A Heart Failure Management Program Using Shared Medical Appointments

Disease Management Programs

Disease management programs for HF in general promote better outcomes and lower health care expenditures.^5,12 Self-management instruction delivered via SMAs may have greater potential for reducing HF-associated health care costs if it were to be integrated earlier in the continuum of care. The sample in this study was composed of veterans who were referred to a specialty clinic only after being hospitalized for HF. These patients likely were experiencing more advanced disease and/or low adherence, as indicated by the relatively high prevalence of AF diagnoses and pacemakers; these null findings are consistent with those from a randomized controlled trial of a disease management program among veterans with heavy HF symptom burden and impaired functional status.¹³ However, integrating self-management programs earlier in HF clinical care (eg, primary care or cardiology clinics) may be more effective in promoting proactive disease management and delaying or preventing initial HF hospitalizations.

For example, a disease management plan implemented by general practitioners for veterans with HF in Australia was associated with a 23% reduction in potentially preventable hospitalization rates.¹⁴ Veterans with HF enrolled in a NP-led disease management intervention, relative to those followed only in primary care, had significantly fewer hospitalizations and nearly half the risk mortality (15% vs 28% after 2 years; HR 0.55).¹⁵ Furthermore, some have suggested that SMAs may be more effective for patients for whom risk of disease is high but current disease burden (ie, symptoms) is low, such as diabetes mellitus management programs.¹⁶ Early intervention also may allow providers to reach more patients more quickly and before they experience advanced symptoms, thereby reducing specialty clinic wait times and overall health expenditures. Developing more effective disease management programs for patients with acute HF and veterans in particular remains a critical matter for future study.

Additional and novel components of HF management programs show promise for future interventions. First, various facets of social support, including emotional support, instrumental/tangible support, informational support, and appraisal support, are associated with improved self-care.¹⁷ For example, the levels of family functioning and family support predict HF outcomes, perhaps because between-appointment monitoring allows patients to report problems that might otherwise go unidentified and receive more external feedback about their disease and symptoms.^18,19 Patients report that family members or especially supportive members of their health care team are invaluable contributors to their successful management of HF.²⁰ A recently published feasibility trial of a couple-based disease management program observed positive trends in HF management for veterans, as well as improvements in caregiver’s depressive symptoms and burden, indicating that even support from informal caregivers may improve HF outcomes.²¹

Advances in technology-delivered disease management programs show promise in improving adherence to chronic disease management programs.^22,23 Specifically for HF, veterans who enrolled in a daily telehealth intervention employing daily vital signs and symptom reporting, automated reminders and tips for self-management, and proactive monitoring and intervention telephone calls from a nurse successfully lowered their blood pressure, lost weight, reduced their HF medication dosages, and spent 80% fewer days in the hospital.²⁴ Among patients with coronary artery disease, a text messaging service was shown to improve a number of cardiovascular risk factors.²⁵ Moreover, mobile applications can be used to support informal caregivers of patients with HF.²⁶ To the authors knowledge, no research studies have been conducted using text messaging or mobile applications among veterans with HF.

Limitations

Some limitations of the present study warrant discussion. First, as discussed earlier, patients were not randomized to the treatment arms. Second, veterans are referred to the HF clinic only after being hospitalized for HF. As a result, all the referred veterans likely were experiencing more advanced disease and/or low adherence, and these results may not be representative of patients with less advanced disease. Finally, the sample used in the present analysis was a small, homogeneous group of 91 male veterans who were 85% black and 95% non-Hispanic. These demographics are largely representative of the JBVAMC. Therefore, the present results may not be generalizable to more racially or ethnically diverse populations, women, or nonveterans.

Conclusion

Minimizing rehospitalization rates for patients with HF continues to be a priority. Health care costs of HF are more than double those of patients in the general population, primarily due to hospitalizations—in 2013, HF hospitalization costs in the U.S. exceeded $10 billion.^27,28 Given the current emphasis on economical, patient-centered care, SMAs may be a cost-effective alternative to individualized disease management plans while continuing to allow providers to tailor treatment to individual patient needs.

Although this study did not find better outcomes among veterans whose specialty HF care was augmented by clinic-based SMAs, the authors believe that this type of program has great potential. Heart failure SMAs may improve HF outcomes, enhance efficiency of health care delivery, and reduce overall HF-associated health care costs if it is integrated earlier along the continuum of care or if other novel components, such as caregiver support or technology-based delivery, is included. Further studies are needed to systematically evaluate HF management programs delivered via SMAs to improve outcomes and reduce the economic burden that HF places on the health care system.