Congestive Heart Failure Collaborative, October 14, 2004,Preventing Readmissions Kenneth A. LaBresh, MD, FAHA, FACC V.P., Medical Affairs and Quality Improvement, MassPRO Clinical Associate Professor, Brown University,ACC/AHA Guidelines for Evaluation and Management of Chronic Heart Failure 2001,HF can be prevented HF has established risk factors HF is a progressive condition with asymptomatic and symptomatic stages HF morbidity and mortality can be reduced by stage specific treatments,Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.,ACC/AHA Proposed Stages of HF,STAGE A High risk for developing HFSTAGE B Asymptomatic LV dysfunctionSTAGE C Past or current symptoms of HFSTAGE D End-stage HF,Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.,Neurohormonal Activation in Heart Failure,Hypertrophy, apoptosis, ischemia, arrhythmias, remodeling, fibrosis,Angiotensin II,Norepinephrine,Morbidity and Mortality, CNS sympathetic outflow, Cardiac sympathetic activity, Renal sympathetic activity,Sodium retention,Myocyte hypertrophy Myocyte injury Increased arrhythmias,Disease progression,1,b1,b1,b2,1, Vascular sympathetic activity,Vasoconstriction,1,Activation of RAS,Adrenergic Pathway in Heart Failure Progression,Beta-blocker Therapy in Heart Failure,Potential Beneficial Effects,Protection from Catecholamine Toxicity,Renin Angiotensin System,Reversal of Remodeling,Up-regulation of b-adrenergic Receptors,Ancillary Factors,Major Placebo Controlled Trials of -Blockade in Heart Failure,34% ,Cumulative Mortality (%),Days,20,15,5,0,10,P=.0062 (adjusted),Metoprolol CR/XL (n=1990),Placebo (n=2001),US Carvedilol Trials1,Probability of Event-free Survival,Carvedilol (n=696),Placebo (n=398),Days,P.001,0.0,0,100,200,300,400,65% ,1.0,0.8,0.7,0.9,MERIT-HF2,Survival (% of Patients),100,90,80,60,70,0,600,0,400,300,200,100,Days,Carvedilol (n=1156),Placebo (n=1133),500,600,0,400,300,200,100,500,35% ,P=.00013,COPERNICUS4,Days,0.0,200,400,800,1.0,0.8,0.6,P.0001,34% ,Bisoprolol (n=1327),Placebo (n=1320),CIBIS-II3,0,600,Survival,1Packer M et al. N Engl J Med. 1996;334:13491355. 2MERIT-HF Study Group. Lancet. 1999;253:20012007. 3CIBIS-II Investigators. Lancet. 1999;353:913. 4Packer M et al. N Engl J Med. 2001;344:16511658.,COPERNICUS: All-Cause Mortality,% Survival,Packer M et al. N Engl J Med. 2001;344:16511658.,900,600,300,0,P=.0012,P=.0002,P.0001,For any,reason,For cardiovascular,reason,For heart,failure,Placebo,Carvedilol,29%,33%,600,400,200,0,450,300,150,8,20%,COPERNICUS: Number of Hospitalizations,Packer M et al. Circulation. 2002;106:21942199.,0,5,10,15,20,25,30,All Patients (n=2289),Higher-Risk Patients (n=624),Number of Events,Krum H et al. JAMA. 2003;289:712718.,0,60,180,All Patients (n=2289),Higher-Risk Patients (n=624),Number of Events,8 Weeks,8 Weeks,Deaths,Death or Hospitalization for Any Reason,Placebo,Carvedilol,COPERNICUS: Early Clinical Outcomes,120,25,19,15,3,153,134,63,44,Does Subspecialty Care Affect CHF Outcome,SUPPORT1298 Hospitalized Patients743 (57%) Cardiolgist (C)555 (43%) Primary Care (P)C PAge 63 71Male 71% 52%EF known 69% 47%EF 20% 52% 39%,SUPPORT Results,Cardiologists vs. Primary Care:RHC 2.9 times more likely Coronary angio 3.9 times more likelyHospital costs 43% higherACE-I 64% IN BOTH groupsShort term mortality similar4.6 year follow up mortality 20% lower for cardiologists (rr 0.80 (0.66 - 0.96),Aurebach ad, AIM 2000;132:191-200,Impact of Subspeciality Care,Upstate New York 10 hospitalsThree patient groupsI Noncardiologist n = 977II Cardiologist Attending n = 419III Cardiology Consult n = 1058Group I more NH, more comorbiditymore females, less B-Blocker use,Upstate New York Results,Results (cont.),Philbin E, CHEST 116:2, 346 - 354,Hospital Based CHF Clinic,Retrospective analysis before (n = 407) and after (n = 357) implementation of a CHF program in 1994 Elements of the Program Multidisiplinary team Inpatient and outpatient treatment protocols Patient and family education Follow up telephone calls Outpatient infusion center,Outcomes,HF Management Meta Analysis,McAlister FA, et al., JACC 2004;44:810-819,29 studies involving 5,039 patients,Conclusions,HF management programs decrease HF hospitalizations in a wide variety of formats Multidisciplinary approaches, particularly HF clinics have been demonstrated to reduce mortality as well 15 0f 18 studies that evaluated costs demonstrate cost savings as well,SPAN-CHF,Specialized Primary and Networked Care in Heart Failure,Kimmelsteil et al., Circ 2004;110:1450-1455,Characteristics of the System,1. Focus on patients who have a resent HF hospitalization 2. Administered by nurses as case managers with strong expertise in HF with the support of HF physicians acting as consultants to the nurses. Telephone monitoring and limited home visitsCommunication between the nurse and the PCP 5. Provided a three-month “active intervention” followed by surveillance out to 1 year,