Home and Community Care Digest

Home and Community Care Digest February 2004 : 0-0

Community-based disease management program has positive impact on patient outcomes

Abstract

Congestive heart failure and angina are treatable conditions in ambulatory settings when appropriate access to high-quality primary care is available. Readmission days for these two conditions were significantly lower for the disease management program (DMP) patients, as were all-cause readmission days per 1000 follow-up days. DMP patients also had significantly fewer emergency department visits, diagnostic or therapeutic services and laboratory services during the first 225 days post-discharge. An appropriately developed and implemented community-based inner-city DMP delivered by home health nurses has a positive impact on patient outcomes.
Background: This comparative study evaluates a cardiac disease management program (DMP) delivered by home health nurses. Studies have shown that complications of myocardial infarction, including congestive heart failure (CHF) and angina, are treatable conditions in ambulatory settings when appropriate access to high-quality primary care is available.

Methods: 715 patients admitted to Toronto East General and Orthopedic Hospital with elevated cardiac markers between August 1999 and August 2000 were screened for the study. Of the 146 patients who met the inclusion criteria of myocardial infarction and needing services to enable them to remain at home, 71 were randomized to the intervention group (DMP) and 71 to the control group (usual care). The DMP intervention included 6 home visits by a cardiac-trained nurse, a standardized nurses' checklist, referral criteria for specialty care, communication with the physician, and patient education. Usual care included referral to a non-invasive cardiac laboratory for diagnostic testing, follow-up by their cardiologist, provision of information about Toronto East General Hospital cardiac teaching class, and information about cardiac rehabilitation at the Toronto Rehabilitation Centre. If referred to home care, these patients received currently practiced home care. The primary outcome measure was readmission days per 1000 follow-up days for angina, CHF and chronic obstructive pulmonary disease. The followup period began on the discharge date of the initial admission and ended July 19, 2001, or the date of death or admission to a long term care institution.

Findings: Readmission days per 1000 follow-up days for angina and CHF were significantly lower for the DMP patients, as were all-cause readmission days. For every readmission day per 1000 follow-up days in the DMP group, there were 1.59 readmission days in the usual care group. Similarly, for every allcause readmission days per 1000 follow-up days in the DMP group, there were 1.53 all-cause readmission days in the usual care group. DMP patients also had significantly fewer emergency department visits, diagnostic or therapeutic services and laboratory services during the first 225 days post-discharge. There were no differences between groups for physician-office visits or for hospital visits.

Conclusions: This study provides evidence that a multi-faceted community based inner-city DMP delivered by home health nurses successfully reduced hospitalization days per 1000 follow-up days for CHF and angina, emergency department encounters, and claims for diagnostic or therapeutic services and laboratory services. It had no impact on readmission days for chronic obstructive pulmonary disease. Further research is required to delineate which component(s) of the DMP accounted for improved cardiac-related outcomes. It could be that the activities of the cardiac-trained nurse contributed to the outcomes (i.e. assessing patient's understanding and compliance with medications, checking that refills had been filled and assessing for side effects).

Reference: Young W, Rewa G, Goodman SG, Jaglal, SB, Cash L, Lefkowitz C, Coyte P. Evaluation of a community-based inner-city disease management program for post-myocardial infarction patients: a randomized controlled trial. CMAJ 2003; 169 (9): 905-10.

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