Why it Pays for Hospitals to Initiate a Heart Failure Disease Management Program

Heart failure is a clinical syndrome usually caused by structural changes in the heart. These changes result in varying degrees of symptomatic functional limitation, typically shortness of breath and fatigue. Heart failure is common, with a lifetime risk for its occurrence in a healthy 40-year-old of 20%. In the US, the cost of heart failure care is now estimated at over $US30 billion annually (year 2007 values). Several forms of treatment have been devised for heart failure: medical, device based, and surgical. These are best individualized to each patient and used in stepped progression to goals that are based on current expert guidelines. When goal-directed treatment is accomplished, three major outcomes are expected: (i) symptom relief and improved quality of life; (ii) a slowing or partial reversal of cardiac structural abnormalities; and (iii) a reduction in mortality. Attempts to deliver care for this complex syndrome have led to the development of heart failure-specific disease management programs. These programs can take different forms. Some involve multi-disciplinary teams that comprise a wide array of specialized physicians, cardiac surgeons, nurses, and other allied health workers, all with specific tasks. Others have a more narrow focus and are nurse-led programs. These programs, when fully implemented, help the patient manage his/her disease more effectively through education about heart failure, the purpose and correct use of medication, and the full utilization of nutritional interventions. These programs are also ideally suited to deliver care for patients with end-stage disease, particularly those needing implantation of left ventricular assist devices or transplantation. When effectively implemented, these programs have been shown to improve quality of life, decrease rate of heart failure hospitalizations, and improve survival compared with usual care. Cost analyses of these programs are challenging, and in the most favorable circumstances the greater up-front cost of more intense care is paid back by a lower rate of utilization of inpatient resources. The details of the University of Wisconsin Program are discussed as an example of a comprehensive management program.