Establishing a Heart Failure Program: The Essential Guide, Third Edition

161 Pages·2007·1.657 MB·English

by  Michael McIvor(auth.)

Establishing
a Heart Failure
Program
THE ESSENTIAL GUIDE
Establishing
a Heart Failure
Program
THE ESSENTIAL GUIDE
Michael McIvor,
MD
WithassistancefromRayandJeffHoward
THIRD EDITION
(cid:1)C 2007MichaelMcIvor
PublishedbyBlackwellPublishing
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Firstpublished2007
1 2007
ISBN:978-1-4051-6750-5
LibraryofCongressCataloging-in-PublicationData
McIvor,Michael.
Establishingaheartfailureprogram:theessentialguide/MichaelMcIvor,
withassistancefromRayandJeffHoward.–3rded.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN-13:978-1-4051-6750-5(alk.paper)
1.Heartfailureclinics. I.Howard,Ray,1936-II.Howard,Jeff,1963-III.Title.
[DNLM:1.HeartDiseases–therapy. 2.HealthFacilities–organization&administration.
3.PracticeManagement–organization&administration. 4.ProgramDevelopment.
WG166M478e2007]
RC685.C53M392007
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2007010317
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Contents
Acknowledgments,vii
Introduction,ix
Companionwebsite,xii
1 Isaheartfailureprogramtherightchoice?1
2 Aformulaforthesuccessofyourheartfailureprogram,9
SectionI Takingthefirststepstowardbuildingyourheart
failureprogram
3 Firststeps:abusinessplanforyourheartfailureprogram,21
4 Firststeps:choosingyourmodelofcare,33
5 Firststeps:aglobalviewofthefinancialprojectionsforyour
heartfailureprogram,47
6 Firststeps:aheartfailureprogramproforma,61
SectionII Assemblingthepiecesofyourprogram
7 Assemblingthepieces:themanagersofyourprogram,75
8 Assemblingthepieces:thefrontlinestaff,83
9 Assemblingthepieces:thephysicalfacility,89
SectionIII Day-to-dayoperations
10 Baselineassessments,95
v
vi Contents
11 Heartfailureclinicfollowupvisits,111
12 Medicaltreatmentprotocols,123
13 Telemanagementalgorithms,135
14 Advancedtherapies,143
15 Positioningyourheartfailureprogramasacenterofexpertise,149
Index,155
Abouttheauthor,161
Acknowledgments
Creatingabookisabigtask.Eventhoughthistextstandsontheshoulders
of the two editions of my previous works on this topic, much of the text
hadtoberewrittenandupdatedtoreflectcurrentthinkinginthisrapidly
changingfield.Myowneffortsweresupportedbytheworkofanumberof
otherswhowerecriticalinbringingthisbooktoreality.IthankRayandJeff
HowardwhoreviewedandeditedChapters5and6onthefinancialpro-
jectionsforaheartfailureprogram.Theirexpertiseinthisareareassured
methatIwasn’tleadingreadersastrayinthesometimesconfusingworld
ofreimbursementformedicalservices.Althoughanyerrorsinthetextare
mysoleresponsibility,IthankSusanNeillandDeniseFullerforreviewing
myworkandpointingoutareasofthebookthatcoulduseimprovement.
Their insights as experts in delivering heart failure care guided the con-
tentrevisionsfrommypreviousbooksinthistherapeuticarea.Likewise,
thanks are due to Karen Sommers for preparing the manuscript and to
Marcello Benedicto for preparing the figures. I also would be remiss if I
didn’tthankGinaAlmondatBlackwellforhavingenoughconfidencein
me to lead the effort of championing the book to her organization, and
FionaPattison,alsoatBlackwell,whoturnedmymanuscriptintoabook.
Ithinkthatwecanallbeproudofthebookthatrepresentsthefruitofour
collectiveefforts.
vii
Introduction
Like most physicians, I have been taking care of patients with heart fail-
ure(HF)beginningwhenIwasinmedicalschool,continuingthroughmy
cardiologyfellowshipatJohnsHopkinsHospital,andtheninprivateprac-
tice. Like other diseases such as HIV disease or cancers, HF is a chronic,
lethal, incurable disease. But unlike those other conditions, most medi-
cal physicians feel comfortable caring for HF patients unassisted. We all
are familiar with the basic precepts of the treatment of HF: therapeutic
lifestyle changes, the basic pharmacologic therapies that prolong the life
ofHFpatients,andthenewerstrategyoflifeprolongingdevicetherapy.
However, every critical examination of HF therapy in the United States
hasdocumentedthatwearenotusingalltheweaponsinourarsenal.We
know what works, yet we are not systematically applying these proven
therapies.
The issue, I think, is the relentlessly dynamic pace of chronic HF. The
continual, frequent adjustments in HF therapy are not the strength of
physician-delivered therapy. Physicians have the training to rescue the
acutelyillpatientintheintensivecareunitwithpulmonaryedema.After
theacutephaseoftheillnesspasses,frequentone-on-onephysicianvisits
aresimplytooexpensivetobethestandardofcare.Whilethereisevidence
that when subspecialists provide the HF care, outcomes are improved,
mostHFcareinthiscountryisprovidedbyprimarycarephysicianswhose
resourcesarestretchedthin.Asaresult,HFremainsthenumberonerea-
sonforhospitalizationintheMedicarepopulation.Despitesignificantad-
vancesinourtherapeuticoptions,fromthedatawehavetherehasbeen
littlesignificantimpactinthemortalityofHFpatientssincethe1950s[1].
WenowknowthatthereisabetterwaytotreatHF.FormalHFprograms
foroutpatientshaveconsistentlyresultedinfewerhospitalizations,andin
somestudies,lowermortalityforHFpatients.AtUCLA,afterphysicians
were told that they were being assessed for the frequency with which
they discharged HF patients on angiotensin-converting enzyme (ACE)
ix
x Introduction
inhibitors, ACE inhibitor use increased to 73%, at a time when the na-
tional average was below 50%. However, when a disease management
program was applied to these same patients using nurse case managers,
ACEinhibitortherapyondischargeincreasedto96%andwassustained
for 6 months. The disease management approach in this study resulted
in an 83% reduction in HF hospitalizations during those 6 months. The
therapyusedwassimplystandardtherapy;thedifferencewasthesystem-
aticapplicationofthistherapy[2].TheexperienceofmyfirstHFdisease
managementprogramduplicatedtheUCLAexperience,reducingannual
HFhospitalizationsby71%.
Myinvolvementinthistherapeuticarenabeganobliquely.Inthemid-
1990s, it became clear to me that my patients who were participating in
HF research trials were receiving a higher level of care than those who
were not in such trials. I was not consciously treating these two groups
differently,butintheresearchtrials,aggressivecareismandatedbypro-
tocol,andthenurseresearchcoordinatorswereseeingthesepatientsmore
frequentlythanwithusualcare.InoneHFtrialinwhichweparticipated,
patients were seen weekly for the first 14 weeks of the protocol. Under
such circumstances, it is difficult for an HF patient to “fall through the
cracks.’’Iwasimpressedthatevenpatientsintheplacebogrouphadvery
fewhospitalizationsorevenexacerbationsoftheirsymptoms.Itwasclear
to me that the clinical improvement of these patients with advanced HF
was that the research nurses had essentially created an HF disease man-
agementprogram,anditworked.Myexperienceisnotunique.Recently
DrBarryLevinetoldmethathisHFprogramattheSanFranciscoVAalso
resulted from the efforts of his research coordinators doing HF research
trials.
After deciding to start a formal HF program in 1995, based on my ex-
perienceswithresearchpatients,Ifoundlittleguidanceonwheretostart
assemblingthenutsandboltstobuildadiseasemanagementprogram.As
aresult,thatfirstprogramwasamatterofon-the-jobtraining,withresul-
tantbumpsandbruisesbeingsuffereduntilIhadtheexperiencenecessary
todiscernthebestwaytomanageanHFpractice.Tosharemyexperiences,
IwroteBlueprintforHeartFailure:APhysician’sGuidetoEstablishingaHeart
FailureCenterinthePrivatePracticeSetting.Theresponsetothetwoeditions
of the book convinced me that I had discovered a real educational need.
Subsequently, I developed and chaired a 5-year program of hundreds of
day-longBlueprintforHeartFailureCMEsymposiaaroundthecountry,
teachingthousandsofhealthcareprofessionalshowtoeffectivelycarefor
patientswithchronicHFintoday’shealthcareenvironment.Ithasbeena
realeducationandprivilegeonmyparttoworkwithHFprogramsofall
Introduction xi
sizesandinallstagesofdevelopment.Whilethediseaseremainsthesame,
the strategies applied to HF care reflect the intelligence and creativity of
talentedmembersofthemedicalcommunity.
Thisbookupdatesmypreviousbooksbothfrommyownongoingexpe-
riencesintreatingpatientswithHFandwhatIhavelearnedfromothers
throughtheBlueprintprogram.Ihopeitallowsyoutoavoidthemistakes
I’vemade(freeingyoutomaketotallynewmistakesofyourownasyou
developyourownprogram!).Asalways,Iappreciatefeedback,questions,
and hearing of your own success stories. I can be reached at 900 Central
Avenue,StPetersburg,Florida,33705.
References
1. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and
survivalwithheartfailure.NewEnglJMed2002;347:1397–1402.
2. FonarowGC,StevensonLW,WaldenJA,etal.Impactofacomprehensiveheartfailure
managementprogramonhospitalreadmissionandfunctionalstatusofpatientswith
advancedheartfailure.JAmCollCardiol1997;30:725–732
Companion website
Be sure to visit the companion website for this book to download the
followingformsforuseinyourownheartfailurecenter
www.blackwellpublishing.com/McIvor
Minnesota Living With Heart Failure Questionnaire
The Kansas City Cardiomyopathy Questionnaire
Berlin Questionnaire
Epworth Sleepiness Scale
Sexual Health Inventory for Men Questionnaire
Nutritional Assessment Form
Dietary Recall Diary
Food Frequency Checklist
Protocol ACE Inhibitors
Angiotensin Receptor Blockers
Hydralazine/nitrate protocol
Aldosterone Antagonists
b Blockers
Telephone Management Guidelines
Telephonic Patient Encounter Algorithm
xii