Establishing a Heart Failure Program: The Essential Guide, Third Edition PDF
Preview Establishing a Heart Failure Program: The Essential Guide, Third Edition
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 BlackwellFuturaisanimprintofBlackwellPublishing BlackwellPublishing,Inc.,350MainStreet,Malden,Massachusetts02148-5020,USA BlackwellPublishingLtd,9600GarsingtonRoad,OxfordOX42DQ,UK BlackwellScienceAsiaPtyLtd,550SwanstonStreet,Carlton,Victoria3053,Australia Allrightsreserved.Nopartofthispublicationmaybereproducedinanyformorbyany electronicormechanicalmeans,includinginformationstorageandretrievalsystems,without permissioninwritingfromthepublisher,exceptbyareviewerwhomayquotebriefpassages inareview. 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 362.196(cid:2)120068–dc22 2007010317 AcataloguerecordforthistitleisavailablefromtheBritishLibrary CommissioningEditor:GinaAlmond DevelopmentEditor:FionaPattison EditorialAssistant:VictoriaPitman ProductionController:DebbieWyer Setin10/13PalatinobyAptaraInc.,NewDelhi,India PrintedandboundinSingaporebyFabulousPrintersPteLtd ForfurtherinformationonBlackwellPublishing,visitourwebsite: www.blackwellcardiology.com Thepublisher’spolicyistousepermanentpaperfrommillsthatoperateasustainableforestry policy,andwhichhasbeenmanufacturedfrompulpprocessedusingacid-freeandelementary chlorine-freepractices.Furthermore,thepublisherensuresthatthetextpaperandcoverboard usedhavemetacceptableenvironmentalaccreditationstandards. BlackwellPublishingmakesnorepresentation,expressorimplied,thatthedrugdosagesinthis bookarecorrect.Readersmustthereforealwayscheckthatanyproductmentionedinthis publicationisusedinaccordancewiththeprescribinginformationpreparedbythe manufacturers.Theauthorandthepublishersdonotacceptresponsibilityorlegalliabilityfor anyerrorsinthetextorforthemisuseormisapplicationofmaterialinthisbook. 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
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