A Heart Failure Management Program Using Shared Medical Appointments
Patients whose care was augmented using shared medical appointments for heart failure disease management did not have significantly better 1-year hospitalization outcomes when compared with patients who only attended a heart failure specialty clinic.
Ms. Carroll is a doctoral candidate at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr. Howrey is a postdoctoral fellow at Siteman Cancer Center/Barnes-Jewish Hospital in St. Louis, Missouri. Dr. Payvar is a clinical psychologist, Ms. Deshida-Such is a clinical dietitian, Dr. Kansal is a cardiologist, and Dr. Brar is an acute care nurse practitioner all at the Jesse Brown VAMC in Chicago.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Rising health care costs have led to threats of nonreimbursement for rehospitalization within 30 days postdischarge. 1,2 Heart failure (HF) in particular is characterized by the highest 30-day rehospitalization rate (23.5% in 2013), which accounts for more than two-thirds of HF expenditures. 3,4
Much of HF-related health care costs can be addressed with effective self-management by patients with HF. Therefore, developing and implementing effective disease management programs for this high-risk patient population is essential. Heart failure management programs may include optimizing HF medications, improving patient understanding of the importance of appropriate diet and physical activity, and cultivating psychological health and well-being. In a 2013 systematic review and meta-analysis, Wakefield and colleagues found that disease management programs improved nearly all HF outcomes, including lower mortality rates, lower hospital readmission rates, fewer clinic visits, higher satisfaction with care, and higher quality of life, compared with a no-treatment control or standard care. 5 Moreover, these programs demonstrated cost-effectiveness by reducing HF-related hospitalizations and health care expenditures. 5
One method to deliver specialized disease management programs to a greater number of patients may be to use shared medical appointments (SMAs). In a randomized controlled trial, Smith and colleagues demonstrated improved HF outcomes through 7 months among veterans who attended SMAs for HF management. 6 However, the trial enrolled only 25% of patients screened, and 63% of the patients who did not enroll were classified as not interested. These findings suggest that patients with HF, and veterans in particular, may face additional barriers to enrolling in HF management programs, and these results may not be fully representative of veterans with HF.
In this study, the authors used a naturalistic study design via retrospective review of the electronic health record (EHR) to evaluate whether patients with acute HF who chose to attend SMAs promoting self-management skills for HF would have better hospitalization outcomes compared with those who received individual disease management instructions in a HF specialty clinic (ie, usual care). The authors hypothesized that veterans who participated in the HF SMA clinic would have fewer 12-month HF-related and all-cause hospitalizations, fewer days in the hospital, and more days to first hospitalization compared with patients in usual care.
Methods
The clinic for veterans with acute HF was initiated in October, 2010 at the Jesse Brown VAMC (JBVAMC) in Chicago, Illinois, to reduce readmissions by targeting patients who had been previously hospitalized for HF. In September 2011, the multidisciplinary SMA clinic was developed within the HF clinic to provide enhanced care focused on self-management strategies for patients with HF. The HF SMA program comprised 4 weekly face-to-face sessions co-led by
