Disease Management for. Heart Failure

Size: px
Start display at page:

Download "Disease Management for. Heart Failure"

Transcription

1 Disease Management for Heart Failure

2 DISCLAIMER: The information contained in this annotated bibliography was obtained from the publications listed. The National Pharmaceutical Council (NPC) has worked to ensure that the annotations accurately reflect the information contained in the publications, but cannot guarantee the accuracy of the annotations or the publications. There are articles available on the treatment of heart failure that are not included in this bibliography and that may include relevant information not covered herein. The inclusion of any publication in this bibliography does not constitute an endorsement of that publication by NPC or an endorsement of the services, programs, treatments, or other information contained in such publication. This bibliography is designed for informational purposes only, and should not be construed as professional advice on any specific set of facts and circumstances. This bibliography is not intended to be a comprehensive source of disease management services or programs for the treatment of heart failure, or a substitute for informed medical advice. If medical advice or other expert assistance is required, readers are urged to consult a qualified health care provider or other professional. NPC is not responsible for any claims or losses that may arise from any errors or omissions in the information contained in this bibliography or in the listed publications, whether caused by NPC or originating in any of the listed publications, or any reliance thereon, whether in a clinical or other setting. October 2004 National Pharmaceutical Council, Inc.

3 Introduction The Disease Management Association of America defines disease management as a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. 1 Disease management supports the clinician-patient relationship and plan of care, and emphasizes prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies. 1 It also evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. 1 More specific goals of disease management include: 2 Improving patient self-care through means such as patient education, monitoring, and communication. Improving physician performance through feedback and/or reports on patient progress in compliance with protocols. Improving communication and coordination of services between the patient, the physician, the disease management organization, and other providers. Improving access to services, including prevention services and prescription drugs as needed. The following functions are components of disease management: 2 Identification of patient populations. Use of evidence-based practice guidelines. Support of adherence to evidence-based medical practice guidelines by providing medical treatment guidelines to physicians and other providers, reporting on the patient s progress in complying with protocols, and providing support services to assist the physician in monitoring the patient. Provision of services designed to enhance the patient s self-management and adherence to his or her treatment plan. Routine reporting and feedback. Communication and collaboration among providers and between the patient and his or her providers. Collection and analysis of process and outcomes measures. Disease management programs are widely used for asthma, diabetes mellitus, and heart failure. 3-5 Considerations in selecting a disease for disease management include: Availability of treatment guidelines with consensus about what constitutes appropriate and effective care. Presence of generally recognized problems in therapy that are well documented in the medical literature. Large practice variation and a range of drug treatment modalities. Large number of patients with the disease whose therapy could be improved. Preventable acute events that often are associated with the chronic disease (e.g., emergency department or urgent care visits). Outcomes that can be defined and measured in standardized and objective ways and that can be modified by application of appropriate therapy (e.g., decreased number of emergency department visits or hospitalizations). Potential for costs savings within a short period (e.g., less than 3 years). Three major not-for-profit organizations whose mission is to promote quality health care have recognized the contribution of disease management activities to quality health care by establishing disease management certification or accreditation programs. The Joint Commission on Accreditation of Healthcare Organizations, an independent, not-for-profit organization and the nation s predominant standards-setting and accrediting body in health care, offers disease-specific care program certification. Program certification is based on an assessment of compliance with consensus-based national standards, effective use of established clinical practice guidelines to manage and optimize care, and an organized approach to performance measurement and improvement activities. 6 The National Committee for Quality Assurance accredits disease management programs on the basis of standards that are patient oriented, practitioner oriented, or both. It also offers organizations certification for program design (i.e., content development), systems (i.e., clinical information and other support systems), or patient or practitioner contact (e.g., for nurse call centers and other organizations without comprehensive activities). 7 The Utilization Review Accreditation Commission (URAC), also known as the American Accreditation HealthCare Commission, establishes standards for the health care and insurance industries. URAC s goal is to Disease Management for Hear Failure [1]

4 Disease Management for Hear Failure [2] promote excellence among purchasers, providers, and patients through continuous improvement in the quality and efficiency of health care delivery. It achieves this goal by establishing standards, education and communication programs, and a process of accreditation. URAC has accreditation programs for disease management as well as case management, claims processing, core accreditation, credential verification, health call centers, health networks, health plans, health provider credentialing, health utilization management, health Web sites, Health Insurance Portability and Accountability Act privacy and security, independent review, and workers compensation utilization management. 8 Penetration And Trends The ultimate goal of disease management is to produce optimal health outcomes for patients. Therefore, virtually all stakeholders in health care want to be involved. Disease management is of interest to providers, patients, managed care organizations, insurance companies, government agencies, pharmacy benefit management (PBM) firms, and employer purchasing coalitions. 9 Most disease management programs are implemented through health maintenance organizations (HMOs), PBM firms, or Medicaid agencies. 4 Some organizations choose to hire a vendor and contract out disease management services, whereas others choose to develop their own programs. Each method has advantages and disadvantages; success often depends on the organization and its level of resources and commitment. Managed Care Organizations and Pharmacy Benefit Management Firms Managed care organizations and PBM firms were the first to implement disease management programs. PBM firms offer disease management programs and services to employers and managed care clients as part of their overall benefit management services. 10 The 1998 Novartis Pharmacy Benefit Report indicated that 75% of PBM pharmacy directors were expending resources to develop disease management programs for conditions that respond to or depend on pharmaceutical products and services. HMOs reported that 16% of their disease management programs were provided thorough a PBM. 10 Most employers reported using PBM firms to manage costs, and many employers used PBM firms to provide disease management services. 10 America s Health Insurance Plans (a trade association created by the joining of the American Association of Health Plans and the Health Insurance Association of America) represents more than 1300 HMOs, preferred provider organizations, and other network-based plans. Members of the association provide health care to more than 200 million Americans nationwide. In a 2000 survey of a random sample of association members, 99% of member health plans offered a disease management program. 5 State Medicaid Programs In the rapidly changing environment of Medicaid managed care, it is essential for Medicaid directors and their top managed care staff to remain abreast of innovations in organization and payment that are occurring to serve the special needs of the Medicaid population. Traditionally, state Medicaid programs either have retained insurance risk and paid on a fee-for-service basis or have outsourced risk and contracted with Medicaid HMOs. Disease management represents a method of managed care in the middle between traditional fee-for-service and HMOs. Four types of models are emerging: 1. Medicaid health outcomes partnerships are usually applied to an existing fee-for-service primary care case management program. Medicaid programs focus on high-priority diseases, offering a number of support systems to help existing Medicaid providers better serve the patients assigned to them Disease management organizations are outside contractors who are retained by the state to address particular diseases, either by supplementing existing Medicaid providers and their case management activities or by taking over responsibility for targeted patients. 3. Pay-for-performance approaches establish new rules for scope of practice or referrals and involve nontraditional providers in the care of patients with specific diseases. The nontraditional providers are paid a special fee contingent on improving health outcomes or lowering costs. 4. Centers of Excellence focus on particular disease episodes for high-cost, high-volume diseases and select a network of hospitals, physicians, and other providers who are already organized to receive a prospective, bundled payment per episode of care. To meet criteria for designation

5 as a center of excellence, an organization must provide written documentation of the quality and outcomes of care for a selected disease. Most states are actively involved in the disease management process. By far, the diseases most often focused on in these programs are asthma and diabetes. Other diseases and conditions included in state disease management programs are arthritis, heart failure, depression, gastrointestinal disease, hemophilia, HIV infection/aids, hyperkinetic activity, dyslipidemia, mental health, otitis media, pregnancy, smoking, ulcer, and upperrespiratory infections. Current information about state disease and case management activities is available on the Web at Why Focus on Heart Failure? Over the last decade, managed care organizations began an intense utilization review process to identify areas where cost control measures would be appropriate. 12 Heart failure was one of the first diseases selected because there is great opportunity to treat this disease more effectively and to develop programs that will help payers and plans manage the high costs associated with it. 12 Economic Impact In the United States, the direct and indirect costs of heart failure in 2004 are estimated at $25.8 billion. 13 This figure includes $23.7 billion in direct costs for expenses related to hospitalization, nursing home care, physicians and other health professionals, medications, and home health care. The indirect costs for lost productivity and earnings due to death from heart failure amount to $2.1 billion. Hospitalization is the largest component of the direct costs of heart failure, and the rate of hospitalization for heart failure has increased substantially over the past decade. 14,15 In 1999, Medicare payments to beneficiaries hospitalized with heart failure amounted to more than $5000 per patient discharged and a total of $3.6 billion. 13 Nearly 75% of the hospitalization expense is incurred within the first 48 hours of hospitalization (except for the daily room charge). 14 Annual expenditures for medications to treat heart failure amount to approximately $500 million. 15 Epidemiology An estimated 5 million Americans have heart failure, and approximately 550,000 new cases are diagnosed each year. 13 The prevalence of heart failure increases with age; it is approximately 1% at age 50 and 5% at age Four out of five cases of heart failure occur in persons 65 years of age or older. 17 Heart failure is the most common cause of hospitalization in this age group, and nearly half of elderly patients with a discharge diagnosis of heart failure are readmitted within 6 months. 17 Men are more likely to be affected by heart failure than are women, probably because the incidence of ischemic heart disease is greater in men than in women. 13,18 Roughly 9 out of 10 patients with a diagnosis of heart failure survive for 1 year. 19 However, only 5 out of 10 patients are alive 5 years after diagnosis, and the quality of life is impaired in many of these patients. 19 Approximately 39,000 Americans die from heart disease annually, and the disease contributes to the deaths of another 225,000 people each year. 16 Death is sudden in 40% of patients, suggesting that it is the result of serious ventricular arrhythmia. 18 Mortality from heart failure is twice as high for African Americans as it is for whites. 16 What Is Heart Failure? Heart failure is the result of dysfunction of the cardiac ventricles during diastole (filling), systole (contraction), or both. 18 This dysfunction may have a variety of causes, including hypertension (which increases the workload for the heart) and diseases of the cardiac valves, muscle, and pericardium (the sac surrounding the heart). Myocardial infarction is a common cause of decreased contractility; damage to heart muscle fibers due to an insufficient oxygen supply impairs the ability of the fibers to shorten during systole. Myocardial infarction also can increase the stiffness of the ventricles and restrict filling during diastole. In most cases, heart failure is characterized by dysfunction of the left ventricle during systole and a low cardiac output (the volume of blood pumped per minute) and ejection fraction (the portion of the left ventricle volume expelled during systole). 18 Common causes of left ventricular systolic dysfunction include hypertension, coronary artery disease, and idiopathic dilated cardiomyopathy. 18 Heart failure is a condition in which the heart cannot pump enough blood to meet the needs of the body s other organs. It can result from: Narrowed arteries that supply blood to the heart muscle (i.e., coronary artery disease). Disease Management for Hear Failure [3]

6 Disease Management for Hear Failure [4] A past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle s normal work. High blood pressure. Heart valve disease due to past rheumatic fever or other causes. Primary disease of the heart muscle itself, called cardiomyopathy. Defects in the heart present at birth (i.e., congenital heart disease). Infection of the heart valves and/or heart muscle itself (i.e., endocarditis and/or myocarditis). The failing heart keeps working, but it doesn t work as efficiently as it should. People with heart failure cannot physically exert themselves because they become short of breath and fatigued. As blood flow out of the heart slows, blood returning to the heart through the veins often backs up, causing congestion in the tissues. Swelling (edema) results, most commonly in the lower legs, ankles, and feet, but possibly in other parts of the body as well. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. Heart failure also affects the ability of the kidneys to excrete sodium and water. Water retention worsens the edema. Compensatory mechanisms involving the blood vessels, kidneys, nervous system, and hormones (e.g., the renin-angiotensin-aldosterone system) allow the cardiovascular system to temporarily adapt to underlying pathologic conditions, maintain a normal cardiac output, and forestall the onset of heart failure signs and symptoms. 18 These mechanisms include hypertrophy of the ventricles (an increase in muscle mass and wall thickness), dilatation of the ventricles (i.e., increased volume), and sympathetic nervous stimulation (to increase heart rate, contractility, and cardiac output). However, some compensatory mechanisms can worsen heart failure; these mechanisms are referred to as maladaptive responses. For example, low renal blood flow due to low cardiac output results in activation of the reninangiotensin-aldosterone system, which increases blood pressure and promotes sodium and water retention and volume overload. 18 Although sympathetic stimulation increases the heart rate, contractility, and cardiac output, it also increases blood pressure and oxygen demand on the heart. Heart failure signs and symptoms manifest when the maladaptive responses overwhelm the beneficial effects of compensatory mechanisms. 18 Maladaptive responses contribute to disease progression in patients with heart failure. Signs and symptoms of heart failure include fatigue, shortness of breath, difficulty breathing (especially at night, when lying down, or during physical exertion), cough, weight gain (from fluid retention), and swelling of the feet and ankles. 16,18 The New York Heart Association functional classification may be used to classify functional disability in patients with heart failure on the basis of the extent to which physical activity is limited because of symptoms. Class I is no impairment (i.e., symptoms only at levels of physical activity that limit normal persons), and Class IV is severe impairment (i.e., symptoms at rest). Table 1 lists commonly used authoritative guidelines for managing heart failure. Up-to-date information on treatment guidelines from various sources also is available from the National Guideline Clearinghouse ( The management of heart failure, based on information in the guidelines, is discussed in Appendix A. Table 2 provides a list of organizations with information about heart failure for patients. Health Goals in Patients with Heart Failure Some of the conditions that cause heart failure (e.g., diseased heart valves) can be corrected. However, in most cases, a cure is not possible. Nevertheless, lifestyle modifications and drug therapies may be used to manage chronic illness. The goals of treatment are to increase survival, reduce symptoms, and improve functional status and quality of life. 16 Review of Heart Failure Disease Management Literature A comprehensive search of the heart failure disease management literature was conducted in preparing this bibliography. The goal was to identify reports describing educational interventions or disease management programs designed to improve the management of heart failure. Thus, whereas some reports describe comprehensive disease management programs, others describe educational interventions directed at patients, health care providers, or both. MEDLINE is the National Library of Medicine s premier database. It contains more than 12 million citations and abstracts from more than 4800 biomedical journals

7 Table 1. Authoritative Guidelines for Managing Congestive Heart Failure a 1. American Heart Association Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Available in print (Circulation. 2003;107: ) and online at: 2. Canadian Cardiovascular Society The Canadian Cardiovascular Society consensus guideline update for the diagnosis and management of heart failure. Available in print (Can J Cardiol. 2003;19: ). 3. Heart Failure Society of America Heart Failure Society of America guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction: pharmacological approaches. Available in print (J Card Fail. 1999;5: , Pharmacotherapy. 2000;20: , or Congestive Heart Failure. 2000;6:11-39) and online at: Update in progress. 4. Institute for Clinical Systems Improvement Health care guidelines on (1) Inpatient Management of Heart Failure (2004) and (2) Heart Failure in Adults (2003). Available online at: 5. European Society of Cardiology Guidelines for the diagnosis and treatment of chronic heart failure. Available in print (Eur Heart J. 2001;22: ) and online at: a Clinical practice is subject to constant change, and the guidelines in this list may become outdated or be superseded by newer ones. The reader is encouraged to consult the National Guideline Clearinghouse ( a public resource for evidence-based clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), in partnership with the American Medical Association and the American Association of Health Plans (now America s Health Insurance Plans), for the most current guidelines. published in the United States and 70 other countries. Topics span the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. Earlier versions of this bibliography were based on searches of the MEDLINE database for the period from January 1985 to May 2002 using the search terms disease AND management AND congestive heart failure. In preparing this updated version of this bibliography, an additional search of the MEDLINE database was performed for the period from May 2002 through May 2004 using the search terms disease management AND heart failure to reflect changes to the National Library of Medicine s controlled vocabulary. This search was limited to clinical trials. The primary criteria for inclusion of a report in this analysis were: An educational intervention undertaken to improve the management of heart failure. Measurement of the impact of the intervention or program. Reports on 68 disease management programs met these criteria. Appendix B presents summaries of these reports, and Appendix C displays associated methodological information and outcome data in tabular form. Methodologies The educational interventions or disease management programs were targeted at adults, including a large percentage of patients more than 55 years of age. Aside from three studies with mixed patient populations (one study included patients with chronic obstructive pulmonary disease [COPD] or congestive heart failure [CHF], another included patients with CHF or cardiomyopathy, and a third included patients with CHF, COPD, or diabetes), all interventions and programs were targeted at individuals with heart failure, including the congestive state. The size of the patient population ranged from to 15 to nearly 5000 patients. Patient participants in the disease management programs and educational interventions were recruited Disease Management for Hear Failure [5]

8 Table 2. Organizations With Information About Congestive Heart Failure for Patients American Heart Association 7272 Greenville Avenue Dallas, TX AHA-USA-1 or Heart Failure Society of America Court International Suite 240 S 2550 University Avenue West Saint Paul, MN Heart Rhythm Society Six Strathmore Road Natick, MA National Heart, Lung, and Blood Institute P.O. Box Bethesda, MD Texas Heart Institute P.O. Box Houston, TX Disease Management for Hear Failure [6] from various sites, including hospitals, clinics, private medical groups, and special heart failure centers. Some interventions and programs focused on patients with specific risk factors for hospital readmission. For example, 14 interventions and programs were conducted with patients who were elderly or had severe heart failure, including 2 programs affiliated with heart transplantation centers. In one case, a medical claims database was used to identify all patients with a heart failure-based claim of more than $50 as well as a recent hospital admission or emergency department visit. Fifty-two of the educational interventions or disease management programs were specifically intended for patients; families of the patients were involved in nine cases. The program content typically included information about: Heart failure (e.g., pathophysiology, signs, symptoms). Appropriate diet, weight, activity level, and other lifestyle factors. Medications and the importance of treatment adherence. Self-monitoring techniques to facilitate the daily measurement and reporting of body weight, dietary intake, and evidence of acute heart failure exacerbation (e.g., weight gain, edema, shortness of breath). Various settings and formats were used to present the educational material, including individualized and smallgroup sessions held at a hospital, outpatient clinic, or the patient s home. Information presented orally usually was supplemented by audiovisual or printed materials (e.g., workbooks, medication calendars, brochures). Common methods to reinforce educational material and promote treatment adherence included home visits by a nurse and outpatient clinic visits by patients. Telemonitoring ranging from regular, provider-initiated telephone calls to the transmission of patient self-reported data via an automated telemanagement system was used in many interventions and programs. New technologies allow for the education of patients at home by health care professionals at a remote location. Some devices also provide for the measurement and transmittal of patient health data from the home to the remote location for review by a health care professional. The use of these technologies has reduced the need for frequent home visits by health care professionals and patient trips to a health care facility. Thirteen educational interventions or disease management programs were directed at both patients and health care professionals. In addition to offering patient education, these programs and interventions provided health care professionals (including physicians) with information about:

9 The program itself or patient status (i.e., patient self-monitoring data). The appropriate use of practice guidelines developed locally or nationally. Techniques for improving patient adherence. The early management of complications. Three interventions were directly solely at health care providers. These interventions involved the development and implementation of critical and clinical pathways for management of patients with heart failure. All or certain aspects (e.g., patient teaching, medication dosage adjustments, critical pathways) of 20 disease management programs or educational interventions were based on guidelines widely accepted in the medical community. These include guidelines issued by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), the American Heart Association, and the American College of Cardiology. Eighteen other interventions or programs relied on internally developed guidelines or critical pathways, or were based partly or entirely on: Unspecified protocols, guidelines, or critical pathways. Guidelines issued by federal agencies (e.g., Medicare), nursing agencies, or home health care agencies. Published research. For example, target angiotensin converting-enzyme (ACE) inhibitor dosages in one disease management program were based on the results from randomized clinical trials. Most of the educational interventions and disease management programs targeting patients were administered by specially trained nurses or pharmacists. Some interventions and programs were administered by a multidisciplinary team of providers, including physicians, nurses, pharmacists, dietitians, social workers, psychologists, and home health care workers. However, a nurse often coordinated the activities of these multidisciplinary teams. Physicians, working alone or in conjunction with another health care professional, often conducted interventions or programs directed at health care providers (i.e., the development and implementation of critical pathways). The studies included 27 randomized, controlled trials; 18 observational, pre- and post-intervention comparison studies; and 5 retrospective chart reviews. Outcomes were assessed over various periods after the intervention (e.g., 30 days, 90 days, 6 months), with 29 studies providing patient follow-up data for 1 year or longer. Outcomes A commonly measured outcome was the hospital admission or readmission rate (readmissions), reflecting the goal of most educational interventions and disease management programs to reduce resource utilization. These rates were measured over relatively short periods (e.g., 30 or 90 days) in some studies and over longer periods (e.g., 1 year) in others. Forty- nine of the 68 educational programs and disease management programs used hospital admission or readmission rate as a measure of effectiveness. Following the intervention, rates dropped in 39 studies, remained unchanged in 7 studies, and increased in 3 studies. Other common hospital-related outcome measures included total number of hospital days and average length of stay (LOS). The average LOS decreased among patients receiving the intervention in 13 of 14 studies in which LOS was assessed. These changes were paralleled by a decrease in the total number of hospital days in 17 of the 18 studies in which this outcome measure was evaluated. Other measures of resource utilization (e.g., emergency department visits) also showed similar improvements. Several studies evaluated the effect of the educational intervention or disease management program on patients emotional or physical status. Patient-related outcome measures in these studies included quality of life, mood, and functional status. Improvement in quality-of-life scores was found among patients participating in the intervention in 17 of the 22 studies in which this parameter was assessed; improved mood also was observed in 3 studies. In 12 studies that assessed functional status, significant improvements were noted among patients participating in the program or intervention compared with controls. Several studies focused on the effectiveness of the educational intervention or disease management program in improving the disease-related knowledge or selfmanagement behavior of patients with heart failure. For example, eight studies assessed patient knowledge of Disease Management for Hear Failure [7]

10 topics such as appropriate medication use, diet, and exercise; improvements attributed to the intervention were observed in seven of these studies. Eleven studies used objective measures of adherence to the medication regimen, dietary restrictions, and other aspects of treatment. All of these studies documented improved adherence among patients who participated in the educational intervention or disease management program. Knowledge of and compliance with practice guidelines among providers were indirectly measured by evaluating the appropriateness of medical management (e.g., appropriate use of an ACE inhibitor to reduce afterload in a patient with heart failure who can tolerate such therapy). Of the six studies that evaluated appropriate medical management, five documented improved care associated with the educational intervention or disease management program, including more appropriate use or dosing of ACE inhibitors in three studies. Health-related costs were evaluated or projected in 37 studies. Thirty-two reports described reduced healthrelated costs among patients who participated in the educational intervention or disease management program. The intervention had no impact on costs in one study. A cost savings was projected in another four reports. The Future of Disease Management Disease management can improve patient outcomes and quality of life while potentially reducing overall costs. It is an important approach to integrated care. As health care payers incorporate disease management principles into the delivery of care, they need to become more sophisticated in contracting with outside vendors for these services. The Disease Management Association of America works with potential customers to address issues associated with contracting, such as data contracting and risk sharing. Currently, the Disease Management Association of America has more than 100 corporate members that provide disease management services. Disease management vendors have begun using the Internet to reach out to target populations. The Internet allows two-way communication between clinicians and patients, as well as immediate and free access to educational materials. Compared with traditional office visits and postal mailings, the Internet may save time and money. Initially the Internet may be used to educate Medicaid physicians, nurses, pharmacists, and other providers about disease management. As more people gain access to personal computers and enter the information superhighway, the Internet will become an increasingly powerful tool. Disease management is a useful, efficient approach to health care. It will continue to gain widespread acceptance among health plans that provide care for patients with chronic disease. Disease Management for Hear Failure [8]

11 Appendix A. Management of Heart Failure Heart failure usually requires a treatment regimen that includes rest, proper diet, modified daily activities, and medications that include angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, digitalis, diuretics, and vasodilators. The various medications used to treat heart failure perform different functions. For example, ACE inhibitors and vasodilators expand blood vessels and decrease resistance, allowing blood to flow more easily and making the heart s work easier or more efficient. Beta-blockers can improve the function of the left ventricle. Digitalis increases the pumping action of the heart, while diuretics help the body eliminate excess salt and water. When a specific cause of heart failure is discovered, it should be treated or, if possible, corrected. For example, in some cases treating high blood pressure can ameliorate heart failure. Some patients are treated surgically by replacing abnormal heart valves. When the heart becomes so damaged that it cannot be repaired, a more drastic treatment such as a heart transplant may be considered. Most cases of mild or moderate heart failure are treatable. With proper medical supervision, people with heart failure need not become invalids. Nonpharmacologic Therapy Regular exercise is recommended for patients with stable heart failure because it may improve functional status and decrease symptoms. 15,20 Moderate restriction of dietary sodium intake is recommended. 18 Excessive fluid intake should be avoided, although fluid restriction is not necessary. Smoking cessation, restriction of dietary fat intake, and treatment of lipid disorders also may be recommended. 15 Alcohol and illicit drug use should be discouraged because they may increase the risk of heart failure. 15 Pharmacologic Therapy Diuretics, ACE inhibitors, beta-blockers, and digitalis are used to treat patients with heart failure. 15 Aldosterone antagonists (e.g., eplerenone), angiotensin receptor blockers (e.g., losartan), hydralazine, and isosorbide dinitrate may be considered for certain patients. 15,21 Diuretics. Diuretics are used to correct and prevent fluid retention. 15 They promote the elimination of sodium and water by the kidneys. Loop diuretics (e.g., furosemide) are the most widely used diuretics for heart failure. 18 Thiazide diuretics (e.g., hydrochlorothiazide) are weaker diuretics than loop diuretics, although they may be used in combination with loop diuretics. Adverse effects of loop and thiazide diuretics include the loss of excessive amounts of potassium, weakness, muscle cramps, joint pain, and impotence. 16 The potassium-sparing diuretic spironolactone acts as an aldosterone antagonist, which can be beneficial in patients with moderate to severe heart failure. 18 However, it can cause gynecomastia (breast pain) and hyperkalemia. Angiotensin-Converting Enzyme Inhibitors. ACE inhibitors are recommended for patients with left ventricular dysfunction (unless the patient has hyperkalemia, symptomatic hypotension, a history of adverse reactions to ACE inhibitors, or another contraindication to the use of ACE inhibitors). 15 ACE inhibitors reduce the conversion of angiotensin I to angiotensin II. Angiotensin II is a vasoconstrictor that increases sympathetic nervous activity and causes aldosterone release, which in turn promotes sodium and water retention by the kidneys. ACE inhibitors also may diminish local production of angiotensin II, which is thought to contribute to ventricular hypertrophy and dilatation in patients with heart failure. 22 ACE inhibitors reduce mortality from heart failure, delay the progression of the disease, improve functional status, and decrease the need for hospitalization. 23,24 These agents also are recommended for asymptomatic patients with moderately or severely impaired leftventricular systolic function (e.g., to prevent heart failure from developing after a myocardial infarction). 15 The use of ACE inhibitors reduces the risk of heart failure in these patients. 25 ACE inhibitors also are recommended for patients at high risk of developing heart failure (e.g., patients with a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension and associated cardiovascular risk factors). 15 Agents that have been shown to reduce mortality in patients with heart failure (e.g., captopril, enalapril, lisinopril, quinapril, ramipril, trandolapril) are preferred over those without a documented survival benefit. 18 Cough is a common adverse effect from ACE inhibitor therapy. 16 Angiotensin receptor blockers may be an alternative for patients who are unable to tolerate ACE inhibitors. Beta-Blockers. In the past, clinicians were advised to use beta-blockers with care in patients with heart failure because of the negative inotropic effect of these drugs. 19 However, the use of beta-blockers for asymptomatic and symptomatic heart failure is now widely accepted because chronic sympathetic activation is thought to play an important role in heart failure. 15,18 Betablockers have been shown to slow the progression of heart failure and reduce hospitalization and mortality, possibly by blocking sympathetic stimulation. 26,27 Beta-blockers with intrinsic sympathomimetic activity (e.g., acebutolol, pindolol) should be avoided. Reductions in mortality have been demonstrated with bisoprolol, carvedilol, and metoprolol. 18 Small beta-blocker dosages should be used initially, and dosages should be increased gradually to avoid aggravating heart failure. 18 Digoxin. Digoxin is recommended (in conjunction with an ACE inhibitor and diuretic) for patients with symptomatic heart failure. 15 It is particularly useful for patients with certain arrhythmias. 18 Digoxin has a positive inotropic effect (i.e., it increases the force of contraction) and increases cardiac output. It also has antiarrhythmic activity and beneficial effects on nervous and hormonal mechanisms that contribute to heart failure. Digoxin reduces symptoms, improves physical function and quality of life, and decreases the rate of hospitalization in patients with heart failure, although it does not appear to affect mortality. 28 Adverse effects from digoxin include arrhythmias, anorexia, nausea, vomiting, diarrhea, confusion, vision disturbances, fatigue, and dizziness. 16,18 Nitrates and Hydralazine. Nitrates (e.g., isosorbide dinitrate) and hydralazine are vasodilators that may be used in patients who are unable to take ACE inhibitors because of contraindications or adverse effects. 18 Nitrates and hydralazine relax vascular smooth muscle and often are used in combination. 18 They reduce mortality from heart failure, although to a lesser extent than ACE inhibitors. 29 Headache is a common adverse effect from these agents. Disease Management for Hear Failure [9]

12 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure Disease Management for for Hear Failure [10] Humana Congestive Heart Failure program cuts costs, admissions. Anon. Healthcare Benchmarks. 1998;5: The effects of a disease management program on hospital admissions, hospital days, inpatient costs, and emergency department visits were studied in nearly 5000 members of the Humana Inc. health plan diagnosed with congestive heart failure (CHF). The program, offered by a private Illinois-based company (Cardiac Solutions), began with a home visit from a contracted home health agency to assess the patient s physical and psychosocial status, diet, and medication compliance. Patients then received a simple workbook that taught them how to manage the disease. Experienced cardiac nurses reviewed the material with patients individually by telephone using a script. The nurses also worked to establish a relationship with each patient, using frequent phone calls and postcards. Protocols for the program were based on guidelines from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and the American Heart Association. The nurses also followed protocols on laboratory, medication, lifestyle, and symptom management, and reported urgent patient problems or discrepancies between guidelines and treatments to attending physicians for clarification about treatment. The content of all nurse-patient and nurse-physician encounters was shared with physicians and patients. In a 2-year study of the program s effectiveness, the Humana Inc. health plan observed a 58% drop in hospital admissions for all diagnoses and a 61% reduction in inpatient health care costs over a 2-year period. Hospital admissions decreased from 7,795 in 1995 to 3,309 in the period between 1996 and The number of hospital days for CHF patients participating in the program decreased by 58%, and emergency department visits decreased by 49%. Health plan administrators concluded that the efficiency of telephone contacts and the personal touch of as-needed home visits improves care for CHF patients. DM programs take different roads to CHF success. Anon. Healthcare Demand & Disease Management Jun;6(6): [Also reported in Clinical Resource Management Feb;2(2):20-25.] A controlled study of a telephone case management system in which nurses provided congestive heart failure patients with education about the disease, symptoms, importance of measuring body weight daily, medications, and other aspects of disease management is described. The nurses had specialized training in cardiac care. Phone calls to patients were made weekly for 4 weeks, biweekly for another 4 weeks, and monthly thereafter. Scales were provided to patients who had none so that they could weigh themselves daily. The control group received usual care. After 6 months of the program, the New York Heart Association functional class and quality of life improved in a significant number of patients in the intervention group (i.e., patients enrolled in the telephone case management system). The annualized hospitalization rate and costs decreased by 49% and 64%, respectively, in the 6-month period after program enrollment compared with the 6- month period before enrollment (the reductions in rate and costs were 32% and 36%, respectively, for the control group). Emergency department visits increased by 10% in the control group and did not change in the intervention group. Total costs decreased by 68% and 44% in the intervention group and the control group, respectively, after program enrollment. Solid outcomes show e-health and chronically ill senior populations are compatible. Anon. Disease Management Advisor Jul;7(7): A 1-year randomized, controlled pilot study comparing the cardiac costs and rate and length of hospitalization associated with a computer-based disease management program, interactive voice response (IVR), and usual care in 69 elderly patients with moderate to severe congestive heart failure (CHF) is described. Patients in the computer group and the IVR group were taught to measure their own blood pressure using a blood pressure cuff, as well as measuring their pulse and their weight. These vital signs and various symptoms of worsening CHF were reported to a nurse via the Internet for the computer group or telephone for the IVR group (using voice response or the telephone key pad). In-home assistance with computer set up was provided for the computer group. There were 20 hospitalizations for a total of 149 days in the computer group and 39 hospitalizations for 258 days in the IVR group over a 1-year period. Hospitalization data were not reported for the usual care (control) group. Cardiac costs per patient per month decreased by $247 in the computer group and $265 in the IVR group and increased by $135 in the usual care group. Web-based educational effort for CHF patients boosts outcomes while cutting costs. Anon. Disease Management Advisor Jun;7(6): A computerized disease management program for 159 patients with congestive heart failure (CHF) is described. Computer software was developed to automatically sort Blue Cross/Blue Shield claims data by International Classification of Diseases, 9th Revision codes and utilization and pharmacy data using an algorithm. The software also stratified patients by risk (to facilitate prioritization by the program coordinator) and generated letters to all patients inviting them to enroll in the disease management program. Patients completed

13 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) questionnaires that assessed education level, readiness to change, and medical history; the forms were automatically read by computer and a plan of action was generated. Physicians completed questionnaires about patients medications, medical history, contraindications, heart failure classification, target weight, and adherence to medications and diet. Program coordinators used this information and the action plan to conduct telephone counseling sessions with patients 1 to 3 times per month. Patient education was provided in these sessions to improve patients self-management skills. Additional information was available on the Internet (on the program Web site and through links to Web sites with good information). Patients were advised to contact their physician if medical problems arose. Physicians received feedback about specific patients and data for their patients as a group (e.g., rates of flu vaccination, angiotensin-converting enzyme [ACE] inhibitor use). After 18 months, 93% of participants reported improved disease knowledge, 56% reported improved functional status, and 96% were satisfied with the program. ACE inhibitor use increased by more than 20% to 65%. Overall costs decreased by about 35% due to decreases in emergency department use, hospital admissions, and hospital length of stay. [see also the summary for Hinkle AJ. Disease management: a smart way to interact with patients. Health Management Technology. 2000;21:38.] DM programs take different roads to CHF success. Anon. Clinical Resource Management Feb;2(2): [Also reported in Healthcare Demand & Disease Management Jun;6(6):80-85.] The impact of a disease management program on angiotensinconverting enzyme (ACE) inhibitor and beta-blocker use, use of target dosages of these medications, clinic visit rate, hospitalization rate and length of stay, and costs for 117 patients with congestive heart failure (CHF) at Duke University Medical Center is described. The disease management program involved planning before hospital discharge, periodic follow-up and emergent care at a CHF clinic, telephone follow-up, and patient education about medications, diet, and what to do if symptoms of worsening CHF develop. The CHF team comprised attending physicians, nurse practitioners, a nurse specialist, a pharmacist, a social worker, and a nutritionist. The pharmacist ensured that drug therapy was appropriate and the risk of adverse drug reactions was minimized. Patients hospitalized for CHF within the previous 6 months with New York Heart Association functional class III or IV and an ejection fraction less than 20% (i.e., severe illness) were included. The use of ACE inhibitors did not change after implementation of the program, probably because most patients were receiving them before program implementation. However, the percentage of patients receiving the target dosage increased from 74% before program implementation to 97% after implementation. The percentage of patients receiving beta-blockers increased from 52% at baseline to 76% after program implementation, and the percentage of patients receiving the target dosage increased from 24% to 40% during that period. The average rate of hospitalization decreased from 1.86 times per patient per year at baseline to 1.21 times per patient per year after program implementation, and the average length of stay decreased from 7.67 days to 6.07 days during that period. The rate of clinic visits increased from 7.8 visits per patient year to 12.9 visits per patient year. The outpatient costs increased by 27%, and the inpatient costs decreased by 38%. The total cost of care decreased by $1.1 million for the 117 patients, which is a 37% decrease. Sacramento hospital boosts outcomes by focusing on highrisk CHF patients. Anon. Data Strategies & Benchmarks May;5(5): A software program called Health Hero was implemented in a hospital-based disease management program for patients with congestive heart failure (CHF). Patients responded at home to preprogrammed questions about general health, diet, and medications and transmitted their responses through an electronic appliance to a nurse case manager. The program compiled a report for the nurse case manager in which patients with potential problems are flagged. Health Hero also provided patient education and reminders to patients about diet and self-monitoring activities (e.g., measuring body weight). The monthly cost of the Health Hero program was about $30 to $60 per patient, but this cost was offset by savings in nursing time. The use of Health Hero did not affect hospitalizations or visits to the emergency department for CHF, but it reduced all-cause hospitalizations and emergency department visits by 23%. The total number of bed days for all causes was reduced by about 50%. The annual savings in direct costs for all causes amounted to $1,266 per patient. CHF managers make the case for home-monitoring technology. Anon. Disease Management Advisor Oct;8(10): , 145. The usefulness of a home health-monitoring device was evaluated in a 3-month pilot program involving 10 patients with congestive heart failure (CHF). The device was programmed to measure weight, blood pressure, heart rate, oxygen saturation, and temperature on a daily basis at a convenient time selected by the patient. [11]

14 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Disease Management for for Hear Failure [12] A recorded voice was used to cue patients to take the measurements. The device had the capability to ask up to 10 questions. Data were transmitted by pager or modem to a central location for review by a nurse practitioner, who contacted the physician if changes in drug therapy were needed. The patient compliance rate with daily measurements was 97% on average. Hospitalizations and emergency department visits were eliminated during the 3-month pilot study. Patients experienced significant improvements in how they felt and in their understanding of the disease process. Most insurance plans did not pay for the device. Arranging for visiting nurses to install the device in patient homes and teach patients to use the device properly is a strategy that was used because insurance plans cover visiting nurse services. Individualized care in patients with chronic congestive heart failure. Bertel O, Conen D. Journal of Cardiovascular Pharmacology. 1987;2:S68 S72. The impact of a comprehensive treatment program for congestive heart failure (CHF) was evaluated in a nonrandomized, observational study of 25 patients with similar degrees of disease despite therapy. Program enrollees consisted of 25 consecutive patients referred to this university-based hospital in Switzerland because of severe CHF that was refractory to treatment. The program focused on three issues: (1) individualized medical therapy for CHF, (2) antiarrhythmic treatment and close follow-up visits, and (3) continuing education of patients and physicians to improve treatment compliance and facilitate the early management of complications. Medical treatment was based on diuretic and vasodilator therapy in all the patients, while positive inotropic substances were selectively administered. Patient education related to the problems and complications of CHF. Education also addressed necessary lifestyle adjustments (e.g., physical activity, reduction in salt intake), and patients were asked to keep a diary of daily body weight measurements, drug intake, and symptoms. All patients were followed at short intervals of 1 to 2 weeks, independent of their symptoms. However, daily visits were scheduled if symptoms increased. To minimize unnecessary changes in the treatment regimen, patients were consistently evaluated by the same physician. The outcomes of patients in the special-care program (intervention patients) were compared with those of 21 consecutive patients described in a previous study. Patients in the control group were also referred to the institution for severe CHF refractory to treatment, but were treated prior to development of the CHF program. After evaluation, patients in the control group were sent back to their family physicians, with a detailed letter containing treatment recommendations. They were then followed only by telephone calls from their treating physicians. Reported outcomes for this study consisted of survival rates, results of medical treatment for CHF, and results of medical treatment for arrhythmias. The 1-year survival of all intervention-group patients was 92%, which was significantly higher than the 1-year survival rate in the control group of only 43%. In addition, the 2- year survival rate for the intervention group was 83%, which reportedly compares favorably with previously reported survival rates. All patients received intensive diuretic and vasodilator therapy as medical treatment of CHF. Vasodilator treatment was started with prazosin in 22 patients and angiotensin-converting enzyme (ACE) inhibitors in 3 patients. However, 55% of the patients on prazosin had to be changed over to ACE inhibitors because of fading clinical efficacy. Digoxin was used effectively in 8 of the 25 patients to control heart rates and/or arrhythmias. These 8 patients remained in sinus rhythm after digoxin was withdrawn. Amiodarone was used as the first-line drug to treat two patients with symptomatic ventricular tachycardia and two survivors of ventricular fibrillation. Six of the 11 patients treated for ventricular arrhythmias remained free of symptoms from malignant ventricular arrhythmias. Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study. Bouvy ML, Heerdink ER, Urquhart J, et al. Journal of Cardiac Failure Oct;9(5): The effect of a pharmacist-led intervention on mediation compliance was evaluated in a randomized controlled trial involving 7 hospitals, 79 pharmacists, and 152 patients with congestive heart failure (CHF) that was treated with loop diuretics. Patients were randomized to the intervention or a control group that received usual care. The intervention involved an interview by the pharmacist in which the patient medication history and reasons for noncompliance were discussed. The pharmacist contacted the patient afterwards on a monthly basis for up to 6 months. Compliance with the prescribed loop diuretic was assessed in both groups by using a container with a microchip that recorded the time and date of opening. Medication compliance during the 6-month study was greater in the intervention group than in the control group. The intervention group had 140 days without loop diuretic use out of 7,556 days, and the control group had 337 days without loop diuretic use out of 6,196 days. There were two consecutive days of loop diuretic nonuse on 18 days out of 7,656 days in the intervention group and 46 days out of 6,196 days in the control group. There were no significant differences between the two groups in rehospitalization, mortality, or quality of life.

15 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. Capomolla S, Febo O, Ceresa M, et al. Journal of the American College of Cardiology. 2002;40: The effectiveness of a heart failure (HF) management program delivered by a day hospital was compared with usual care in 234 chronic HF outpatients in a 12-month randomized controlled trial. Patients were randomized to the intervention or usual care. The intervention involved creation of a plan of care by a day hospitalbased multidisciplinary team comprising a cardiologist, nurses, physiotherapists, dietitian, psychologist, and social assistant. Cardiovascular risk stratification and tailoring of therapy according to evidence-based criteria were performed, and health care education and counseling were provided to the intervention group. After 12 months, significantly fewer patients in the intervention group had died than patients in the usual-care group. The hospital readmission rate was significantly lower in the intervention group (14%) than in the usual-care group (86%). In the intervention group, New York Heart Association (NYHA) functional class was improved in 23% of patients and it had worsened in 11% of patients, a difference that is significant. However, in the usual-care group, NYHA functional class was improved in 13% of patients and it had worsened in 16% of patients, a difference that is not significant. The intervention was cost-effective, with a cost of $19,462 for each quality-adjusted life-year saved. The cost/utility ratios for the intervention and usual- care groups were similar ($2,244 for the intervention group and $2,409 for the usual-care group). There was a cost savings of $1,068 for each quality-adjusted life-year gained by using the intervention instead of usual care. Hospital length of stay (LOS), cost of care, mortality, readmission statistics, and performance rates of processes of care were evaluated in a 12-month randomized retrospective study of 95 elderly patients with congestive heart failure (CHF) who were managed according to a clinical pathway. These data were compared with those from a historical cohort of 200 patients who had been treated for CHF in a traditional manner. Study participants consisted of patients who had been admitted to a tertiary-care teaching hospital in metropolitan Detroit for management of CHF. These patients were randomly admitted to medical wards, including two wards participating in the pathway for the study s duration. The CHF pathway had been developed as part of a quality enhancement and clinical resource management project designed to enhance care in the elderly and improve resource management. Health care providers were instructed to follow the clinical pathway, and a clinical nurse manager monitored all processes of care. Any variances in processes of care were reported to the attending physician for corrective action. The control group consisted of patients who had been hospitalized for CHF the year preceding the study, prior to pathway implementation. Randomization was achieved in the control population by retrieving every third chart from a computerized discharge log of patients with a primary diagnosis of CHF. All patients were older than 65 years of age, and there were no statistically significant differences between groups in terms of sex or New York Heart Association functional classification. Analysis of outcome data revealed a significant reduction in LOS, from 6.36 days for the prepathway group (controls) to 5.25 days for the pathway group. This reduction in LOS was accompanied by a significant reduction in variable cost of $776 per patient. The mortality rate during hospitalization remained unchanged at 3.5%. However, the rate of readmission (at 31 days) showed a significant increase, from 9.25% in the prepathway group to 13.5% for the pathway group. Significant improvements were noted in performance of three of the six processes of care evaluated (early discharge planning, patient education, and early patient mobilization); lesser improvements were documented for the three remaining processes (heparin prescription, recording of daily weights, use of echocardiography). The authors concluded that the lower costs of care in the pathway patients compared with the prepathway patients reflected the shorter LOS. The significant increase in hospital readmissions observed in the pathway patients was considered a matter for concern and is currently being investigated. Potential reasons for a higher admission rate include sicker patients, comorbid illnesses, premature discharges, and inadequate discharge plans. Assessing the efficacy of a clinical pathway in the management of older patients hospitalized with congestive heart failure. Cardozo L, Aherns S. Journal of Healthcare Quality. 1999;21: Development of a heart failure center: a medical center and cardiology practice join forces to improve care and reduce costs. Chapman DB, Torpy J. American Journal of Managed Care. 1997;3: The effectiveness of The Heart Failure Center s comprehensive outpatient program in reducing hospital admissions, number of hospital days, and average length of stay was evaluated in 67 patients with congestive heart failure (CHF). The Omaha-based Heart Institute s Heart Failure Center represented a partnership between a private-practice cardiology group and a tertiary-care medical center. Its program for CHF patients emphasized continuity of care and patient education. Patients were assigned to a clinician group that provided education and treatment using internally generated protocols and standardized clinic visit forms. These protocols were based on both the 1994 Cardiology Preeminence Report on CHF [13]

16 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Disease Management for for Hear Failure [14] and a 2-day Cardiology Roundtable meeting. A medical director physician helped to implement the program (and protocols) by meeting with all department personnel and educating all staff members. A registered nurse, with experience in treating CHF, was the identified program coordinator. Patient education was provided by a multidisciplinary team (nurse, physician, pharmacist, dietician, nurse program coordinator). It addressed a variety of issues (pathophysiology, appropriate diet, medication compliance, weight loss). Patient education began with a formal one-on-one curriculum prior to hospital discharge and continued at later outpatient visits. Other elements of the program included outpatient infusions of inotropic agents (to help reduce hospital readmissions), electronic linkages between the clinic and the emergency department (to reduce unnecessary clinic patient admissions), and home health care visits by nurses. The latter were intended to detect signs of clinical decompensation between clinic visits. The nurses also saw the patients regularly at the clinic to reinforce the need for adherence to medications, diet, and office visits. The 67 patients in this study were followed for a minimum of 1 year before enrollment in the program and 16 months after enrollment. The mean age of the patients was 64.7 years, and 50% had advanced heart failure (New York Heart Association functional class III or class IV). Comparison of pre- and post-enrollment data revealed that hospital admissions dropped 30%, from 38 before program enrollment to 27 after implementation. In addition, the number of hospital days decreased by 42% from 202 to 118, and the average length of stay decreased from 5.3 days to 4.4 days (a decrease of 17%). The investigators also noted that a year of frequent visits to the center costs less than one hospital admission. Each year, the average patient was seen 15 to 20 times at the clinic for an average cost of $2,000; the average cost of a hospitalization was about $9,000. The authors concluded that an effective heart failure outpatient program can reduce the economic burden of CHF and improve the quality of patient care. Congestive heart failure clinical outcomes study in a private community medical group. Civitarese LA, DeGregorio N. Journal of the American Board of Family Practice. 1999;12: A 21-month, prospective study was conducted to assess whether congestive heart failure (CHF) clinical practice guidelines, implemented with a continuous quality improvement program, would optimize use of angiotensin-converting enzyme (ACE) inhibitors and, thus, decrease hospital admissions for systolic CHF. The recipients of the program included 10 family practitioners and 10 internists at an independent medical group. The patients consisted of all 275 patients admitted to the group s primary communitybased hospital during the study with a confirmed discharge diagnosis of CHF. The group physicians developed CHF guidelines by reviewing the literature and guidelines from other hospital systems and health plans. The new guidelines were presented to the group s physicians at a formal continuing medical education session at the study s outset. Physicians were provided an opportunity to modify the guidelines, and each physician endorsed the final version. The guidelines, available for reference at office and hospital sites, were then reinforced at monthly quality improvement meetings. Other points emphasized at each meeting included (1) assessment of left ventricular function to optimize treatment, (2) appropriate use of ACE inhibitors in patients with systolic CHF, and (3) instruction of patients to obtain daily weights and contact the physician to report a weight gain. Standardized inpatient orders were also developed to parallel the guidelines, and physicians reviewed their own performance data at quarterly meetings. Rates of classifying systolic and diastolic dysfunction remained unchanged during the study, and documentation of patient discharge instructions was suboptimal. However, use of ACE inhibitor therapy substantially improved for patients with systolic dysfunction. Pharmacy utilization data from Aetna U.S. Healthcare showed a 39% increase in ACE inhibitor use by patients cared for by participating physicians. By the study s end, 100% of these patients had been prescribed ACE inhibitors or had documentation that they met exclusion criteria for such therapy. There was also a 49% reduction in quarterly admissions for CHF due to systolic dysfunction during the study; patient admissions for diastolic dysfunction remained stable. Associated economic effects were not addressed. Thus, use of disease management guidelines, ongoing physician education, and review of performance data significantly reduce quarterly admissions for systolic dysfunction-based CHF and optimized the use of ACE inhibitors. Cost effective management programme for heart failure reduces hospitalisation. Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR. Heart. 1998;80: A 1-year prospective, randomized trial evaluated the effects of a heart failure (HF) management program on outcomes in 190 patients with HF. Patients age years who were hospitalized at a Swedish university hospital for HF were eligible to participate. Patients were randomly assigned to the intervention or control group. Control patients received standard care at the university cardiology department s outpatient clinic following discharge. Intervention-group patients underwent an educational program managed by registered nurses followed by treatment at a HF clinic.

17 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) The intervention began with two 30-minute hospital visits by a nurse, followed by a 1-hour informational visit for patients and families 2 weeks after discharge. Information about the pathophysiology and treatment of HF was presented, with emphasis on compliance with medications. Patients next received guidelines for the selfmanagement of diuretic therapy based on symptoms and signs of worsening HF and were asked to record such data in a diary. Finally, patients were followed at an easy-access, nurse-directed outpatient clinic, in which patients could call or be seen on short notice. Patients were also offered outpatient visits with doctors at 1 and 4 months after discharge and at the study nurse s discretion. Clinical assessment followed a protocol, but no guidelines for evaluation or treatment specific to the study were used. Data on hospitalization and outpatient visits were obtained from hospital records and questionnaires. All patients were followed for 1 year, and final results were obtained from 135 surviving patients. The 1-year survival rate did not differ significantly between groups. However, the mean number of days until readmission was significantly longer in the intervention group (141) than in the control group (106), and the number of days spent in the hospital by the intervention group tended to be fewer than those spent by the control group (4.2 vs. 8.2, respectively). There was also a trend toward fewer patients being hospitalized in the intervention group than in the control group, with a similar number of outpatient visits in the two groups. The mean cost of the intervention per patient was $208. Costs for doctors outpatient visits tended to be $55 less per patient in the intervention group compared with the control group. In addition, the mean cost per patient for hospital readmission tended to be lower in the intervention group ($1,628 vs. $3,081), which contributed to a mean annual reduction in overall costs of $1,300 per patient. Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure. Costantini O, Huck K, Carlson MD, et al. Archives of Internal Medicine. 2001;161: The impact of daily use of new guideline-based recommendations for treating congestive heart failure (CHF) by a care management team (a nurse care manager, faculty cardiologist, and physician representative from the part-time faculty) at a large university-based medical center was assessed. All participating patients were hospital inpatients. Care-managed patients were compared with noncare-managed patients who were not followed by the team and with baseline patients (i.e., patients hospitalized before implementation of the new care management approach). National guidelines were available during the baseline period, but care-managed patients were monitored daily by the care management team and recommendations consistent with the guidelines were made. Clinical measures of quality of care (the use of angiotensin-converting enzyme inhibitors, documentation of assessment of left ventricular function using echocardiography, and the consistent daily measurement of body weight) were significantly improved and hospital length of stay and costs were significantly reduced in caremanaged patients compared with non-care-managed patients and baseline. The median hospital length of stay was 3 days with care management and 5 days without care management. Care management was associated with a $2,204 reduction in hospital costs. The relationship between hospital readmissions of Medicare beneficiaries with chronic illnesses and home care nursing interventions. Dennis LI, Blue CL, Stahl SM, Benge ME, Shaw CJ. Home Healthcare Nurse. 1996;14: A 12-month retrospective audit of the charts of 62 Medicare patients with a diagnosis of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) was conducted to evaluate the relationship between various home health care nursing interventions and hospital readmissions. Criteria for patient selection included those who were (1) admitted with a primary diagnosis of CHF or COPD of given severity, (2) under the care of a visiting home health care nurse within a 1-year interval, (3) Medicare beneficiaries, and (4) receiving services provided by an agency that had Medicare reimbursement. Interventions for patients with CHF consisted of assessment of vital signs; lip, skin, and nail bed color; presence of edema; presence of chest pain; specific signs/symptoms of CHF; activity tolerance; and weight measurement. Patient educational interventions included the signs/symptoms of CHF, prevention of an exacerbation, components of a low-sodium diet, medication actions/side effects, and use of medications. Interventions (assessment and teaching) specific to COPD were also carried out. A home health care nurse documented each intervention, and the total number of hospital readmissions was determined in a convenience sample of 42 patients. Interventions were selected from agency nursing care plans and Medicare regulations appropriate for patients with CHF or COPD. Fifty-seven percent of the patients (n=24) had CHF versus 43% (n=18) with COPD. Sixty-four percent of the patients were never readmitted to a hospital during the study. Of those who were readmitted once (n=15), 20% were readmitted twice and another 29%, three times. No patients were readmitted more than three times during the interval studied. As the number of home health care nursing visits increased, hospital readmissions decreased. Hospital readmissions also decreased as the total number of assessment interventions implemented increased. Interventions most strongly related to readmission rates were assessment of lungs, cough, and respiratory rate. The teaching interventions were more weakly related to the hospitalization rate and were only implemented 29% of the time. [15]

18 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Disease Management for for Hear Failure [16] Outcomes of an integrated telehealth network demonstration project. Dimmick SL, Burgiss SG, Robbins S, Black D, Jarnagin B, Anders M. Telemedicine Journal and E-Health Spring;9(1): A disease management program for congestive heart failure (CHF) was implemented for residents of a Tennessee county using an integrated telehealth/telemedicine network with home videoconferencing, telephone conversations, and remote monitoring of blood pressure, blood oxygen saturation, and pulse. The number of program participants varied over time because of deaths and dropouts. Weight control (a measure of medication and dietary compliance) was achieved by more than 50% of patients after program implementation. Sleep problems (a measure of mood) improved, although feelings of fatigue, depression, and loss of appetite increased. Only 14% of patients were hospitalized in the first 6 months after program implementation. The hospitalization rate decreased from 1.7 times per patient per year to 0.6 times per patient per year as a result of program implementation. The hospital length of stay decreased from a national benchmark of 6.2 days to 4 days. The cost per patient per year for the program included $2,353 for nursing labor and $833 for equipment. A reduction in annual costs for hospital care for CHF from $8 billion to $4.2 billion was projected on a national basis. Heart failure disease management: impact on hospital care, length of stay, and reimbursement. Discher CL, Klein D, Pierce L, Levine AB, Levine TB. Congestive Heart Failure Mar-Apr;9(2): A congestive heart failure (CHF) disease management program was developed for use in an inpatient setting. The program involved a treatment algorithm/clinical pathway for the time from hospital admission to discharge and inservice education programs for physicians, nurses, and other health care professionals. Patients were assigned to a managed group unless the physician objected or cognitive impairment or inadequate living conditions interfered with patient participation. Of 593 patients enrolled in the study, 396 patients were assigned to the managed group and 197 patients were assigned to an unmanaged group. The latter group did not participate in the program. Documentation of left ventricular ejection fraction improved significantly in the first quarter and throughout the first year after program implementation in the managed group but not in the unmanaged group. Documentation of angiotensin converting-enzyme (ACE) inhibitor use (or intolerance) increased significantly in both groups in the first quarter after program implementation, but the improvement was greater in the managed group than in the unmanaged group and further improvement in subsequent quarters was observed only in the managed group. The average hospital length of stay in the managed group decreased significantly from 6.1 days before program implementation to 3.9 days after implementation. There was no significant change in average length of stay over the course of the study in the unmanaged group. The average cost per patient after program implementation was lower for managed patients ($4,404) than unmanaged patients ($6,828), despite intensified involvement of nursing staff. Nurse satisfaction was high. Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Doughty RN, Wright SP, Pearl A, et al. European Heart Journal. 2002;23: The impact of an integrated heart failure (HF) management program on mortality, hospital readmissions, and quality of life was evaluated in 197 patients hospitalized with HF. General practitioners were randomized to the intervention group or a control group so that all of the patients treated by that practitioner were assigned to the same group as a cluster. The intervention involved clinical review at a hospital-based clinic shortly after hospital discharge, individual and group education sessions, a personal diary to record medication administration and body weight measurements, information booklets, and regular clinical follow-up alternating between the general practitioner and clinic. The control group received usual care. There was no significant difference between the two groups in the number of patients who died or were readmitted to the hospital during 12 months of follow up (68 patients in the intervention group and 61 patients in the control group). The number of first readmissions for HF and the number of hospital bed days for first readmissions were similar for the two groups. However, fewer subsequent readmissions for HF and fewer bed days during subsequent readmissions were associated with the intervention compared with the control group. Quality of life was markedly impaired at baseline in both groups. There was a significantly greater improvement in the physical-functioning component of quality of life in the intervention group than in the control group.

19 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Effects of an exercise adherence intervention on outcomes in patients with heart failure. Duncan K, Pozehl B. Rehabilitation Nursing Jul-Aug;28(4): The effectiveness of an intervention designed to facilitate patient adherence to an exercise regimen was tested in 16 patients with heart failure (HF). Patients were randomized to the intervention or an exercise-only (i.e., control) group. Both groups participated in a 12-week supervised exercise program (phase 1), which was followed by 12 weeks of unsupervised home exercise (phase 2). Goals were established for exercise frequency and duration for both groups. The adherence facilitation intervention involved the provision of graphic feedback about exercise frequency and duration, positive feedback when goals were achieved, and help with problem solving when goals were not achieved. Physiologic outcomes that were assessed include maximum oxygen consumption (a measure of exercise capacity), baseline dyspnea index (a measure of breathlessness), and level of fatigue. Functional status was evaluated using a 6-minute walk test. A validated questionnaire was used to assess quality of life. In phase 1, there was no significant difference between the two groups in adherence (i.e., the number of exercise sessions completed). Improvement in all physiologic outcomes and functional status but not in quality of life was observed in phase 1 in the intervention group. In the control group, improvement was observed only in functional status and level of fatigue in phase 1. In phase 2, quality of life and symptoms of dyspnea and fatigue improved and maximum oxygen consumption decreased in the intervention group, although all outcomes were better than at baseline at the end of phase 2. In the control group, maximum oxygen consumption, functional capacity, and qualify of life were worse and dyspnea and fatigue were improved at the end of phase 2 compared with baseline. Adherence during phase 2 was significantly higher in the intervention group than in the control group. Thus, the patient adherence intervention has the potential to improve physiologic, functional, and quality of life outcomes in patients with HF. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. Fonarow GC, Stevenson LW, Walden JA, et al. Journal of the American College of Cardiology. 1997;30: The impact of a comprehensive heart failure (HF) management program on hospital admissions and functional status was assessed in 214 patients with HF in a nonrandomized observational study spanning 3 years. Subjects included patients referred to the Ahmanson-UCLA Cardiomyopathy Center as potential candidates for heart transplantation who met study inclusion criteria (i.e., candidates for transplantation with no contraindications; discharged, but not too well ). All patients were initially hospitalized for formal transplant evaluation, which included invasive testing, medication evaluation, and a review of all medical records. Intensive medical therapy was then initiated (or systematically adjusted) to control HF symptoms, optimize hemodynamics, and address concomitant conditions (e.g., angina, arrhythmias). Comprehensive patient education was also provided to patients and their families in accordance with Heart Failure Practice Guidelines. This included a review of diet, lifestyle factors, and exercise, as well as symptoms and signs of worsening HF and complications. This information was conveyed by a HF clinical nurse specialist and was reinforced with patient brochures. After discharge, patients were followed by HF cardiologists in conjunction with referring physicians. This follow-up included weekly visits to the HF center until the patient was clinically stable, followed by telephone calls and clinic visits at various intervals. At each visit, medications were adjusted and patient education was reinforced. Reassessment 6 months after the intervention revealed improved New York Heart Association functional classification and exercise tolerance (i.e., improved functional status). Hospitalization rates were significantly lower, with only 63 admissions for HF during the 6 months following the program compared with 429 admissions during the 6 months prior to the program (i.e., an 85% reduction). Ninety-two percent of the patients required hospitalization prior to the program, compared with 26% after the program. Qualitatively similar results were obtained when the analysis was confined to the 179 patients who completed 6 months of follow-up without death or transplantation. For the entire group, the cost of hospital readmission after the program was estimated at $578,000 compared with $3,937,000 prior to the program. After considering the cost of the initial hospitalization for management and cost of the nurse specialist s services during follow-up (estimated at $200 to $400 per patient), the net savings was estimated at about $9,800 per patient. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Gattis WA, Hasselblad V, Whellan DJ, O Connor CM. Archives of Internal Medicine. 1999;159: The effect of involving a clinical pharmacist in the management of outpatients with heart failure (HF) was evaluated in a controlled study. Of 1,568 patients with HF evaluated at a Duke University cardiology faculty clinic, 181 patients satisfied the enrollment criteria (e.g., presence of signs and symptoms of HF, an ejection fraction less than 45%) and agreed to participate. These patients were randomized to an intervention (n = 90) or control (n = 91) group. All patients answered questions about current drug treatment to assess the regimen, compliance, and any adverse effects. [17]

20 Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Congestive Heart Failure (continued) Disease Management for for Hear Failure [18] Patients in the intervention group underwent evaluation by a clinical pharmacist, including medication review, therapeutic recommendations to the attending physician, patient education, and follow-up telemonitoring. Therapeutic recommendations included increasing use of angiotensin-converting enzyme (ACE) inhibitors, raising ACE inhibitor dosages to target levels, and using alternative vasodilators in ACE-intolerant patients, in accordance with published results from clinical research. Patient education consisted of detailed information about the purpose of each drug, importance of adherence to the prescribed regimen, directions for use, and potential adverse effects. Patients were encouraged to ask questions and were given the pharmacist s telephone number for future contact. The pharmacist also provided telephone follow-up 2, 12, and 24 weeks after the initial clinic visit to identify problems, answer questions, and evaluate HF clinical events (i.e., emergency department visits, hospitalizations for HF). Pharmacists communicated information to physicians and referred patients for evaluation when appropriate. Control subjects received standard care and were assessed and educated by physicians, physician assistants, and/or nurse practitioners. Pharmacists contacted patients in the control group at 12 and 24 weeks to identify HF clinical events but provided no recommendations or education. The median follow-up interval was 6 months. All-cause mortality and HF events (emergency department visits, hospitalizations) were significantly lower in the intervention group compared with the control group (4 events vs. 16 events). At the 6-month follow-up, patients in the intervention group were also significantly closer to the target ACE inhibitor dosage, with higher rates of use of other vasodilators in ACE inhibitor intolerant patients (75% vs. 26%). No economic effects were assessed. The authors concluded that including a clinical pharmacist in the management of HF patients improved outcomes, possibly because of increased use of ACE inhibitors and closer follow-up care. Disease management hits home. Gilbert JA. Health Data Management. 1998;6:54-56, Crozer-Keystone Health System, a Springfield, Pennsylvania based integrated delivery system, developed a disease management program for patients with congestive heart failure (CHF). This program, called Heart Success, was a multidisciplinary program designed to monitor patients after hospital visits and provide them with education and support to keep them as healthy and independent as possible. Central to the Heart Success program was a personal computer-based, automated patient follow-up system, which made automatic telephone calls to certain patients to determine their condition. The system was designed to ask a series of customized questions when the patient answers the telephone. Patients used the keypad of their touch-tone telephone to respond to the questions. The patient also had the option of speaking with a nurse after answering the last question. In 1996, Crozer-Keystone compared hospital readmission rates for an unspecified number of patients enrolled in the Heart Success program with readmission rates among patients receiving traditional home care follow-up. Results of this 9-week pilot study showed that 76% of the patients receiving home care (home visits by nurses) were readmitted to the hospital within 3 to 4 weeks after discharge. In contrast, only 18% of the patients enrolled in the Heart Success program were readmitted after 9 weeks of monitoring. The program director concluded that telemanagement is effective because it keeps patients in contact with clinicians long after discharge and it also provides a cost-effective way of identifying the 20% of patients who require additional attention. Does encouraging good compliance improve patients clinical condition in heart failure? Goodyer LI, Miskelly F, Milligan P. British Journal of Clinical Practice. 1995;49: A prospective, randomized controlled trial was conducted to evaluate whether improving medication compliance in elderly patients with chronic stable heart failure (HF) would influence objective and subjective measures of HF severity. Patients (age >70 years) at a London clinic who (1) had a diagnosis of chronic stable HF, (2) supervised their own medication use, (3) required no medication changes, and (4) met no physical or mental exclusion criteria were invited to participate. Fifty elderly patients were randomly assigned to a 3-month, intensive medication counseling program carried out by a pharmacist. Instruction about the correct use of medications proceeded according to a standard written protocol using verbal communication, medication calendars, and informational brochures. Another 50 patients constituted a no-counseling (i.e., control) group. Tablet counts and patient questionnaires were completed at the beginning and end of the study to assess knowledge and compliance. Other measures recorded at the beginning and end of the study included results on a submaximal 6-minute exercise test, visual analogue scores of breathlessness, Nottingham Health Profile scores, and clinical signs of HF. Use of clinical practice guidelines was not specified. Baseline measures were similar in the two groups. Compliance improved significantly (by 32%) in the counseled group but remained unchanged for the control group. Medication knowledge improved only for the counseled patients. Results for the 6-minute exercise test improved by 20 meters for the counseled group but worsened by 22 meters for the control patients. Distance to breathlessness also improved for the counseled patients and worsened for patients in the control group. In contrast, body weights, jugular venous pressures, and Nottingham Health Profile scores did not change significantly for either group. Peripheral and pulmonary edema scores improved for the counseled group only, along with a

Heart Failure: Diagnosis and Treatment

Heart Failure: Diagnosis and Treatment Heart Failure: Diagnosis and Treatment Approximately 5 million people about 2 percent of the U.S. population are affected by heart failure. Diabetes affects 20.8 million Americans and 65 million Americans

More information

2013 ACO Quality Measures

2013 ACO Quality Measures ACO 1-7 Patient Satisfaction Survey Consumer Assessment of HealthCare Providers Survey (CAHPS) 1. Getting Timely Care, Appointments, Information 2. How well Your Providers Communicate 3. Patient Rating

More information

Concept Series Paper on Disease Management

Concept Series Paper on Disease Management Concept Series Paper on Disease Management Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing

More information

Population Health Management Program

Population Health Management Program Population Health Management Program Program (formerly Disease Management) is dedicated to improving our members health and quality of life. Our Population Health Management Programs aim to improve care

More information

SYMPTOMS Heart failure symptoms may vary and can be hard to detect. Symptoms may include:

SYMPTOMS Heart failure symptoms may vary and can be hard to detect. Symptoms may include: Heart Failure Heart failure is a condition in which the heart has trouble pumping blood. This means your heart does not pump blood efficiently for your body to work well. In some cases of heart failure,

More information

1 Congestive Heart Failure & its Pharmacological Management

1 Congestive Heart Failure & its Pharmacological Management Harvard-MIT Division of Health Sciences and Technology HST.151: Principles of Pharmocology Instructor: Prof. Keith Baker 1 Congestive Heart Failure & its Pharmacological Management Keith Baker, M.D., Ph.D.

More information

Congestive Heart Failure Management Program

Congestive Heart Failure Management Program Congestive Heart Failure Management Program The Congestive Heart Failure Program is the third statewide disease management program developed by CCNC. The clinical directors reviewed prevalence and outcome

More information

Medical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South

Medical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South Medical management of CHF: A New Class of Medication Al Timothy, M.D. Cardiovascular Institute of the South Disclosures Speakers Bureau for Amgen Background Chronic systolic congestive heart failure remains

More information

CONGESTIVE HEART FAILURE PATIENT TEACHING

CONGESTIVE HEART FAILURE PATIENT TEACHING CONGESTIVE HEART FAILURE PATIENT TEACHING What is Heart Failure? Congestive Heart Failure occurs when the heart loses its ability to pump enough blood to meet the body s needs. Because the heart is not

More information

Cardiovascular System & Its Diseases. Lecture #4 Heart Failure & Cardiac Arrhythmias

Cardiovascular System & Its Diseases. Lecture #4 Heart Failure & Cardiac Arrhythmias Cardiovascular System & Its Diseases Lecture #4 Heart Failure & Cardiac Arrhythmias Dr. Derek Bowie, Department of Pharmacology & Therapeutics, Room 1317, McIntyre Bldg, McGill University derek.bowie@mcgill.ca

More information

ADULT HYPERTENSION PROTOCOL STANFORD COORDINATED CARE

ADULT HYPERTENSION PROTOCOL STANFORD COORDINATED CARE I. PURPOSE To establish guidelines for the monitoring of antihypertensive therapy in adult patients and to define the roles and responsibilities of the collaborating clinical pharmacist and pharmacy resident.

More information

KIH Cardiac Rehabilitation Program

KIH Cardiac Rehabilitation Program KIH Cardiac Rehabilitation Program For any further information Contact: +92-51-2870361-3, 2271154 Feedback@kih.com.pk What is Cardiac Rehabilitation Cardiac rehabilitation describes all measures used to

More information

HealthCare Partners of Nevada. Heart Failure

HealthCare Partners of Nevada. Heart Failure HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with

More information

Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification

Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification Disease Management UnitedHealthcare Disease Management (DM) programs are part of our innovative Care Management Program. Our Disease Management (DM) program is guided by the principles of the UnitedHealthcare

More information

CARDIOLOGIST What does a cardiologist do? A cardiologist is a doctor who specializes in caring for your heart and blood vessel health.

CARDIOLOGIST What does a cardiologist do? A cardiologist is a doctor who specializes in caring for your heart and blood vessel health. YOUR TREATMENT TEAM CARDIOLOGIST What does a cardiologist do? A cardiologist is a doctor who specializes in caring for your heart and blood vessel health. To become a cardiologist, a doctor completes additional

More information

Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL

Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL www.goldcopd.com GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT

More information

Provider Manual. Section 18.0 - Case Management and Disease Management

Provider Manual. Section 18.0 - Case Management and Disease Management Section 18.0 - Case Management and Disease Management 18.1.1 Introduction 18.2.1 Scope 18.3.1 Objectives 18.4.1 Procedures Case Management 18.4.1-A. Referrals 18.4.1-B. Case Management Mercy Maricopa Acute

More information

Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis

Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis Methodology: 8 respondents The measures are incorporated into one of four sections: Highly

More information

An Integrated, Holistic Approach to Care Management Blue Care Connection

An Integrated, Holistic Approach to Care Management Blue Care Connection An Integrated, Holistic Approach to Care Management Blue Care Connection With health care costs continuing to rise, both employers and health plans need innovative solutions to help employees manage their

More information

A Patients Guide to Heart Failure

A Patients Guide to Heart Failure A Patients Guide to Heart Failure Exceptional healthcare, personally delivered Heart Failure The term heart failure means that your heart is weakened and is having difficulty in pumping as hard as it would

More information

Cardiac Rehabilitation

Cardiac Rehabilitation Cardiac Rehabilitation Introduction Experiencing heart disease should be the beginning of a new, healthier lifestyle. Cardiac rehabilitation helps you in two ways. First, it helps your heart recover through

More information

CME Test for AMDA Clinical Practice Guideline. Diabetes Mellitus

CME Test for AMDA Clinical Practice Guideline. Diabetes Mellitus CME Test for AMDA Clinical Practice Guideline Diabetes Mellitus Part I: 1. Which one of the following statements about type 2 diabetes is not accurate? a. Diabetics are at increased risk of experiencing

More information

Chapter Three Accountable Care Organizations

Chapter Three Accountable Care Organizations Chapter Three Accountable Care Organizations One of the most talked-about changes in health care delivery in recent decades is Accountable Care Organizations, or ACOs. Having gained the attention of both

More information

Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare

Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare O N L I N E A P P E N D I X E S 6 Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare 6-A O N L I N E A P P E N D I X Current quality

More information

Congestive Heart Failure

Congestive Heart Failure Healthy People 2010 Conference Health Education on the Internet Welcome Mr. System Administrator Congestive Heart Failure What is congestive heart failure? How does it occur? What are the symptoms? How

More information

Demonstrating Meaningful Use Stage 1 Requirements for Eligible Providers Using Certified EMR Technology

Demonstrating Meaningful Use Stage 1 Requirements for Eligible Providers Using Certified EMR Technology Demonstrating Meaningful Use Stage 1 Requirements for Eligible Providers Using Certified EMR Technology The chart below lists the measures (and specialty exclusions) that eligible providers must demonstrate

More information

INTRODUCTION TO EECP THERAPY

INTRODUCTION TO EECP THERAPY INTRODUCTION TO EECP THERAPY is an FDA cleared, Medicare approved, non-invasive medical therapy for the treatment of stable and unstable angina, congestive heart failure, acute myocardial infarction, and

More information

Supportive Cardiology: Living with Advanced Heart Failure A GUIDE FOR PATIENTS AND FAMILIES

Supportive Cardiology: Living with Advanced Heart Failure A GUIDE FOR PATIENTS AND FAMILIES Supportive Cardiology: Living with Advanced Heart Failure A GUIDE FOR PATIENTS AND FAMILIES Table of contents Contact information...1 Advanced heart failure care at North York General Hospital...2 What

More information

READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION. sacubitril/valsartan film-coated tablets

READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION. sacubitril/valsartan film-coated tablets READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION Pr ENTRESTO TM sacubitril/valsartan film-coated tablets Read this carefully before you start taking ENTRESTO TM and

More information

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation How Does CMS Measure the Rate of Acute Care Hospitalization (ACH)? Until January 2013, CMS measured Acute Care Hospitalization (ACH) through the Outcomes Assessment and Information Set (OASIS) reporting

More information

Procedure for Inotrope Administration in the home

Procedure for Inotrope Administration in the home Procedure for Inotrope Administration in the home Purpose This purpose of this procedure is to define the care used when administering inotropic agents intravenously in the home This includes: A. Practice

More information

Successful Heart Failure Management Nurse/NP Run Clinics

Successful Heart Failure Management Nurse/NP Run Clinics Dagmar Knot RN BScN CCCN Transplant Coordination Team Leader Organ Transplant Center KFSHRC Riyadh, KSA Heart Failure Nurses Role, responsibilities & education Successful Heart Failure Management Nurse/NP

More information

Exchange solutes and water with cells of the body

Exchange solutes and water with cells of the body Chapter 8 Heart and Blood Vessels Three Types of Blood Vessels Transport Blood Arteries Carry blood away from the heart Transport blood under high pressure Capillaries Exchange solutes and water with cells

More information

High Blood Pressure (Essential Hypertension)

High Blood Pressure (Essential Hypertension) Sacramento Heart & Vascular Medical Associates February 18, 2012 500 University Ave. Sacramento, CA 95825 Page 1 916-830-2000 Fax: 916-830-2001 What is essential hypertension? Blood pressure is the force

More information

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG

More information

CARDIAC CARE. Giving you every advantage

CARDIAC CARE. Giving you every advantage CARDIAC CARE Giving you every advantage Getting to the heart of the matter The Cardiovascular Program at Northwest Hospital & Medical Center is dedicated to the management of cardiovascular disease. The

More information

Clinical Quality Measure Crosswalk: HEDIS, Meaningful Use, PQRS, PCMH, Beacon, 10 SOW

Clinical Quality Measure Crosswalk: HEDIS, Meaningful Use, PQRS, PCMH, Beacon, 10 SOW Clinical Crosswalk: HEDIS, Meaningful Use, PQRS, PCMH, Beacon, 10 SOW NQF 0105 PQRS 9 NQF 0002 PQRS 66 Antidepressant Medication Management Appropriate Testing for Children with Pharyngitis (2-18 years)

More information

Medicare Risk Adjustment and You. Health Plan of San Mateo Spring 2009

Medicare Risk Adjustment and You. Health Plan of San Mateo Spring 2009 Medicare Risk Adjustment and You Health Plan of San Mateo Spring 2009 Background CMS reimburses health plans on a risk-adjusted basis: The sicker a member is expected to be, the more CMS pays a plan, which

More information

DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study

DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study National Diabetes Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What

More information

Identifying High-Risk Medicare Beneficiaries with Predictive Analytics

Identifying High-Risk Medicare Beneficiaries with Predictive Analytics Identifying High-Risk Medicare Beneficiaries with Predictive Analytics September 2014 Until recently, with the passage of the Affordable Care Act (ACA), Medicare Fee-for-Service (FFS) providers had little

More information

Drug Treatment in Type 2 Diabetes with Hypertension

Drug Treatment in Type 2 Diabetes with Hypertension Hypertension is 1.5 2 times more prevalent in Type 2 diabetes (prevalence up to 80 % in diabetic subjects). This exacerbates the risk of cardiovascular disease by ~ two-fold. Drug therapy reduces the risk

More information

Improving Quality of Care for Medicare Patients: Accountable Care Organizations

Improving Quality of Care for Medicare Patients: Accountable Care Organizations DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Improving Quality of Care for Medicare Patients: FACT SHEET Overview http://www.cms.gov/sharedsavingsprogram On October

More information

Essentia Health. Heart Failure and Remote Monitoring. Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager

Essentia Health. Heart Failure and Remote Monitoring. Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager Essentia Health Heart Failure and Remote Monitoring Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager Essentia Health Oct 2014 No reproduction without permission Why Heart Failure? Prevalence

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal. Drugs for the treatment of pulmonary arterial hypertension

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal. Drugs for the treatment of pulmonary arterial hypertension NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Health Technology Appraisal Drugs for the treatment of Remit / Appraisal objective: Final scope To appraise the clinical and cost effectiveness of

More information

Milwaukee School of Engineering Gerrits@msoe.edu. Case Study: Factors that Affect Blood Pressure Instructor Version

Milwaukee School of Engineering Gerrits@msoe.edu. Case Study: Factors that Affect Blood Pressure Instructor Version Case Study: Factors that Affect Blood Pressure Instructor Version Goal This activity (case study and its associated questions) is designed to be a student-centered learning activity relating to the factors

More information

OBJECTIVES AGING POPULATION AGING POPULATION AGING IMPACT ON MEDICARE AGING POPULATION

OBJECTIVES AGING POPULATION AGING POPULATION AGING IMPACT ON MEDICARE AGING POPULATION OBJECTIVES Kimberly S. Hodge, PhDc, MSN, RN, ACNS-BC, CCRN- K Director, ACO Care Management & Clinical Nurse Specialist Franciscan ACO, Inc. Central Indiana Region Indianapolis, IN By the end of this session

More information

Mar. 31, 2011 (202) 690-6145. Improving Quality of Care for Medicare Patients: Accountable Care Organizations

Mar. 31, 2011 (202) 690-6145. Improving Quality of Care for Medicare Patients: Accountable Care Organizations DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Media Affairs MEDICARE FACT SHEET FOR IMMEDIATE RELEASE

More information

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented National Quality Strategy Domain: Community / Population Health 2016 PQRS OPTIONS F INDIVIDUAL MEASURES:

More information

8/14/2012 California Dual Demonstration DRAFT Quality Metrics

8/14/2012 California Dual Demonstration DRAFT Quality Metrics Stakeholder feedback is requested on the following: 1) metrics 69 through 94; and 2) withhold measures for years 1, 2, and 3. Steward/ 1 Antidepressant medication management Percentage of members 18 years

More information

Inpatient Heart Failure Management: Risks & Benefits

Inpatient Heart Failure Management: Risks & Benefits Inpatient Heart Failure Management: Risks & Benefits Dr. Kenneth L. Baughman Professor of Medicine Harvard Medical School Director, Advanced Heart Disease Section Brigham & Women's Hospital Harvard Medical

More information

Aligning Incentives for Quality: Pharmacy's Role in Achieving Hospital and National Goals. Objectives. National Organizations: Key Linkages

Aligning Incentives for Quality: Pharmacy's Role in Achieving Hospital and National Goals. Objectives. National Organizations: Key Linkages Aligning Incentives for Quality: Pharmacy's Role in Achieving Hospital and National Goals Kasey K. Thompson, Pharm.D. Director, Practice Standards and Quality Division Director, Patient Safety American

More information

Maureen Mangotich, MD, MPH Medical Director

Maureen Mangotich, MD, MPH Medical Director Maureen Mangotich, MD, MPH Medical Director Prepared for the National Governors Association Healthy America: State Policy Leaders Meeting, December 2005 Delivering value from the center of healthcare Pharmaceutical

More information

Prescription Pattern of Anti Hypertensive Drugs used in Hypertensive Patients with Associated Type2 Diabetes Mellitus in A Tertiary Care Hospital

Prescription Pattern of Anti Hypertensive Drugs used in Hypertensive Patients with Associated Type2 Diabetes Mellitus in A Tertiary Care Hospital Research Article Prescription Pattern of Anti Hypertensive Drugs used in Hypertensive Patients with Associated Type2 Diabetes Mellitus in A Tertiary Care Hospital *T. JANAGAN 1, R. KAVITHA 1, S. A. SRIDEVI

More information

Breathe With Ease. Asthma Disease Management Program

Breathe With Ease. Asthma Disease Management Program Breathe With Ease Asthma Disease Management Program MOLINA Breathe With Ease Pediatric and Adult Asthma Disease Management Program Background According to the National Asthma Education and Prevention Program

More information

PACKAGE LEAFLET: INFORMATION FOR THE USER. ADRENALINE (TARTRATE) STEROP 1 mg/1 ml Solution for injection. Adrenaline (Levorenine, Epinephrine)

PACKAGE LEAFLET: INFORMATION FOR THE USER. ADRENALINE (TARTRATE) STEROP 1 mg/1 ml Solution for injection. Adrenaline (Levorenine, Epinephrine) PACKAGE LEAFLET: INFORMATION FOR THE USER ADRENALINE (TARTRATE) STEROP 1 mg/1 ml Solution for injection Adrenaline (Levorenine, Epinephrine) Read all of this leaflet carefully before you start using this

More information

PCHC FACTS ABOUT HEALTH CONDITIONS AND MOOD DIFFICULTIES

PCHC FACTS ABOUT HEALTH CONDITIONS AND MOOD DIFFICULTIES PCHC FACTS ABOUT HEALTH CONDITIONS AND MOOD DIFFICULTIES Why should mood difficulties in individuals with a health condition be addressed? Many people with health conditions also experience mood difficulties

More information

CHAPTER V DISCUSSION. normal life provided they keep their diabetes under control. Life style modifications

CHAPTER V DISCUSSION. normal life provided they keep their diabetes under control. Life style modifications CHAPTER V DISCUSSION Background Diabetes mellitus is a chronic condition but people with diabetes can lead a normal life provided they keep their diabetes under control. Life style modifications (LSM)

More information

To provide standardized Supervised Exercise Programs across the province.

To provide standardized Supervised Exercise Programs across the province. TITLE ALBERTA HEALTHY LIVING PROGRAM SUPERVISED EXERCISE PROGRAM DOCUMENT # HCS-67-01 APPROVAL LEVEL Executive Director Primary Health Care SPONSOR Senior Consultant Central Zone, Primary Health Care CATEGORY

More information

HEART FAILURE ROBERT SOUFER, M.D.

HEART FAILURE ROBERT SOUFER, M.D. CHAPTER 14 HEART FAILURE ROBERT SOUFER, M.D. The heart s primary function is to pump blood to all parts of the body, bringing nutrients and oxygen to the tissues and removing waste products. When the body

More information

CORONARY ARTERY BYPASS GRAFT & HEART VALVE SURGERY

CORONARY ARTERY BYPASS GRAFT & HEART VALVE SURGERY CORONARY ARTERY BYPASS GRAFT & HEART VALVE SURGERY www.cpmc.org/learning i learning about your health What to Expect During Your Hospital Stay 1 Our Team: Our cardiac surgery specialty team includes nurses,

More information

Overview. Geriatric Overview. Chapter 26. Geriatrics 9/11/2012

Overview. Geriatric Overview. Chapter 26. Geriatrics 9/11/2012 Chapter 26 Geriatrics Slide 1 Overview Trauma Common Medical Emergencies Special Considerations in the Elderly Medication Considerations Abuse and Neglect Expanding the Role of EMS Slide 2 Geriatric Overview

More information

Hypertension and Heart Failure Medications. Dr William Dooley

Hypertension and Heart Failure Medications. Dr William Dooley Hypertension and Heart Failure Medications Dr William Dooley Plan Heart Failure Acute vs. chronic Mx Hypertension Common drugs used Method of action Choice of medications Heart Failure Aims; Short term:

More information

CARE GUIDELINES FROM MCG

CARE GUIDELINES FROM MCG 3.0 2.5 2.0 1.5 1.0 CARE GUIDELINES FROM MCG Evidence-based guidelines from MCG span the continuum of care, supporting clinical decisions and care planning, easing transitions between care settings, and

More information

Managing Patients with Multiple Chronic Conditions

Managing Patients with Multiple Chronic Conditions Best Practices Managing Patients with Multiple Chronic Conditions Advocate Medical Group Case Study Organization Profile Advocate Medical Group is part of Advocate Health Care, a large, integrated, not-for-profit

More information

Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases

Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Epidemiology Over 145 million people ( nearly half the population) - suffer from asthma, depression and other chronic

More information

2012 Physician Quality Reporting System:

2012 Physician Quality Reporting System: DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Official CMS Information for Medicare Fee-For-Service Providers 2012 Physician Quality : Medicare Electronic Health Record

More information

About High Blood Pressure

About High Blood Pressure About High Blood Pressure Your Treatment & You: working together to help manage your health Glaxo- Blood Pressure Booklet (ASK) EN.indd 1 10/7/2014 4:49:14 PM Glaxo- Blood Pressure Booklet (ASK) EN.indd

More information

ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol

ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Isoproterenol Major Indications Status Asthmaticus As a last resort for

More information

See page 331 of HEDIS 2013 Tech Specs Vol 2. HEDIS specs apply to plans. RARE applies to hospitals. Plan All-Cause Readmissions (PCR) *++

See page 331 of HEDIS 2013 Tech Specs Vol 2. HEDIS specs apply to plans. RARE applies to hospitals. Plan All-Cause Readmissions (PCR) *++ Hospitalizations Inpatient Utilization General Hospital/Acute Care (IPU) * This measure summarizes utilization of acute inpatient care and services in the following categories: Total inpatient. Medicine.

More information

How To Manage Your Health At Oxford

How To Manage Your Health At Oxford Oxford Condition Management Programs: Helping your employees learn, be encouraged and get support UnitedHealthcare is committed to helping improve the health and well-being of the individuals we serve

More information

Cardiac Rehabilitation

Cardiac Rehabilitation Cardiac Rehabilitation Exercise and Education Program Always thinking. Always caring. Cardiac Rehabilitation Dear Patient: Cardiac rehabilitation is an important part of your recovery. Our progressive

More information

Cardiovascular diseases. pathology

Cardiovascular diseases. pathology Cardiovascular diseases pathology Atherosclerosis Vascular diseases A disease that results in arterial wall thickens as a result of build- up of fatty materials such cholesterol, resulting in acute and

More information

New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery

New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery USING THE 48 HOUR OBSERVATION BED USING THE 48 HOUR OBSERVATION BED Detoxification

More information

CIRCULAR 13 OF 2014: MANAGED CARE ACCREDITATION - FINAL MANAGED HEALTH CARE SERVICES DOCUMENT

CIRCULAR 13 OF 2014: MANAGED CARE ACCREDITATION - FINAL MANAGED HEALTH CARE SERVICES DOCUMENT CIRCULAR Reference: Classification and naming conventions of Managed Health Care Services Contact person: Hannelie Cornelius Accreditation Manager: Administrators & MCOs Tel: (012) 431 0406 Fax: (012)

More information

James F. Kravec, M.D., F.A.C.P

James F. Kravec, M.D., F.A.C.P James F. Kravec, M.D., F.A.C.P Chairman, Department of Internal Medicine, St. Elizabeth Health Center Chair, General Internal Medicine, Northeast Ohio Medical University Associate Medical Director, Hospice

More information

Case Study 6: Management of Hypertension

Case Study 6: Management of Hypertension Case Study 6: Management of Hypertension 2000 Scenario Mr Ellis is a fit 61-year-old, semi-retired market gardener. He is a moderate (10/day) smoker with minimal alcohol intake and there are no other cardiovascular

More information

Re: CMS-1345-P; Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Proposed Rule

Re: CMS-1345-P; Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Proposed Rule Department of Health and Human Services Attention: CMS 1345 P P.O. Box 8013, Baltimore, MD 21244 8013 Re: CMS-1345-P; Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations;

More information

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Quality Management Program 2012 Overview Quality Improvement

More information

Acquired, Drug-Induced Long QT Syndrome

Acquired, Drug-Induced Long QT Syndrome Acquired, Drug-Induced Long QT Syndrome A Guide for Patients and Health Care Providers Sudden Arrhythmia Death Syndromes (SADS) Foundation 508 E. South Temple, Suite 202 Salt Lake City, Utah 84102 800-STOP

More information

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable

More information

Manitoba EMR Data Extract Specifications

Manitoba EMR Data Extract Specifications MANITOBA HEALTH Manitoba Data Specifications Version 1 Updated: August 14, 2013 1 Introduction The purpose of this document 1 is to describe the data to be included in the Manitoba Data, including the

More information

The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012. Penny S. Milanovich President UPMC Visiting Nurses Association

The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012. Penny S. Milanovich President UPMC Visiting Nurses Association The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012 Penny S. Milanovich President UPMC Visiting Nurses Association Cost of Chronic Conditions An average of 40-50% of healthcare

More information

CHAPTER 17: HEALTH PROMOTION AND DISEASE MANAGEMENT

CHAPTER 17: HEALTH PROMOTION AND DISEASE MANAGEMENT CHAPTER 17: HEALTH PROMOTION AND DISEASE MANAGEMENT HEALTH SERVICES AND PROGRAMS The Plan s Health Promotion and Disease Management Department seeks to improve the health and overall well-being of our

More information

The new Heart Failure pathway

The new Heart Failure pathway The new Heart Failure pathway An integrated and seamless Strategy Dr Sunil Balani Definition of Heart Failure The inability of the heart to pump blood at a rate commensurate with the requirements of metabolising

More information

Kaiser Permanente: Health Education. Mei Ling Schwartz, MPH Director, Health & Physician Education Kaiser Permanente Panorama City Medical Center

Kaiser Permanente: Health Education. Mei Ling Schwartz, MPH Director, Health & Physician Education Kaiser Permanente Panorama City Medical Center Kaiser Permanente: Health Education Mei Ling Schwartz, MPH Director, Health & Physician Education Kaiser Permanente Panorama City Medical Center Who Is Kaiser Permanente? Founded in 1945, Kaiser Permanente

More information

Cardiac Rehabilitation. Exercise and Education Program

Cardiac Rehabilitation. Exercise and Education Program Cardiac Rehabilitation Exercise and Education Program Cardiac Rehabilitation Dear Patient: Cardiac rehabilitation is an important part of your recovery. Our progressive cardiac rehabilitation program

More information

Cardiac Rehabilitation (Outpatient Phase II) Corporate Medical Policy. Medical Policy

Cardiac Rehabilitation (Outpatient Phase II) Corporate Medical Policy. Medical Policy Cardiac Rehabilitation (Outpatient Phase II) Corporate Medical Policy File name: Cardiac Rehabilitation (Outpatient Phase II) File code: UM.REHAB.04 Origination: 08/1994 Last Review: 08/2011 Next Review:

More information

Nutrition. Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT

Nutrition. Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT 1 Nutrition Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT 2 Type 2 Diabetes: A Growing Challenge in the Healthcare Setting Introduction and background of type 2 diabetes:

More information

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. Diabetes Definition Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood. Causes Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused

More information

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] I. Definitions: Detoxification is the process of interrupting the momentum of compulsive drug and/or alcohol use in an individual

More information

Member Health Management Programs

Member Health Management Programs Independent Health s Member Health Management Programs Helping employees manage their health. Helping you manage your costs. Independent Health s Member Health Management Programs A Comprehensive Approach...

More information

Cardioversion for. Atrial Fibrillation. Your Heart s Electrical System Cardioversion Living with Atrial Fibrillation

Cardioversion for. Atrial Fibrillation. Your Heart s Electrical System Cardioversion Living with Atrial Fibrillation Cardioversion for Atrial Fibrillation Your Heart s Electrical System Cardioversion Living with Atrial Fibrillation When You Have Atrial Fibrillation You ve been told you have a heart condition called atrial

More information

Tackling the Semantic Interoperability challenge

Tackling the Semantic Interoperability challenge European Patient Summaries: What is next? Tackling the Semantic Interoperability challenge Dipak Kalra Cross-border health care The context for sharing health summaries Also useful for within-border health

More information

Improving Quality of Care for Medicare Patients: Accountable Care Organizations

Improving Quality of Care for Medicare Patients: Accountable Care Organizations DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Improving Quality of Medicare Patients: Overview The Centers for Medicare & Medicaid Services (), an agency within the Department

More information

Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing

Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing Overview Depression is significantly higher among elderly adults receiving home healthcare, particularly among

More information

Type 1 Diabetes ( Juvenile Diabetes)

Type 1 Diabetes ( Juvenile Diabetes) Type 1 Diabetes W ( Juvenile Diabetes) hat is Type 1 Diabetes? Type 1 diabetes, also known as juvenile-onset diabetes, is one of the three main forms of diabetes affecting millions of people worldwide.

More information

Automatic External Defibrillators

Automatic External Defibrillators Last Review Date: May 27, 2016 Number: MG.MM.DM.10dC2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth

More information

Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1

Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Test Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Heart Failure - Definition European Heart Journal (2008) 29, 2388 2442 Akute Herzinsuffizienz Diagnostik und

More information

HYPERTROPHIC CARDIOMYOPATHY

HYPERTROPHIC CARDIOMYOPATHY HYPERTROPHIC CARDIOMYOPATHY Most often diagnosed during infancy or adolescence, hypertrophic cardiomyopathy (HCM) is the second most common form of heart muscle disease, is usually genetically transmitted,

More information

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic

More information