Author + information
- Received January 22, 1997
- Revision received April 23, 1997
- Accepted May 16, 1997
- Published online July 1, 1997.
- Gregg C Fonarow, MD, FACCA,*,
- Lynne W Stevenson, MD, FACCB,
- Julie A Walden, MNA,
- Nancy A Livingston, MNA,
- Anthony E Steimle, MDA,
- Michele A Hamilton, MD, FACCA,
- Jaime Moriguchi, MDA,
- Jan H Tillisch, MDA and
- Mary A Woo, DScNA
- ↵*Dr. Gregg C. Fonarow, University of California at Los Angeles School of Medicine, Division of Cardiology, 47-123 CHS, 10833 Le Conte Avenue, Los Angeles, California 90095-1679.
Objectives. To assess the impact of a comprehensive heart failure management program, functional status, hospital readmission rate and estimated hospital costs were determined and compared for the 6 months before and the 6 months after referral.
Background. The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost.
Methods. Over a 3-year period, 214 patients were accepted for heart transplantation and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per min and a total of 429 hospital admissions in the previous 6 months (average 2.0 per patient). Changes in the medical regimen included a 98% increase in angiotensin-converting enzyme inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling also regarding diet and progressive exercise.
Results. During the 6 months after referral, there were only 63 hospital readmissions (85% reduction), with 0.29/patient (p < 0.0001). Functional status improved as assessed by functional class (p < 0.0001) and peak oxygen consumption (15.2 vs. 11.0 ml/kg per min, p < 0.001). The same results were seen after excluding the 35 patients without full 6-month follow-up (9 deaths, 14 urgent transplant procedures during hospital readmission, 12 elective transplant procedures from home); 34 hospital admissions occurred after referral, compared with 344 before referral. Even when adding in the initial hospital admission after referral for these 179 patients, there was a 35% decrease in total hospital admissions in the 6-month period. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient.
Conclusions. Comprehensive heart failure management led to improved functional status and an 85% decrease in the hospital admission rate for transplant candidates discharged after evaluation. The potential to reduce both symptoms and costs suggests that referral to a heart failure program may be appropriate not only for potential heart transplantation, but also for medical management of persistent functional class III and IV heart failure.
☆ This work was supported by the Ahmanson Foundation, Los Angeles, California and the Eastern Star Foundation, Los Angeles, California. Dr. Fonarow is an Initial Investigator of the American Heart Association, Greater Los Angeles Affiliate. Drs. Fonarow and Steimle were supported by NIH Training Grant 1T32HL07412-10 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
This study was presented in part at the 44th Annual Scientific Session of the American College of Cardiology, New Orleans, Louisiana, March 1995.
- Received January 22, 1997.
- Revision received April 23, 1997.
- Accepted May 16, 1997.