A Heart Failure Management Program Using Shared Medical Appointments

Rising health care costs have led to threats of nonreimbursement for rehospitalization within 30 days postdischarge.^1,2 Heart failure (HF) in particular is characterized by the highest 30-day rehospitalization rate (23.5% in 2013), which accounts for more than two-thirds of HF expenditures.^3,4

Much of HF-related health care costs can be addressed with effective self-management by patients with HF. Therefore, developing and implementing effective disease management programs for this high-risk patient population is essential. Heart failure management programs may include optimizing HF medications, improving patient understanding of the importance of appropriate diet and physical activity, and cultivating psychological health and well-being. In a 2013 systematic review and meta-analysis, Wakefield and colleagues found that disease management programs improved nearly all HF outcomes, including lower mortality rates, lower hospital readmission rates, fewer clinic visits, higher satisfaction with care, and higher quality of life, compared with a no-treatment control or standard care.⁵ Moreover, these programs demonstrated cost-effectiveness by reducing HF-related hospitalizations and health care expenditures.⁵

One method to deliver specialized disease management programs to a greater number of patients may be to use shared medical appointments (SMAs). In a randomized controlled trial, Smith and colleagues demonstrated improved HF outcomes through 7 months among veterans who attended SMAs for HF management.⁶ However, the trial enrolled only 25% of patients screened, and 63% of the patients who did not enroll were classified as not interested. These findings suggest that patients with HF, and veterans in particular, may face additional barriers to enrolling in HF management programs, and these results may not be fully representative of veterans with HF.

In this study, the authors used a naturalistic study design via retrospective review of the electronic health record (EHR) to evaluate whether patients with acute HF who chose to attend SMAs promoting self-management skills for HF would have better hospitalization outcomes compared with those who received individual disease management instructions in a HF specialty clinic (ie, usual care). The authors hypothesized that veterans who participated in the HF SMA clinic would have fewer 12-month HF-related and all-cause hospitalizations, fewer days in the hospital, and more days to first hospitalization compared with patients in usual care.

Methods

The clinic for veterans with acute HF was initiated in October, 2010 at the Jesse Brown VAMC (JBVAMC) in Chicago, Illinois, to reduce readmissions by targeting patients who had been previously hospitalized for HF. In September 2011, the multidisciplinary SMA clinic was developed within the HF clinic to provide enhanced care focused on self-management strategies for patients with HF. The HF SMA program comprised 4 weekly face-to-face sessions co-led by a nurse practitioner (NP), a dietitian, and a clinical psychologist, similar to what has been shown to be successful and cost-effective in nonveteran populations.^6-8 Patients attended at least 4 sessions before graduating to the advanced HF SMA program where they could attend monthly booster sessions. The program promoted self-management by providing education about and support for the HF process, HF medications, diet adherence, physical activity, psychological well-being, and stress management via interactive presentations. During the visit, patients’ medication and food logs were reviewed. Patients were encouraged to discuss successes and obstacles in achieving their goals. All study procedures were approved by the institutional review board at JBVAMC.

Study Design

Data were collected by retrospective review of the JBVAMC EHR. The EHR was reviewed for all veterans scheduled for ≥ 1 SMA clinic visit within the HF specialty clinic using predetermined, convenient selection between January 1, 2012, and December 31, 2013. Outcome data were collected through 12-month follow-up (through December 31, 2014).

Patients in both treatment arms received HF care through the HF clinic, including one-on-one education regarding HF self-management provided by a NP. Patients were assigned to the HF SMA group if they also attended the HF SMA clinic within 3 months of their initial HF clinic consult. The number of SMAs attended was included as a covariate in the models. Patients who were scheduled for, but did not attend, the HF SMA clinic were assigned to the HF clinic group. Patients who attended the initial HF consult before September 1, 2011, were excluded, thereby ensuring that all patients included in the present analyses had the opportunity to attend the HF SMA appointment within the predetermined period of chart review.

Data for all VA hospitalizations that occurred between January 1, 2012 and December 31, 2014, were extracted from the EHR. Extracted data included admission date, discharge date, and discharge diagnoses. From these data, the authors assessed 4 hospitalization outcomes for each HF hospitalization and all-cause hospitalization within 12 months of the initial HF clinic consult date: hospitalization (yes/no), number of hospitalizations, number of days in the hospital, and days to first hospitalization.