Disease Management Models for Cardiovascular Care
Nancy Houston Miller
Erika S. Sivarajan Froelicher
Since the mid-1990s disease management programs have served as an important method of caring for patients with chronic illness to improve patient outcomes, increase quality of life, and decrease health care utilization and cost. Disease management has been adopted on the basis of results of numerous randomized controlled trials showing that patients with cardiovascular conditions such as heart failure, coronary heart disease, diabetes, and hypertension are better supported through methods involving a team approach, coordinated delivery of care, systematic education, and documentation of outcomes directed at improving program delivery. The trend toward caring for patients through disease management programs has spread rapidly and now involves not only researchers, but also numerous health care organizations, the government, and for-profit organizations that are attempting to improve chronic disease care and reduce costly emergency department visits and hospitalizations. Data from managed care organizations indicate that at least 88% of such organizations have implemented at least one disease management program.1
In a health care system faced with an overburden of chronic illnesses, disease management is a concept likely to enable Americans to live differently in the future. It is necessary in any society whose population is growing older and a health care system that is focused on managing the acute aspects of illness. By 2030 it is expected that one in five Americans will enter the age group older than 65 years.2 Moreover, life expectancy has increased 44% between 1900 and 1950, 13% between 1950 and 2000, and is projected to increase by 9% between 2000 and 2050. In 1997, the average life expectancy was 79 years for women and 74 years for men. As of 2005, only 8 years later, life expectancy was 80 years for women and 75 years for men.3 Life expectancy at ages 65 and 85 years has also increased substantially over the past 50 years; women who survive to age 65 years can expect to live to age 84 years, and those who survive to age 85 years can expect to live to age 92 years.4 Although the average American then can expect to live much longer, will their quality of life enable them to enjoy both independence and function?
In 2005 more than 133 million Americans had one or more chronic conditions.5 This figure is expected to increase by 1% per year through the year 2030, where the number will increase by 46 million Americans.5 Moreover, women will experience the major burden of chronic diseases. Many of these conditions are related to the vascular system including hypertension, which is the leading chronic condition in those younger and older than 65 years and heart disease, which is the leading cause of death in both men and women.5 Other chronic conditions most prevalent in those older than 65 years include pulmonary disease, diabetes, arthritis, and chronic mental disorders. Treatment is complicated by the coexistence of multiple medical conditions and the social and psychological sequelae that accompany them.5
It is estimated that three quarters of all health care expenditures go to caring for individuals with chronic conditions. With health care expenditures exceeding $1.7 trillion and 15% of the gross domestic product,6 numerous health care plans, including Medicaid and Medicare have implemented disease management programs to improve high-cost care. Whether disease management programs will succeed in significantly lowering the costs associated with managing chronic disease remains to be seen as the evidence of cost-effectiveness remains limited.7 Advanced Practice Nurses are well positioned to take on the challenge of disease management, as they constitute the largest group of health care professionals, with more than 2.4 million employed in the United States.8
The resources to manage those with an acute illness are quite different from those with a chronic condition. Acute care services are provided primarily by physicians and nurses, often in intensive, hospital-based care requiring the use of expensive technology. In contrast, effective chronic care requires a comprehensive approach that combines social, educational, vocational, and medical services provided in a variety of settings that increasingly focus on the home as the setting of care. The scope of chronic care is broad, encompassing social, community, and personal services as well as medical and rehabilitative care. The management of chronic conditions also requires a network of health care professionals including nurses, social workers, family, and caregivers. Finally, much of chronic care requires education and support of patients and family members to maximize self-management.
In the late 1990s, in a review of the literature, Wagner et al.9 identified five important elements associated with improved outcomes for those with chronic conditions such as hypertension and diabetes. Successful programs tended to be those that (1) incorporated guidelines and protocols in practice; (2) used a multidisciplinary team with careful allocation of tasks and ongoing patient contact; (3) provided counseling, education, information feedback, and other support to patients; (4) offered access to necessary clinical expertise such as referral to specialists, collaborative care models, and computer-decision support; and (5) used supportive information systems that offer reminders for preventive care and follow-up as well as feedback to providers on patient compliance and service use. Various disease management models have been developed to meet the needs of those with chronic conditions, incorporating many of these elements associated with chronic care delivery. Moreover, a systems approach to care delivery is needed to enhance long-term adherence (see Chapter 40).10 This chapter focuses on various models of disease management, including clinic and nurse case management approaches developed for
cardiovascular care. Elements important to care delivery are discussed.
cardiovascular care. Elements important to care delivery are discussed.
DISEASE MANAGEMENT: DEFINITION AND MODELS
Disease management is a term that has been used for more than a decade to encompass the way in which care is delivered to individuals, but more specifically to groups of patients. Many associate the term with managed care and a way to control health care services.11 Although numerous definitions for this term exist, Ellrodt et al.12 define disease management as an approach to patient care that emphasizes coordinated comprehensive care along a continuum of disease and across health care delivery systems.
The most comprehensive definition for disease management has been developed by the Disease Management Association of America (DMAA), a nonprofit trade association.13 However, not all programs meet the standards held by this organization. The DMAA states that disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management components include the following: (1) population identification processes; (2) evidence-based practice guidelines; (3) collaborative practice models, which include nurses, physician, and other support service providers; (4) patient self-management education; (5) process and outcomes measurement, evaluation, and management; and (6) routine reporting and feedback. This organization suggests that full-service disease management involves all six components. More recently recognizing the significant variation in the heterogeneous variation of disease management programs, the American Heart Association developed taxonomy for disease management that may serve as a guide to help individuals involved in developing programs and attempting to identify factors associated with effectiveness.14 This taxonomy provides a framework for reporting on disease management which offers specific details to help the reader note all aspects of the delivery of care. It is highlighted in Figure 42-1.
In addition to numerous definitions used for disease management and the many models that exist fall under the rubric of disease management. Case management was a term used early in the course of managing patients with chronic illness with a primary focus of managing patients at high risk for expensive outcomes. Case managers often undertake a broad assessment of the medical, functional, social, and emotional needs of individuals developing written plans of care and incorporating community resources to support individuals. Education about symptom management, compliance with medications, diet and medical follow-up, and ways of accessing the emergency department are often part of the care provided by case managers. Case managers may also be involved in care coordination, which is another term that is often used to specify how these individuals integrate the efforts of medical and social service providers.15
Another model of disease management offers programs that are specific to patient-focused diagnoses such as heart failure or diabetes. Often undertaken by nurses, these disease management programs follow guidelines for a particular disease, utilize standardized education related to the disease, and often use technology to monitor a patient’s condition. Follow-up is often long-term as well noting that conditions like heart failure and diabetes are
not amenable to care and that patients are likely to lapse into old behaviors.
not amenable to care and that patients are likely to lapse into old behaviors.
Disease management is also often provided by a group of individuals focused on providing multidisciplinary care. Utilizing numerous health care providers such as nurses, pharmacists, social workers, dieticians, and others, multidisciplinary care teams may facilitate the transition from hospital to long-term care at home.14 Each individual of the multidisciplinary team offers unique services to provide lifestyle interventions and health care. These teams may employ “coaching” a term coined in disease management to support behavior modification.
Finally, Ed Wagner and colleagues at Group Health Cooperative of Puget Sound have developed the chronic care model embraced by large organizations such as Kaiser Permanente of Northern California and Health Partners Medical Group in Minneapolis, Minnesota, which is the most comprehensive form of disease management focused on changing an entire system of care delivery. Operationalized, the chronic care model addresses the community, health care system, and provider organization and ensures that six elements are in place to ensure optimal care. These elements include (1) community resources and policies, (2) health care organization, (3) self-management support, (4) delivery system design, (5) decision support, and (6) clinical information systems. A large focus for this type of disease management is geared toward coordinating activities within primary care.16
Models of Disease Management in Cardiovascular Care by Nurses
Since the early 1970s, unique models for delivering care to individuals with chronic conditions by nurses have evolved. Much of this early work in disease management occurred in hypertension control in the United States and Europe.17,18 Most often, attempts were made to deliver high-quality care in various settings that were convenient to the population being studied. In one of the first disease management programs,18 patients with hypertension, diabetes, or cardiac disease chose to be followed by specially trained nurses in decentralized clinics close to their homes or in a hospital-based outpatient clinic for chronic disease that was staffed by internists. Patients had similar sociodemographic and clinical characteristics. After 2 years, hypertension control rates were superior in those patients cared for by specially trained nurses, and they had 50% fewer hospital admission days. The authors of this study attributed the success of the nurse-run clinics to greater follow-up and time devoted to helping patients manage their chronic conditions.
In another early trial,17 nurses played a key role in the screening and follow-up of individuals within a work site setting in New York City. Nurses screened and enrolled patients over an 11-day period and followed up hypertensive individuals over 1 year. Working closely with a medical director, they performed an initial medical history, obtained preliminary laboratory data, and followed treatment algorithms, initiating and titrating medications for hypertension treatment. Diuretics were chosen as first-line therapy for hypertension treatment, and after controlling blood pressure to goal, patients were seen for review of therapy and were monitored for compliance every 3 months by the nurses. At the end of the year, 84% of the work site had been screened, 97% of those followed up by the nurses remained in therapy, and 81% succeeded with optimal blood pressure lowering. The cost per patient of $100 offset the costs associated with hypertension, including the time lost from work.
These early studies suggested that the convenience of helping individuals manage their health in settings conducive to work and home offered an optimal opportunity for disease management to be brought to the patient. Since the 1970s, disease management by nurses has been applied not only to hypertension,17, 18, 19, 20, 21, 22, 23, 24, 25, 26 but also to other aspects of cardiovascular management, including dyslipidemia,27, 28, 29, 30 tobacco dependence,31, 32, 33, 34, 35 diabetes,36, 37, 38, 39, 40 coronary artery disease,41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54 and heart failure.55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71 Much of the early work before the term disease management was coined occurred in managing patients after myocardial infarction using a multidisciplinary approach to managing risk factors, adherence to diet, exercise, medications, and medical regimens to improve functioning and quality of life through the provision of individual and group education, counseling, and behavioral interventions, which included the patient and family as part of rehabilitation.72
The largest number of studies related to disease management are in heart failure, in which considerable interest has arisen about how to care for a large and growing population of high-risk patients with the most costly cardiovascular condition (see Chapter 24). The aforementioned body of work and the reviews conducted by investigators in the area of heart failure,73, 74, 75, 76, 77 diabetes,78, 79, 80 and hypertension81 offer insights and guidance to nurses on the application of disease management systems for care delivery. Disease management systems have now also been used in randomized controlled trials21,27,28,39 and clinical practice settings,11 which include younger,28 older,49,66,82 and minority populations,83,84 clinics,41,59 hospitals,32, 33, 34 work sites,17 home-based39,43 and cardiac rehabilitation settings,46,85 and the use of multidisciplinary44,47,65 or physician-nurse teams41,71 to direct care delivery. Moreover, these disease management programs have been shown to effectively reduce multiple risk factors,36,43,46,47 improve quality of life,41,62 and functional status,59 increase short-term compliance,10 reduce total admissions, and cardiovascular readmissions,49,63,65,67 improve survival,68 reduce days of hospitalizations,55,68 and reduce rehospitalization costs.49,86