Fonarow G C, Stevenson L W, Walden J A, Livingston N A, Steimle A E, Hamilton M A, Moriguchi J, Tillisch J H, Woo M A
Ahmanson-University of California, Los Angeles Cardiomyopathy Center, USA.
J Am Coll Cardiol. 1997 Sep;30(3):725-32. doi: 10.1016/s0735-1097(97)00208-8.
To assess the impact of a comprehensive heart failure management program, functional status, hospital readmission rate and estimated hospital costs were determined and compared for the 6 months before and the 6 months after referral.
The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost.
Over a 3-year period, 214 patients were accepted for heart transplantation and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per min and a total of 429 hospital admissions in the previous 6 months (average 2.0 per patient). Changes in the medical regimen included a 98% increase in angiotensin-converting enzyme inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling also regarding diet and progressive exercise.
During the 6 months after referral, there were only 63 hospital readmissions (85% reduction), with 0.29/patient (p < 0.0001). Functional status improved as assessed by functional class (p < 0.0001) and peak oxygen consumption (15.2 vs. 11.0 ml/kg per min, p < 0.001). The same results were seen after excluding the 35 patients without full 6-month follow-up (9 deaths, 14 urgent transplant procedures during hospital readmission, 12 elective transplant procedures from home); 34 hospital admissions occurred after referral, compared with 344 before referral. Even when adding in the initial hospital admission after referral for these 179 patients, there was a 35% decrease in total hospital admissions in the 6-month period. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient.
Comprehensive heart failure management led to improved functional status and an 85% decrease in the hospital admission rate for transplant candidates discharged after evaluation. The potential to reduce both symptoms and costs suggests that referral to a heart failure program may be appropriate not only for potential heart transplantation, but also for medical management of persistent functional class III and IV heart failure.
为评估一项综合性心力衰竭管理项目的影响，我们确定并比较了转诊前6个月和转诊后6个月的功能状态、医院再入院率及预估的住院费用。
晚期心力衰竭病程的特点是临床状况不断恶化，表现为频繁住院，这构成了主要的经济成本。
在3年期间，214例患者接受了心脏移植评估并出院，评估内容包括调整药物治疗和强化患者教育。患者为纽约心脏协会心功能Ⅲ级或Ⅳ级（分别为94例和120例），平均左心室射血分数为0.21，峰值耗氧量为每分钟11 ml/kg，前6个月共住院429次（平均每位患者2.0次）。药物治疗方案的改变包括血管紧张素转换酶抑制剂剂量增加98%，在净利尿4.2升后采用灵活的利尿方案，并就饮食和渐进性运动提供咨询。
在转诊后的6个月内，仅63次再入院（减少85%），每位患者0.29次（p<0.0001）。通过心功能分级（p<0.0001）和峰值耗氧量（15.2 vs. 11.0 ml/kg每分钟，p<0.001）评估，功能状态有所改善。排除35例未进行完整6个月随访的患者（9例死亡、14例在住院再入院期间进行紧急移植手术、12例在家中进行择期移植手术）后，结果相同；转诊后发生34次住院，而转诊前为344次。即使将这179例患者转诊后的首次住院计算在内，6个月期间的总住院次数仍减少了35%。减去管理的初始住院费用后，预估每位患者的住院再入院费用节省了9800美元。
综合性心力衰竭管理使功能状态得到改善，经评估后出院的心脏移植候选患者的住院率降低了85%。减轻症状和降低成本的潜力表明，转诊至心力衰竭管理项目不仅可能适用于潜在的心脏移植，也适用于持续性心功能Ⅲ级和Ⅳ级心力衰竭的药物治疗。
