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A Heart Failure Management Program Using Shared Medical Appointments

Patients whose care was augmented using shared medical appointments for heart failure disease management did not have significantly better 1-year hospitalization outcomes when compared with patients who only attended a heart failure specialty clinic.
Federal Practitioner. 2017 April;34(4):14-19
April 11, 2017|Federal Practitioner
Allison J. Carroll, MS;Hillary L. Howrey, PhD;Susan Payvar, PhD;Kristen Deshida-Such, Mph, RD;Mayank Kansal, MD;Charanjit K. Brar, DNP, ACNP-BC
Author and Disclosure Information

Ms. Carroll is a doctoral candidate at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr. Howrey is a postdoctoral fellow at Siteman Cancer Center/Barnes-Jewish Hospital in St. Louis, Missouri. Dr. Payvar is a clinical psychologist, Ms. Deshida-Such is a clinical dietitian, Dr. Kansal is a cardiologist, and Dr. Brar is an acute care nurse practitioner all at the Jesse Brown VAMC in Chicago.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Data Analysis

Demographic, HF characteristics, and HF outcome variables for the HF SMA and HF clinic groups were compared using t tests and chi-square analyses. Logistic regressions were used to predict 12-month hospitalization, linear regressions were used to predict number of hospitalizations and number of days hospitalized, and Cox proportional hazards regressions were used to predict time from initial HF consult to first hospitalization for each HF-related hospitalization variable and all-cause hospitalization variable. A separate logistic regression was conducted to predict 12-month all-cause mortality. The primary predictor variable of interest for all models was group membership (HF SMA vs HF clinic). Covariates in all models included race (black vs nonblack), ethnicity (Hispanic/Latino vs non-Hispanic/Latino), age, and number of HF SMAs attended.

Results

Of 709 HF SMA clinic appointments made for 141 patients between January 1, 2012, and December 31, 2013, 54 patients were assigned to the HF SMA group and 37 patients were assigned to the HF clinic group (Figure). The majority of the sample was black (87%), non-Hispanic/Latino (96%), and the average age was 68 years. Patients were more likely to have nonischemic (rather than ischemic) cardiomyopathy (66%) and more likely to have HF with reduced (rather than preserved) ejection fraction (76%; ie, systolic HF). Furthermore, 40% of the sample was diagnosed with atrial fibrillation (AF) or atrial flutter (A-flutter), and 24% had an implantable cardioverter-defibrillator or pacemaker. There were no significant differences in demographics or HF characteristics between the HF SMA group and the HF clinic group (Table).

HF Hospitalization Outcomes

During the 12-month follow-up, 32 patients were hospitalized for HF, 18 (33.3%) in the SMA group and 14 (37.8%) in the HF clinic group, P = .658. Patients were hospitalized up to 4 times for between 1 and 38 days, and from 1 to 352 days postconsult. No differences between the HF SMA group and HF clinic group were observed on any of the HF hospitalization outcomes (Table). Group membership did not predict HF hospitalization (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.11-1.42), number of HF hospitalizations (β: 0.15, SE: 0.29), number of days hospitalized for HF (β: 0.1.66, SE: 2.01), or time to first HF hospitalization (hazard ratio [HR]: 1.35, 95% CI: 0.66-2.77), all Ps > .10. In the Cox proportional hazards regression predicting time to HF hospitalization, the coefficients did not converge when the model included demographic covariates; therefore, the model was run only with HF group as a predictor variable. For all other models, no covariates significantly predicted HF hospitalization outcomes.

All-Cause Hospitalization Outcomes

During the 12-month follow-up, 57 patients were hospitalized for any cause (including HF hospitalizations), 32 (59.3%) in the SMA group and 25 (67.6%) in the HF clinic group, P = .421. Patients were hospitalized up to 6 times for between 1 and 106 days and from 1 to 352 days postconsult. No differences were observed between the groups on any of the all-cause hospitalization outcomes (Table). Group membership did not predict all-cause hospitalization (OR: 0.34, 95% CI: 0.10-1.19), number of all-cause hospitalizations (β: 0.49, SE: 0.41), number of days hospitalized for any cause (β: 5.15, SE: 5.15), or time to first all-cause hospitalization (HR: 0.98, 95% CI: 0.56-1.72), all P > .05. None of the covariates predicted any of the all-cause hospitalization outcomes.

All-Cause Mortality Outcomes

During the 12-month follow-up, 14 patients (15%) died of any cause, 8 (15%) in the SMA group and 6 (16%) in the HF clinic group, P = .856. Group membership did not predict all-cause mortality (OR: 2.32, 95% CI: 0.44-12.18), and likewise none of the covariates were associated with 12-month all-cause mortality.

Discussion

This study was a naturalistic, retrospective examination of a HF management program promoting self-management delivered via multidisciplinary SMAs among veterans who enrolled in an acute HF specialty clinic. The authors’ hypothesis was not supported: patients who attended the HF SMA clinic did not have lower 12-month hospitalization or mortality rates, shorter hospital stays, or longer time to hospitalization compared with patients in the HF clinic only.

In contrast to the patient-centered approach of this study, a randomized trial delivering a similar disease management program found that patients with acute HF in the SMA group had better short-term (< 7 months) hospitalization outcomes, specifically greater time to first HF-related hospitalization (HR 0.45, 95% CI: 0.21-0.98), but this effect did not last through 12 months when compared with patients in standard care.6 These disparate findings may be explained by the gap in bench-to-bedside research, where despite scientific evidence indicating better outcomes among patients randomized to an intervention, when patients are given a choice, they may not choose to engage in the best option for their HF treatment.

In the present study, veterans who chose not to attend the HF SMA clinic may have done so for numerous reasons that may have influenced the outcomes. For example, those veterans who did not attend the HF SMA clinic may have had higher health literacy and less need for an educational program. Health literacy has been inversely associated with HF outcomes, such that patients with HF with lower health literacy have greater risk of HF rehospitalization or mortality.9,10 In addition, many of the veterans who were followed in the HF clinic were taught the same disease management strategies by the NP during one-on-one visits, and they may have gained the same self-management skills in a different setting.

Another possibility is that the veterans enrolled in the HF clinic were less likely to be followed exclusively at the VA and therefore may have had external hospitalizations not recorded in their VA health records. In 2000, more than half the veterans who received health care services at the VA reported that they did not receive their care exclusively at the VA.11 This may be especially true since the Veteran’s Choice Program permits veterans who reside > 40 miles from a VA hospital to receive care closer to home.

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