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.
This study was a naturalistic, retrospective examination of a HF management program promoting self-management delivered via multidisciplinary SMAs among veterans who enrolled in an acute HF specialty clinic. The authors’ hypothesis was not supported: patients who attended the HF SMA clinic did not have lower 12-month hospitalization or mortality rates, shorter hospital stays, or longer time to hospitalization compared with patients in the HF clinic only.
In contrast to the patient-centered approach of this study, a randomized trial delivering a similar disease management program found that patients with acute HF in the SMA group had better short-term ( < 7 months) hospitalization outcomes, specifically greater time to first HF-related hospitalization (HR 0.45, 95% CI: 0.21-0.98), but this effect did not last through 12 months when compared with patients in standard care. 6 These disparate findings may be explained by the gap in bench-to-bedside research, where despite scientific evidence indicating better outcomes among patients randomized to an intervention, when patients are given a choice, they may not choose to engage in the best option for their HF treatment.
In the present study, veterans who chose not to attend the HF SMA clinic may have done so for numerous reasons that may have influenced the outcomes. For example, those veterans who did not attend the HF SMA clinic may have had higher health literacy and less need for an educational program. Health literacy has been inversely associated with HF outcomes, such that patients with HF with lower health literacy have greater risk of HF rehospitalization or mortality. 9,10 In addition, many of the veterans who were followed in the HF clinic were taught the same disease management strategies by the NP during one-on-one visits, and they may have gained the same self-management skills in a different setting.
Another possibility is that the veterans enrolled in the HF clinic were less likely to be followed exclusively at the VA and therefore may have had external hospitalizations not recorded in their VA health records. In 2000, more than half the veterans who received health care services at the VA reported that they did not receive their care exclusively at the VA. 11 This may be especially true since the Veteran’s Choice Program permits veterans who reside > 40 miles from a VA hospital to receive care closer to home.
Disease Management Programs
Disease management programs for HF in general promote better outcomes and lower health care expenditures. 5,12 Self-management instruction delivered via SMAs may have greater potential for reducing HF-associated health care costs if it were to be integrated earlier in the continuum of care. The sample in this study was composed of veterans who were referred
