a b s t r a c t
Maximizing Quality of Life and
Optimizing Health Care Utilization by
Older Adults with Congestive Heart
Failure
Jane Oshinowo, RN(EC), BScN, PNC,Primary Health Care Nurse Practitioner,York Community Services, Staff Nurse, St. Michael’s Hospital,Toronto, ON.
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Introduction
Heart failure imposes both a heavy finan-cial burden as well as a physical and emotional burden on affected individu-als and their families by reducing exer-cise tolerance, increasing frequency of hospitalizations and shortening life expectancy.1Congestive heart failure (CHF) occurs in approximately 1–2% of the population older than 65 years.2The portion of the Canadian population with CHF is anticipated to grow from 12.6% to 21% between 2000 and 2025,3with more people living beyond 80 years. Other trends, such as decreased frequency of myocardial infarction (MI), increased sur-vival from MI with left ventricular sys-tolic dysfunction, and a new cohort of survivors of congenital heart disease will affect the future incidence and prevalence of this disease.4
In 2000–01, 85,679 Canadians diag-nosed with CHF were discharged from hospital. CHF patients experienced a 16% in-hospital mortality rate and a 32.7% readmission rate.5The number of hospital days estimated per person was 26.9 per year. CHF ranked second in the number of hospital beds used per person per year; data are not available for emer-gency room visits. As well, 10–38% of all persons hospitalized for CHF are dis-charged to a long-term care facility.2,6 Surgical interventions, such as insertion of implantable cardioverter defibrillators, biventricular pacemakers and left ven-tricular assistive devices, as well as mitral annuloplasty, left ventricular restoration
and coronary revascularization for select-ed CHF patients, may increase future hospital spending.7Insertion of a left ven-tricular assistive device costs the same as a heart transplant. As technology and surgical techniques improve, more can-didates may benefit. Thus, with the pop-ulation at risk for CHF growing, an exponential rise in CHF-related hospital-ization is anticipated.
The continuing challenge in CHF care is containing health care costs while at the same time improving quality of life for those living with CHF.
Quality of Life
Quality of life (QOL) is a multidimen-sional concept that includes physical, social, spiritual and psychological well-being.8Persons living with CHF have to contend with such difficulties as reduced exercise tolerance, social isolation and reliance on others for activities of daily living. Independence may be compro-mised by loss of a driver’s licence. Uncer-tainty becomes a daily challenge, as survival after diagnosis is < 40% at five years. This implies that individuals must prepare for dying while at the same time trying to cope with the limitations of the disease. Thus, much research is directed at the impact of QOL on disease out-come, and what interventions improve QOL.
Measurements
Researchers continue to develop and evaluate different instruments to better
Heart failure is a serious illness charac-terized by impaired quality of life, decreased survival and frequent hospi-talization, which mainly affects older adults. As the population ages, there is concern that congestive heart failure-related costs will place an undue strain on the health care system unless more cost-effective management is implement-ed.Various multidisciplinary strategies researched have demonstrated improved quality of life, reduced hospitalization, a trend towards decreased mortality, and a potential for cost savings.
Key words:heart failure, quality of life, cardiac nurse, disease management, cost.
capture and quantify QOL. In the litera-ture on CHF, two commonly used tools are the Minnesota Living with Heart Fail-ure Questionnaire (MLHFQ) and the Medical Outcomes Study 36-item short form health survey (SF-36). The MLHFQ is a 21-question instrument used to iden-tify factors limiting QOL in persons with CHF. The SF-36 health status survey measures eight health concepts with physical, mental and general health com-ponents.9The SF-36 assesses overall health whereas the MLHFQ is specific to CHF symptoms. Differences observed between the two scales in a study popu-lation may be attributed to patient comorbidity.
Harrison, et al.used both instru-ments to measure the outcome of their intervention,6and reported an inverse correlation between QOL as measured by the MLHFQ and emergency room use in the intervention group. However, the intervention’s impact on the general QOL as measured by the SF-36 was not statistically significant.
Another study found a correlation between the SF-36 score and improve-ment in symptom status as measured by a modified cardiac symptom survey.10 Westlake, et al.demonstrated a significant correlation between the physical and mental health components of the SF-36 and the NYHA class and the 6-minute walk test among their subjects.9As well, they found a significant correlation between the mental health component and neuroticism. However, the study was unable to demonstrate a relationship between social network and the social support components of the SF-36.
Benatar, et al.used four instruments, two of which were the MLHFQ and the QOL index-70 item cardiac version, to measure QOL in their study popula-tion.11The two instruments correspond-ed in the degree of improvement in QOL measured. Improvement in QOL occurred in both arms of the study but greater improvement occurred in the intervention arm.
QOL is a difficult concept to capture with an objective measurement. The SF-36 and the MLHFQ are two instruments
that have been rigorously tested and, despite their limitations, do provide a measure of QOL.12
The New York Heart Association (NYHA) classification and the 6-minute walk test provide an effective measure-ment of functional capacity and both are widely accepted tools. The 6-minute walk test is a useful objective measure both in clinical practice and for studies that have functional capacity as an out-come.
Optimizing Health Care
Utilization
Perception of health is strongly correlat-ed to functional status. Juenger, et al.
found that individuals with poorer func-tional status had significantly lower QOL as measured by the SF-36.13However, functional indices alone only partly explain the impairment of QOL.13
Cardiac rehabilitation is more than exercise training. As a secondary preven-tion, it has the potential to benefit persons with CHF by improving their functional capacity. Other benefits include improved QOL, decreased hospitaliza-tion and reduced morbidity and mortal-ity.14Even modest improvements in the very old can delay the onset of depend-ency. Programs for older patients may need to be adapted, as benefits of a three-month program were not sustained in the long-term, suggesting that ongoing rehabilitation may be necessary to sustain functional improvement in this group.14 Unfortunately, despite recent expansion of cardiac rehabilitation centres, accessi-bility remains a problem.15
Living with uncertainty is a chal-lenge to persons with CHF, as long-term survival is poor. Although interventions that will enhance event-free survival are highly valued, survival alone was not considered to be of greater value than QOL.10No other study reviewed com-pared QOL and mortality. However, both disease management studies and drug trials have shown a reduction in mortal-ity among the intervention group.16 Stromberg, et al.demonstrated the effec-tiveness of a specialist nurse-led disease management program in improving
event-free survival at 12 months post-dis-charge, as well as significantly reducing days in hospital and a trend towards fewer re-admissions.17In terms of self-care behaviours, the intervention suc-cessfully improved daily weighing, alerting the health care provider of an increase in weight and restricting fluid intake.17Stewart, et al.’sstudy of a home-based intervention utilized an experi-enced cardiac nurse who coordinated efforts to optimize management, fol-lowed up with telephone calls and facil-itated interactions with other health care providers as required.18This study fol-lowed patients for an average of 4.2 years with none lost to follow-up. There was a 30% reduction in the risk of death or re-admission independently associated with the intervention.18Other studies have not seen a statistically significant reduction in mortality (Table). A review of earlier studies did not find an associa-tion between intervenassocia-tion with a special-ized disease-management program and mortality.19However, the intervention group had fewer hospitalizations, and in one study the intervention improved QOL.19
Hospitalization is a major concern, as more than 80% of costs attributable to CHF are incurred during hospitaliza-tion.2 In Sweden, hospitalization accounts for 50–75% of the costs attribut-able to CHF, while pharmaceuticals account for 2–8% of the costs.17In the U.K., spending directly attributable to CHF has almost doubled over the past decade, to consume 2% of health care expenditure.4
It is estimated that as many as two-thirds of hospitalizations may be pre-ventable.16Factors that contribute to hospitalization include non-adherence to prescribed medication and failure to seek treatment for worsening symptoms. Other modifiable factors include inade-quate discharge planning and follow-up, lack of social support, poverty and comorbid conditions.16
Many position statements, consen-sus conferences and practice guidelines on the management of heart failure have been written and published in Europe
First Author, Sample Length Study NYHA Mean Age QOL Intervention Outcomes Country Size Type Class HF (years) Tool
Benatar,11 216 3 mo RT III/IV 63 MLHFQ, 1. APN computer ↓ cost
USA 3 other monitoring & mgmt ↑ QOL (SS)
tools - education & meds adjustment ↓ readmission (SS) 2. HV, cardiologist, RN
education & monitoring
Harrison,6 192 3 mo RT 80% 76 MLHFQ, In-hospital discharge, ↑ QOL (NSS)
Canada III/IV SF-36 education + book by RN + ↓ ER visits (SS)
HV program ↓ re-admission (NSS)
Control: primary MD
Todero,10 102 2 mo Descriptive U.K. 70.5 SF-36, Education + book by RN + Trend towards
USA CSS either TC, HV, HB, or HB+HV ↑ QOL & symptom
improvement
Kasper,21 200 6 mo RT II-IV 63.5 MLHFQ 1. Team of telephone ↓ mortality (NSS)
USA RNs, CHF RNs, cardiologists, ↓ hospitalization (SS)
primary MDs: education, ↑ QOL (NSS) monitoring, mgmt, APN, Cost: same meds adjustment
2. Cardiologist plan + primary MD
Stromberg,17 106 12 mo RT II-IV 77 HFC: RN-led monitoring, ↓ mortality (SS)
Sweden education, adjustment ↓hospitalization by 42%
of meds, TC Control: PHC
Stewart,18 297 4.2 yr Cohort 75 HV & TC by Cardiology RN: ↓ mortality (SS)
Australia assessment, education, ↓ hospitalization (SS)
case mgmt ↓ cost (SS)
Blue,23 165 1 yr RT II/IV 75 GP+APN: HV, TC, education, ↓ hospitalization
U.K. monitoring, RN mgmt No change in mortality
with protocols ↓ risk of re-admission
Control: GP care (SS)
Krumholz,22 88 1 yr RT 74 Cardiac RN: education, ↓ mortality (NSS)
USA + book + HV + ↓ hospitalization (SS)
telemonitoring ↓ cost (SS)1
Control: primary MD
Capomolla,24 234 1 yr RT, I-IV 56 HFMP by day hospital ↑ life expectancy
Italy CUR Control: usual community & QALY (SS)
care ↓ cost
APN: advance practice nurse; book: educational booklet; CSS: cardiac symptom status; CUR: cost utility ratio; ER: emergency room; HB: health buddy device; HFC: heart failure clinic; HFMP: heart failure management program; HV: home visits; MLHFQ: Minnesota Living with Heart Failure Questionnaire; NSS: not statistically significant; NYHA: New York Heart Association; PHC: primary health care; QALY: quality-adjusted life years; QOL: quality of life; RN: registered nurse; RT: randomized trial; SF-36: medical outcome study 36-item short form health survey; SS: statistically significant; TC: telephone calls.
and North America. Their benefit has been to provide physicians and other health care providers with the most cur-rent evidence and research to guide the management of persons living with CHF. Despite wide publication, there remains a significant gap between optimal care and actual care received by people with CHF.2However, there is evidence that use of angiotensin-converting enzyme inhibitors and beta-blockers is increasing, as well as assessment of left ventricular ejection fraction.20
The 2002–03 Canadian Cardiovascu-lar Society consensus guideline update for the diagnosis and management of heart failure recommends the use of spe-cialized hospital-based multidisciplinary heart failure clinics for the assessment and management of higher risk patients. In Ontario, these few specialized clinics are situated in large urban teaching hos-pitals. In Sweden, within the past decade two-thirds of all hospitals have opened nurse-led heart failure clinics. Other countries are examining different models of care, as indicated in the literature. A discussion of some of the trials published from 2001 onwards ensues.
Heart Failure Management
Programs: Evidence
To address factors leading to hospitaliza-tion and decreased quality of life, a num-ber of well-designed studies have tested a variety of nursing/multidisciplinary interventions (Table). Various delivery models, such as telephone outreach, Health Buddy device, patient education booklets and care maps, home visits and cardiac clinic visits, have been exam-ined.6,10,11,17,18,21These trials have used experienced cardiac nurses, advanced practice nurses, nurses with extra train-ing6,18,22or case managers to integrate patient care. In the studies reviewed, the intervention included some variation on the following components: patient edu-cation, drug protocols, self-monitoring, treatment adherence, psychological sup-port, and coordination and facilitation of care by other providers. The physicians providing medical care were either spe-cialists (cardiologists or internists) or
gen-eral physicians (GPs). Care was usually initiated by the cardiologist and then transferred back to the GP or internist. Blue, et al.enrolled patients admitted under a GP only.23The intervention group received specialist nurse follow-up care in addition to usual physician visits.
Study results of the different inter-ventions have shown either a clear reduc-tion in or a trend towards reduced re-admission and days spent in hospi-tal.6,11,17,21-23Harrison, et al.also reported a significant decline in emergency room (ER) visits, but this study only ran over the course of three months.6In the other studies, participants were followed for up to one year.17,18,22,23
New resources are required when setting up a new program. Thus, Harri-son, et al.determined to answer the question of how to reduce CHF-related hospitalization within the normal organization of services and with the usual nurse providers.6They were able to show that by bridging the gap between hospital and community using evidence-based nursing care/education provided to CHF patients, ER visits decreased and participants experienced an improved QOL.
Disease management programs uti-lizing various nursing and multidiscipli-nary interventions have clearly demonstrated a benefit in terms of reduc-ing hospital use, and in some studies a decrease in mortality and improved QOL for persons with CHF. However, many questions remain, such as, which patients can benefit most from which program? What are the benefits of the individual components of a program? CHF patients are not a homogeneous group; thus, the intensity of the intervention may need to vary. High-risk groups, such as those with cognitive impairment, have been excluded from these studies. In order to answer these questions and provide ben-efit to specific groups, further research is required.
A cost utility analysis reported a sig-nificant reduction in mortality and mor-bidity from implementing a heart failure management program delivered by day-hospital.24The cost savings from
re-admissions was modest due to the high cost of the program. A major limitation of this study was that the average age of the participants was 56years.24An economic analysis by Stewart, et al.examined the economic consequences of applying a specialist nurse-mediated, post-discharge management service for heart failure within a whole population.25The authors analysed three different models of care— clinic based, home based and a combina-tion. Based on prior research, they assumed that implementation of these programs would result in cost savings from reduced hospitalization. It was determined that a threshold of approxi-mately 40% reduction in hospital bed use would be required to offset the cost of implementing one of these mentioned programs. Although this analysis is encouraging, larger multisite studies would be helpful in generating the nec-essary data on which to base the analysis.
Conclusions
Modifiable factors that result in exacer-bation of CHF and hospitalization have been identified, and the impact of CHF on QOL has been researched. As hospi-talization bears the largest cost to the sys-tem, various strategies to reduce re-admission are being explored and solutions offered. Evidence from current research suggests that heart failure dis-ease management programs do prevent hospitalization and improve QOL for individuals living with heart failure. Swe-den has led the way with the introduc-tion of a naintroduc-tion-wide program of nurse-led cardiac outreach clinics. Hope-fully they will soon provide a system-wide review of their national heart failure program to shed further light on its ben-efits in terms of costs and outcomes.
In Ontario, the possibility of a multi-tiered network of CHF manage-ment programs exists. A coordinated effort to expand current programs and implement innovative outreach pro-grams through existing structures has the potential to reduce costs in the
health care sector. ◆
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