of β-blocker use in their study.8 Patients’ knowledge and β-blocker treatment improve prognosis of patients from a heart failure clinic.15 This clinic- and home-based intervention of heart failure improved patients’ knowledge of heart failure and increased compliance with β-blocker therapy. Cost-effectiveness studies also suggest that β-blockers for heart failure are cost-saving over a period of approximately 6 months.16,17 On the other hand, angiotensinconverting enzyme inhibitors are a mainstay of treatment in patients who can tolerate them; in patients who cannot take these drugs, angiotensin II receptor blocking agents offer an alternative. Both medications improve functional status and survival in heart failure patients. With good compliance to both medications, the New York Heart Association functional class improved in this study. Improvement in functional status and exercise capacity has also been reported by West et al.18 This improvement reduced the readmission of heart failure patients. In this study, the total number of OPD visits increased by 24.6%, but the average fees of visiting OPD were significantly reduced. The total OPD fees only increased 4.4%. On the other hand, the total number of ES visits decreased by 37.2% and the total fees of visiting ES decreased by 6.5%. Any intervention capable of decreasing even a small fraction of the adverse outcome, most notably hospital admission and length of stay, could trigger significant cost savings in the management of heart failure.12 There were several study limitations. First, there were no reference patients for comparison and this study was not a randomized controlled trial. Second, some patients had been treated by cardiologists before enrollment. Thus, the improvement in clinical and economic parameters may partially be affected by previous therapeutic modalities. 318

Therefore, a longer period of time is needed to evaluate the cost-effectiveness of the clinic- and homebased intervention for patients with heart failure.

Acknowledgments This study was partially supported by National Taiwan University Hospital (grant NTUH 95.N11) and National Taiwan University Hospital Yun-Lin Branch (grant NTUHYL 95.S017). We also wish to thank Chia-Ling Cheng, Graduate Institute of Health Care Organization Administration, National Taiwan University, and Yu-Li Lin, Department of Business Administration, Chihlee Institute of Technology.

References 1. McKee PA, Castelli WP, McNamara PM, et al. The natural history of heart failure: the Framingham Study. N Engl J Med 1971;285:1441–6. 2. Stewart S, Blue L, Walker A, et al. An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J 2002;23: 1369–78. 3. Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999; 354:1077–83. 4. Blue L, Lang E, McMurray JJ, et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ 2001;323:715–8. 5. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333:1190–5. 6. Fonarow GC, Stevenson LW, Walden JA, et al. Impact off a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol 1997;30: 725–32. 7. Cline CM, Israelsson BY, Willenheimer RB, et al. Cost effective management programme for heart failure reduces hospitalisation. Heart 1998;80:442–6. 8. Thompson DR, Roebuck A, Stewart S. Effects of a nurseled, clinic and home-based intervention on recurrent hospital use in chronic heart failure. Eur J Heart Failure 2005; 7:377–84.

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9. Hunt SA, Baker DW, Chin MH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure); International Society for Heart and Lung Transplantation; Heart Failure Society of America. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation 2001;104:2996–3007. 10. Berry C, Murdoch DR, McMurray JJ. Economics of chronic heart failure. Eur J Heart Failure 2002;3:283–91. 11. The treatment of heart failure. Task Force of the Working Group on Heart Failure of the European Society of Cardiology. Eur Heart J 1997;18:736–53. 12. Lee WC, Chavez YE, Baker T, et al. Economic burden of heart failure: a summary of recent literature. Heart Lung 2004;33:362–71.

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13. Krumholz HM, Chen J, Murillo JE, et al. Admission to hospitals with on-site cardiac catheterization facilities: impact on long-term costs and outcomes. Circulation 1998;98: 2010–6. 14. Nieminen MS, Bohm M, Cowie MR, et al; ESC Committee for Practice Guideline (CPG). Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J 2005;26: 384–416. 15. Lainscak M, Keber I. Patients’ knowledge and beta blocker treatment improve prognosis of patients from a heart failure clinic. Eur J Heart Failure 2006;8:187–90. 16. Delea TE, Vera-Llonch M, Richner RE, et al. Cost effectiveness of carvedilol for heart failure. Am J Cardiol 1999;83: 890–6. 17. Vera-Llonch M, Menzin J, Richner RE, et al. Costeffectiveness results from the US Carvedilol Heart Failure Trials Program. Ann Pharmacother 2001;35:846–51. 18. West JA, Miller NH, Parker KM, et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol 1997;79:58–63.

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