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Clinical Investigations: CARDIOLOGY |

Improving Outcomes in Heart Failure in the Community*: Long-term Survival Benefit of a Disease-Management Program FREE TO VIEW

Kwame O. Akosah, MD; Ana M. Schaper, PhD; Lindsay M. Haus, BA; Michelle A. Mathiason, MS; Sharon I. Barnhart, BSN; Vicki L. McHugh, MS
Author and Funding Information

*From the Gundersen Lutheran Health System, La Crosse, WI.

Correspondence to: Kwame O. Akosah, MD, Gundersen Lutheran Health System, 1900 South Ave, La Crosse, WI 54601; e-mail: koakosah@gundluth.org



Chest. 2005;127(6):2042-2048. doi:10.1378/chest.127.6.2042
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Objectives: The purpose of our current study was to determine whether our disease-management model was associated with long-term survival benefits. A secondary objective was to determine whether program involvement was associated with medication maintenance and reduced hospitalization over time compared to usual care management of heart failure.

Design: A retrospective chart review was conducted in patients who had been hospitalized for congestive heart failure between April 1999 and March 31, 2000, and had been discharged from the hospital for follow-up in the Heart Failure Clinic vs usual care.

Setting: An integrated health-care center serving a tristate area.

Patients: Patients (n = 101) were followed up for 4 years after their index hospitalization for congestive heart failure.

Measurements and results: The patients followed up in the Heart Failure Clinic comprised group 1 (n = 38), and the patients receiving usual care made up group 2 (n = 63). The mean (± SD) age of the patients in group 1 was 68 ± 16 years compared to 76 ± 11 years for the patients in group 2 (p = 0.002). The patients in group 1 were more likely to have renal failure (p = 0.035), a lower left ventricular ejection fraction (p = 0.005), and hypotension at baseline (p = 0.002). At year 2, more patients in group 1 were maintained by therapy with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) [p = 0.036]. The survival rate over 4 years was better for group 1. Univariate Cox proportional hazard ratios revealed that age, not receiving ACEIs or ARBs, and renal disease or cancer at baseline were associated with mortality. When controlling for these variables in a multivariate Cox proportional hazards ratio model, survival differences between groups remained significant (p = 0.021). Subjects in group 2 were 2.4 times more likely to die over the 4-year period than those in group 1.

Conclusions: Our study demonstrated that, after controlling for baseline variables, patients participating in a heart failure clinic enjoyed improved survival.

Figures in this Article

Multiple clinical trials have led to advancements in the management of chronic heart failure.13 Guidelines have been published in an attempt to improve physician education and bring the benefit of evidence-based medicine to heart failure patients.4Since the publication of the latest guidelines, further studies have demonstrated that certain strategies are associated with improved outcomes. For example, evidence on the role of device therapy,57 and therapy with angiotensin receptor blockers (ARBs)89 as well as aldosterone inhibitors10for the treatment of heart failure patients continues to accrue. However, limitations in the management of heart failure patients exist in both academic centers and, to a larger extent, in the community. Studies have suggested that many heart failure patients do not receive standardized medications, and that many who do, receive suboptimal treatment.1113 These limitations have led to the development of many quality improvement interventions and have generated considerable interest from both regulatory and third-party payers. The Joint Commission for Accreditation of Health Care Organizations and the Centers for Medicare and Medicaid Services have identified the use of angiotensin-converting enzyme inhibitors (ACEIs) in heart failure patients as a key quality measure.1415 Institutions have responded by developing varying models of heart failure programs.1516 While many have reported benefits in terms of reduced hospitalizations and cost, the effect on mortality has not been demonstrated.

In 2002, we published the results of our Heart Failure Clinic model17 in which we demonstrated improved event-free survival at 1 year posthospitalization for heart failure. The purpose of our current study was to determine whether our program was associated with long-term survival benefits. A secondary objective was to determine whether the benefit that we demonstrated in the short term for medication maintenance and reduced rates of the combined end point of rehospitalization for congestive heart failure and death at 1 year were sustained over time.

Our Heart Failure Clinic model has been previously described.17 Briefly, the program utilizes an aggressive short-term, multidisciplinary approach to maximize the use of standardized medications. The personnel in the Heart Failure Clinic include cardiologists with specialty training in heart failure and nurse practitioners who closely monitor patient responses to medication management while focusing on self-care practices. In addition, nurse educators provide ongoing individual and group education programming for patients and their families. Key components of the model include the following: (1) easy access for heart failure patient clinic visits; (2) frequent visits during the first few months to titrate medications as tolerated; and (3) phone contacts from the patient to problem-solve health concerns. Our primary goal was to reach the maximal doses of recommended medications that each individual can effectively tolerate to enhance quality of life. We have been able to accomplish this, in part, by establishing a collaborative network including reciprocal consultations with other specialty departments such as the renal, pulmonary, and endocrinology departments. Reciprocity involves easy access for appointments in these specialty practices. This format allows for the concurrent management of comorbidities such as renal disease, sleep apnea, peripheral vascular disease, and diabetes. Patients are typically seen in our Heart Failure Clinic for 3 to 6 months. At that time, they are discharged from the clinic and followed up by their primary care providers. Patients may return for follow-up if desired at 6-month intervals or as requested by the primary care provider. The Heart Failure Clinic is available for consultation by primary care providers at all times.

Patient Population

As previously published,17 patients were included in this study if they had been hospitalized with a diagnosis of congestive heart failure between April 1, 1999, and March 31, 2000, and had received follow-up care within the index hospital system. A chart review to retrieve follow-up data was conducted following institutional review board approval of a Health Insurance Portability and Accountability Act waiver. Data were collected from electronic clinic records. Standardized heart failure medications included the use of ACEIs, ARBs, β-blockers, and spironolactone. An optimized ACEI was defined as ≥ 20 mg lisinopril or an equivalent brand of ACEI. Outcome information including hospital readmission, mortality, and a combined end point of hospital readmission for congestive heart failure plus death was determined. Two independent reviewers coded hospital readmissions at the index hospital. For the purposes of this study, hospital admissions were classified as follows: (1) heart failure if there was evidence of disease exacerbation; (2) cardiac if cardiac-related but not associated with a heart failure exacerbation; and (3) other noncardiac hospital admissions. All-cause hospitalization included any admission at the index hospital. The time to event was defined as the number of years from the initial hospital discharge to the event (ie, congestive heart failure rehospitalization or death).

Statistical Analysis

Comparisons between groups were performed using the independent t test, the paired-sample t test, and a 2 × 2 factorial analysis for repeated measures. Univariate Cox proportional hazards model ratios were used to determine which factors were predictive of survival. A multivariate Cox proportional hazards model ratio was developed to determine the significance of group risk factors while controlling for traditional risk factors by using these risk factors as covariates. The group survival data were displayed using Kaplan-Meier curves. A p value of < 0.05 was considered to be significant, and all p values reflect two-tailed tests.

Patients’ baseline clinical profiles and short-term outcomes were previously published.17 Briefly, patients who had been referred to the Heart Failure Clinic on discharge from the hospital (n = 38) were categorized as being in group 1. Group 2 (n = 63) was composed of patients who were followed up by their respective physicians after hospital discharge. The mean (± SD) ages of patients in group 1 and group 2 were 68 ± 16 and 76 ± 11 years, respectively (p = 0.002). Although the patients in group 1 were younger, the mean left ventricular ejection fraction for patients in group 1 (29%) was lower than that in group 2 (39%; p = 0.005). In addition, group 1 patients were more likely to have baseline renal failure at (p = 0.035), severe dysrhythmia (p = 0.039), an automated implantable cardiac defibrillator (p = 0.028), and hypotension (p = 0.002) [Table 1] . Both groups of patients had similar rates of the following comorbidities: diabetes mellitus; COPD; and thyroid disease.

Follow-up Medication Utilization

Medication prescription rates for optimized ACEIs, ARBs, or β-blockers were not different at hospital discharge. An analysis of drug utilization over time showed that at 1 and 2 years after the index hospitalization more patients in group 1 were receiving a therapeutic dose of an ACEI or ARB compared with patients in group 2. Similarly, more group 1 patients were receiving therapy with a β-blocker compared to patients in group 2, even though the rate of pulmonary comorbidities was not different. Overall, group 1 patients were more likely to be receiving recommended doses of standardized medications after 1 year than group 2 patients (Table 2 ).

Survival

At 4 years, 71% of patients (27 of 38 patients) in group 1 were alive compared with 51% of those in group 2 (32 of 63 patients). A Kaplan-Meier graph indicated that the curves began to widen soon after 1 year and remained divergent at 4 years posthospitalization (Fig 1 ). In a univariate Cox proportional hazards model analysis, several biomedical variables were related to survival, including age, renal disease, and cancer at baseline. In addition, patients receiving an ACEI or ARB lived longer than those who were not prescribed these medications at hospital discharge (Table 3 ).

Next, we sought to determine whether the survival benefit of patients in group 1 was related to the difference in baseline variables between the two groups. A multivariate Cox proportional hazards model was developed to assess the prognostic value of the group while controlling for the following variables: age; cancer at baseline; renal disease at baseline; and ACEI or ARB not prescribed at hospital discharge. The results are displayed in Table 4 . The multivariate model increased the prognostic ability of the group, while holding constant the variables age, cancer, and renal disease at baseline, as well as not being prescribed an ACEI or ARB at hospital discharge (p = 0.021). The risk of death for the heart failure patients in group 1 remained lower over the 4-year follow-up period (hazard ratio, 2.422; 95% confidence interval [CI], 1.143 to 5.132). Patients in group 2 were more than twice as likely to die within 4 years after hospital discharge from the index hospitalization compared to patients in group 1.

Similarly, outcome in terms of the combined end point of heart failure admission and death were different after controlling for age, cancer, and renal disease at baseline, and the use of ACEI or ARB medication. Specifically, group 1 patients tended to benefit from a better event-free survival in terms of freedom from death or hospitalization for heart failure (hazard ratio, 1.765; 95% CI, 0.966 to 3.225; p = 0.065) [Fig 2] . The median time to hospital admission for heart failure was delayed for group 1 (8 months; n = 10) vs group 2 (2 months; n = 22; p < 0.010).

In the multivariate model, age and renal disease were strong predictors of both survival and event-free survival. Additional Kaplan-Meier curves were created to assess the effect of these variables by group. Overall, the mean age of the patients in group 1 was 8 years younger than the patients in group 2. The multivariate model indicated that for every additional year there was a 3.6% increase in the risk of death. In order to display the effect of age by group, the median age of our population was determined (74 years). The Kaplan-Meier curves in Figure 3 display the effect of older vs younger age on survival for the two groups. Regardless of age categorization, the patients in group 1 survived longer than the patients in group 2. While the presence of renal disease at baseline was a significant predictor of mortality, patients lived longer if they were in group 1 (Fig 4 ). Similarly, for the subset of patients without renal disease, the patients in group 1 lived longer than patients in group 2. These data support the premise that patients participating in the Heart Failure Clinic experienced an added benefit in terms of survival.

The optimal management for heart failure patients continues to evolve. Since the publication of the last clinical guidelines for heart failure,4several studies510 have shown a further survival benefit derived from pharmacologic and nonpharmacologic therapy. Each new publication of positive study results contributes to the complexity of heart failure management. Unfortunately, studies1113 have also continued to indicate that physician adherence to evidence-based medicine remains suboptimal. The failure to prescribe recommended therapy is consistent across a wide spectrum of health-care institutions.12 In the rural community, there are unique structural, infrastructural, and resource barriers that further compound the efforts to improve care.1820 For example, there are generally fewer specialists in rural communities, where the typical patient is elderly, has multiple comorbidities, and travels a long distance for care. An attractive alternative approach to improving care may be the use of a multidisciplinary collaborative resource team.21

In a previous publication,17 we showed that a collaborative disease-management approach improved short-term outcome measures, including reduced hospitalization rates, improved event-free survival, and higher prescription rates for recommended therapy. The current study highlights three issues. First, medications that begin to be used and are titrated to optimal doses during short-term participation in a disease-management program are likely to continue being used long after care is resumed by a patient’s own primary health-care provider. Second, the short-term benefits of a collaborative team approach are maintained over time. Third, patient management by a multidisciplinary team working in collaboration with the primary care physicians is associated with survival benefits when compared with usual care practice.

Currently, there are several models of disease management programs for heart failure that have been shown to reduce hospitalization rates and costs.16 However, because studies have been limited to short-term follow-up, it is unclear whether the observed benefits are maintained over time. This study showed that a collaborative multidisciplinary team approach that adheres to evidence-based medicine is associated with short-term benefits that are maintained over the long term. Although many accept that there are benefits of participating in disease-management programs for heart failure, improved survival has not been proven. We thought that the lack of evidence for improved survival could be explained, in part, by several factors. Studies to date have been limited by single-center experiences, small sample sizes, and rather short study durations. Furthermore, several of these studies have used methods (before and after program enrollment) that do not allow for survival analysis. In this study, we showed that patients enrolled in our Heart Failure Clinic benefited from improved survival compared with patients followed up by usual care standards.

Due to institutional initiatives, patients admitted to our hospital receive recommended medications. However, as our study shows, many do not receive dose titrations to recommended levels. Thus, the percentages of patients receiving optimal doses of ACEIs and β-blockers were similar for subjects in the two groups at baseline. Patients seen in the Heart Failure Clinic had their medications titrated to recommended doses, while patients followed up by usual care typically did not. The difference persisted in year 1 and again in year 2, even though the Heart Failure Clinic patients resumed care with their primary physicians after an average duration of 3 months. When patients were stabilized on recommended doses, not only were their physicians more likely to continue using those medications and to maintain the high dose, but the patient also was more likely to adhere to their regimen. By contrast, patients who were followed up by usual care remained on low doses. A recent report22 on drug utilization in Medicare patients in Tennessee illustrates this point. Butler et al22 reported that even though their patients had prescription drug benefits, many were not prescribed an ACEI on hospital discharge. Furthermore, the rate of utilization of prescribed drugs declined over the 1-year follow-up period. Several physician-related and patient-related factors account for the low prescription and utilization rates of the recommended medications.

There is wide variability among disease-management programs for the treatment of congestive heart failure patients. For this reason, it is not possible to determine the “most effective” program. However, as previously published by Grady and associates,21 a successful program incorporates certain features. We think that the following characteristics are important among community-based programs. First is the use of a multidisciplinary collaborative approach, which includes specialists and the patient’s primary care provider, in addressing all comorbidities. Heart failure patients in the community are generally elderly with a high likelihood of having multiple comorbid conditions. This may be different from patients who are seen in tertiary academic centers located in urban settings where patients are referred for transplantation. Most of the comorbidities present in our population disqualify them from receiving transplants. Since survival is affected by the general health of the patient, a program that addresses all comorbidities may work best in rural community settings. The second crucial element is aggressive up-titration and maintenance of medications. Although our sample size was small, our data showed that in a univariate model, patients who did not receive an ACE or ARB at baseline were 2.6 times more likely to die. In addition, the failure to receive a β-blocker at baseline was associated with a strong trend toward poorer outcomes. Another important feature of our program is that it has been well-received by the community physicians. Our clinic is viewed as a resource service that is available to patients, in which the patient’s primary physician continues to play a vital part.

As expected, comorbidities and the use of standardized medications impacted survival. The effect of renal failure on mortality in patients with congestive heart failure is well-known.23 At baseline, there were higher rates of renal disease in group 1 patients. Interestingly, patients in group 1 experienced improved survival despite higher rates of renal disease. This observed benefit in survival suggests that heart failure patients with comorbidities and advanced age may be ideal candidates for collaborative disease-management programs. A Cox proportional hazards model analysis suggested that at any time point there were differences in survival after controlling for age, comorbidities, and medication utilization. This suggests that participation in the Heart Failure Clinic was associated with survival beyond what can be explained by these variables.

The results of our study showed that a collaborative team approach of dedicated heart failure practitioners working in conjunction with primary physicians may be one way to improve prescription rates and ensure long-term treatment adherence. In the community setting, a disease-management model utilizing a short-term, aggressive management approach may bring the benefits of evidence-based medicine to many who might otherwise not have access to specialized care.

Limitations

This was not a randomized study, and the baseline clinical characteristics were not equivalent. For instance, patients in group 2 were significantly older, which is important because age by itself is a strong predictor of mortality. To examine the extent to which the results were confounded by age or other baseline variables, we adjusted for their effects using a multivariate Cox proportional hazards model. Another limitation of the study relates to the small sample size of our cohort, although we were able to observe the cohort for an extended period of time. Because disease-management programs vary across institutions, it is not clear whether our results are generalizable beyond programs that are similar to ours. However, we think that our results are important and that they may form the basis for future prospective trials, which are clearly needed to determine the long-term benefits of disease-management programs. Our methodology did not allow us to determine which elements of the program may be responsible for the observed benefit. We hope that future trials will include an appropriate methodology and the power to answer this question.

We have shown that a collaborative, multidisciplinary, short-term, aggressive disease-management model for heart failure may be one way to address the barriers to effective heart failure management. Our experience demonstrates that the benefits shown in the short term are sustained over the long term. Importantly, patients who are managed in such a program benefited in terms of improved survival.

Abbreviations: ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CI = confidence interval

Table Graphic Jump Location
Table 1. Clinical Profile of Subjects at Hospital Discharge (Baseline)*
* 

AICD = automatic implantable cardioverter defibrillator.

 

Systolic BP ≤ 90 mm Hg.

Table Graphic Jump Location
Table 2. Medication Maintenance Rates
Figure Jump LinkFigure 1. A Kaplan-Meier plot illustrating freedom from death. The upper curve represents patients who were referred to the Heart Failure Clinic following hospitalization (group 1). The lower curve represents the survival distribution for group 2 patients who were followed up by their primary care provider. A Cox proportional hazards model controlling for the baseline covariates of age, cancer, renal disease, and usage of an ACEI or ARB was significant for a group effect (p = 0.021).Grahic Jump Location
Table Graphic Jump Location
Table 3. Univariate Cox Proportional Hazards Model Ratios for Death*
* 

See Table 1 for abbreviation not used in the text.

 

Systolic BP ≤ 90 mm Hg.

Table Graphic Jump Location
Table 4. Multivariate Cox Regression for Death by Group Controlling for Confounding Variables
Figure Jump LinkFigure 2. Kaplan-Meier plot illustrating freedom from hospitalization for heart failure and death. A Cox proportional hazards model controlling for the baseline covariates of age, cancer, renal disease, and usage of an ACEI or ARB was almost significant for a group effect (p = 0.065).Grahic Jump Location
Figure Jump LinkFigure 3. Patient survival by group during the 4-year follow-up period in patients > 75 years of age and < 75 years of age.Grahic Jump Location
Figure Jump LinkFigure 4. Four-year survival rates stratified by group and by the absence or presence of renal disease (RD) at baseline.Grahic Jump Location
Pitt, B, Zannad, F, Remme, W, et al (1999) The effect of spironolactone morbidity and mortality in patients with severe heart failure: randomized aldactone evaluation study investigators.N Engl J Med341,709-717. [CrossRef] [PubMed]
 
Kostis, J, Shelton, B, Gosselin, G, et al Adverse effects of enalapril in the Studies of Left Ventricular Dysfunction (SOLVD).Am Heart J1996;131,350-355. [CrossRef] [PubMed]
 
St. John, S, Pfeffer, M, Moye, L, et al Cardiovascular death and left ventricular remodeling two years after myocardial infarction: baseline predictors and impact of long-term use of captopril: information from the Survival and Ventricular Enlargement (SAVE) trial.Circulation1997;96,3294-3299. [CrossRef] [PubMed]
 
American College of Cardiology/American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the 1995 guidelines for the evaluation and management of heart failure). Available at: http://www.acc.org/clinical/guidelines/failure/hf_index.htm. Accessed May 16, 2005.
 
Young, JB, Abraham, W, Smith, A, et al Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial.JAMA2003;289,2685-2694. [CrossRef] [PubMed]
 
Teerlink, JR, Massie, BM Late breaking heart failure trials from the 2003 ACC meeting: EPHESUS and COMPANION.J Card Fail2003;9,158-163. [CrossRef] [PubMed]
 
Klein, H, Auricchio, A, Reek, S, et al New primary prevention trials of sudden cardiac death in patients with left ventricular dysfunction: SCD-HEFT and MADIT-II.Am J Cardiol1999;83,91D-97D. [CrossRef] [PubMed]
 
McMurray, J, Ostergren, J, Pfeffer, M, et al Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and Morbidity (CHARM) programme.Eur J Heart Fail2003;5,261-270. [CrossRef] [PubMed]
 
Pfeffer, MA, McMurray, JJ, Velazwquez, EJ, et al Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both.N Engl J Med2003;349,1893-1906. [CrossRef] [PubMed]
 
Pitt, B, Remme, W, Zannad, F, et al Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med2003;348,1309-1321. [CrossRef] [PubMed]
 
McGlynn, EA, Asch, SM, Adams, J, et al The quality of health care delivered to adults in the United States.N Engl J Med2003;348,2635-2645. [CrossRef] [PubMed]
 
Fonarow, G, ADHERE Scientific Committee ASA. The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure.Rev Cardiovasc Med2003;4(suppl),S21-S30
 
Tierney, WM, Overhage, JM, Murray, MD, et al Effects of computerized guidelines for managing heart disease in primary care.J Gen Intern Med2004;18,967-976
 
Joint Commission on Accreditation of Healthcare Organizations. JCAHO overview of the heart failure (HF) core measure set (3/22/2002). Available at: http://www.jcaho.org/pms/core+measures/hf_overview.htm. Accessed May 16, 2005.
 
Centers for Medicare and Medicaid Services. Quality improvement organizations: statement of work. Available at: http://www.cms.hhs.gov/qio/2.asp. Accessed May 16, 2005.
 
Akosah, KO, Carothers, S Short term aggressive disease management programs for heart failure: effect on drug utilization, clinical outcomes, and costs.Dis Manage Health Outcomes2004;12,221-227. [CrossRef]
 
Akosah, KO, Schaper, AM, Havlik, P, et al Improving care for patients with chronic heart failure in the community.Chest2002;122,906-912. [CrossRef] [PubMed]
 
The National Advisory Committee on Rural Health and Human Services. Health Care Quality: the rural context; a report to the Secretary, U.S. Department of Health and Human Services. Available at: http://ruralcommittee.hrsa.gov/QR03.htm. Accessed May 16, 2005.
 
Wagnild, G, Rowland, J, Dimmler, L, et al Differences between frontier and urban elders with chronic heart failure.Prog Cardiovasc Nurs2004;19,12-18. [CrossRef] [PubMed]
 
Moscovice, I, Rosenblatt, R Quality of care challenges for rural health.J Rural Health2000;16,168-176. [CrossRef] [PubMed]
 
Grady, KL, Dracup, K, Kennedy, G, et al Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association.Circulation2000;102,2445-2456
 
Butler, J, Arbogast, PG, Daugherty, J, et al Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge.J Am Coll Cardiol2004;43,2036-2043. [CrossRef] [PubMed]
 
McAlister, RA, Ezekowitz, J, Tonelli, M, et al Renal insufficiency and heart failure: prognostic and therapeutic implications from a prospective cohort study.Circulation2004;109,1004-1009. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. A Kaplan-Meier plot illustrating freedom from death. The upper curve represents patients who were referred to the Heart Failure Clinic following hospitalization (group 1). The lower curve represents the survival distribution for group 2 patients who were followed up by their primary care provider. A Cox proportional hazards model controlling for the baseline covariates of age, cancer, renal disease, and usage of an ACEI or ARB was significant for a group effect (p = 0.021).Grahic Jump Location
Figure Jump LinkFigure 2. Kaplan-Meier plot illustrating freedom from hospitalization for heart failure and death. A Cox proportional hazards model controlling for the baseline covariates of age, cancer, renal disease, and usage of an ACEI or ARB was almost significant for a group effect (p = 0.065).Grahic Jump Location
Figure Jump LinkFigure 3. Patient survival by group during the 4-year follow-up period in patients > 75 years of age and < 75 years of age.Grahic Jump Location
Figure Jump LinkFigure 4. Four-year survival rates stratified by group and by the absence or presence of renal disease (RD) at baseline.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Clinical Profile of Subjects at Hospital Discharge (Baseline)*
* 

AICD = automatic implantable cardioverter defibrillator.

 

Systolic BP ≤ 90 mm Hg.

Table Graphic Jump Location
Table 2. Medication Maintenance Rates
Table Graphic Jump Location
Table 3. Univariate Cox Proportional Hazards Model Ratios for Death*
* 

See Table 1 for abbreviation not used in the text.

 

Systolic BP ≤ 90 mm Hg.

Table Graphic Jump Location
Table 4. Multivariate Cox Regression for Death by Group Controlling for Confounding Variables

References

Pitt, B, Zannad, F, Remme, W, et al (1999) The effect of spironolactone morbidity and mortality in patients with severe heart failure: randomized aldactone evaluation study investigators.N Engl J Med341,709-717. [CrossRef] [PubMed]
 
Kostis, J, Shelton, B, Gosselin, G, et al Adverse effects of enalapril in the Studies of Left Ventricular Dysfunction (SOLVD).Am Heart J1996;131,350-355. [CrossRef] [PubMed]
 
St. John, S, Pfeffer, M, Moye, L, et al Cardiovascular death and left ventricular remodeling two years after myocardial infarction: baseline predictors and impact of long-term use of captopril: information from the Survival and Ventricular Enlargement (SAVE) trial.Circulation1997;96,3294-3299. [CrossRef] [PubMed]
 
American College of Cardiology/American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the 1995 guidelines for the evaluation and management of heart failure). Available at: http://www.acc.org/clinical/guidelines/failure/hf_index.htm. Accessed May 16, 2005.
 
Young, JB, Abraham, W, Smith, A, et al Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial.JAMA2003;289,2685-2694. [CrossRef] [PubMed]
 
Teerlink, JR, Massie, BM Late breaking heart failure trials from the 2003 ACC meeting: EPHESUS and COMPANION.J Card Fail2003;9,158-163. [CrossRef] [PubMed]
 
Klein, H, Auricchio, A, Reek, S, et al New primary prevention trials of sudden cardiac death in patients with left ventricular dysfunction: SCD-HEFT and MADIT-II.Am J Cardiol1999;83,91D-97D. [CrossRef] [PubMed]
 
McMurray, J, Ostergren, J, Pfeffer, M, et al Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and Morbidity (CHARM) programme.Eur J Heart Fail2003;5,261-270. [CrossRef] [PubMed]
 
Pfeffer, MA, McMurray, JJ, Velazwquez, EJ, et al Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both.N Engl J Med2003;349,1893-1906. [CrossRef] [PubMed]
 
Pitt, B, Remme, W, Zannad, F, et al Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med2003;348,1309-1321. [CrossRef] [PubMed]
 
McGlynn, EA, Asch, SM, Adams, J, et al The quality of health care delivered to adults in the United States.N Engl J Med2003;348,2635-2645. [CrossRef] [PubMed]
 
Fonarow, G, ADHERE Scientific Committee ASA. The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure.Rev Cardiovasc Med2003;4(suppl),S21-S30
 
Tierney, WM, Overhage, JM, Murray, MD, et al Effects of computerized guidelines for managing heart disease in primary care.J Gen Intern Med2004;18,967-976
 
Joint Commission on Accreditation of Healthcare Organizations. JCAHO overview of the heart failure (HF) core measure set (3/22/2002). Available at: http://www.jcaho.org/pms/core+measures/hf_overview.htm. Accessed May 16, 2005.
 
Centers for Medicare and Medicaid Services. Quality improvement organizations: statement of work. Available at: http://www.cms.hhs.gov/qio/2.asp. Accessed May 16, 2005.
 
Akosah, KO, Carothers, S Short term aggressive disease management programs for heart failure: effect on drug utilization, clinical outcomes, and costs.Dis Manage Health Outcomes2004;12,221-227. [CrossRef]
 
Akosah, KO, Schaper, AM, Havlik, P, et al Improving care for patients with chronic heart failure in the community.Chest2002;122,906-912. [CrossRef] [PubMed]
 
The National Advisory Committee on Rural Health and Human Services. Health Care Quality: the rural context; a report to the Secretary, U.S. Department of Health and Human Services. Available at: http://ruralcommittee.hrsa.gov/QR03.htm. Accessed May 16, 2005.
 
Wagnild, G, Rowland, J, Dimmler, L, et al Differences between frontier and urban elders with chronic heart failure.Prog Cardiovasc Nurs2004;19,12-18. [CrossRef] [PubMed]
 
Moscovice, I, Rosenblatt, R Quality of care challenges for rural health.J Rural Health2000;16,168-176. [CrossRef] [PubMed]
 
Grady, KL, Dracup, K, Kennedy, G, et al Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association.Circulation2000;102,2445-2456
 
Butler, J, Arbogast, PG, Daugherty, J, et al Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge.J Am Coll Cardiol2004;43,2036-2043. [CrossRef] [PubMed]
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543