Heart Disease - Case Management

J Cardiopulm Rehabil 1998 Mar-Apr;18(2):113-23

A new model for risk stratification and delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease.

Roitman JL, LaFontaine T, Drimmer AM

Research Medical Center, Kansas City, Missouri 64132-1199, USA.

This model for risk stratification includes variables that classify patients for Risk of Event similar to current models of risk stratification, as well as variables that stratify patients for Risk of Progression of Atherosclerosis by established risk factors. Categories of risk are established using accepted data from the literature for each risk factor that targets regression or plaque stabilization as the goal for Low Risk. A case-rate charging system and the proposed removal of time restrictions for length of cardiovascular rehabilitation fit neatly into the present climate for health care. Health maintenance organizations will be seeking programs that use similar models to address cost issues inherent in cardiovascular rehabilitation programs under current fee-for-service models. Improved outcomes will also be targets for these programs and case-management lends itself to disease management, thus, improved outcomes. Tracking outcomes becomes even more important to both the provider and the insurer because results drive referrals. Likewise, removal of the time restriction for cardiovascular rehabilitation allows programs to individualize care and to target risk factors that are not only most deleterious, but also where patients show readiness for change. The changing environment of health care virtually mandates change in cardiovascular rehabilitation. It is imperative that programs manage the disease process, are effective in achieving outcomes that affect both patient function and the disease process, and are cost effective. This model for risk stratification and delivery of services addresses these requirements and provides a beginning for implementing these changes in cardiovascular rehabilitation.

Publication Types:

• Review
• Review, academic

Comments:

• Comment in: J Cardiopulm Rehabil 1998 Jul-Aug;18(4):313-4

PMID: 9559448, UI: 98220202

HMO Pract 1998 Mar;12(1):30-5

Secondary prevention in coronary heart disease.

Yox SB

Publication Types:

• Congresses

PMID: 10184879, UI: 98231771

Am J Cardiol 1997 Oct 30;80(8B):39H-44H

Management of hypercholesterolemia: practice patterns for primary care providers and cardiologists.

Bramlet DA, King H, Young L, Witt JR, Stoukides CA, Kaul AF

Heart Institute of St. Petersburg, Florida 33707, USA.

This retrospective study, conducted as part of a private practice quality assurance process for patients with coronary artery disease (CAD), compares practice patterns in the LIFEHELP lipid clinic and non-lipid clinic settings at the Heart Institute of St. Petersburg. Quality assurance parameters included documentation of low-density lipoprotein (LDL) cholesterol, initiation of lipid-lowering therapy, and achievement of the Second National Cholesterol Education Program (NCEP II) goal for CAD patients of LDL cholesterol < or =100 mg/dL. A total of 934 patient charts with ICD-9 codes of 410-414 for ischemic heart disease were randomly selected and reviewed by a utilization review nurse. A higher level of documentation and treatment of elevated LDL cholesterol to NCEP II goal in CAD patients was found for those followed in the lipid clinic. Among non-lipid clinic physicians, cardiologists documented and treated elevated LDL cholesterol more frequently than primary care physicians. Women and the elderly subgroups received improved care in the lipid clinic setting. Screening activities and risk-factor management by cardiologists within a lipid clinic, therefore, demonstrated an improved standard of care that came closer to achieving national guidelines in the secondary prevention of CAD.

Comments:

• Comment in: Am J Cardiol 1998 Mar 1;81(5):663

PMID: 9372997, UI: 98038834

Am J Med Sci 1997 Sep;314(3):173-84

Management of the cardiac transplant recipient: roles of the transplant cardiologist and primary care physician.

Wagoner LE

Division of Cardiology, University of Cincinnati Medical Center, OH 45267-0542, USA.

Cardiac transplantation has become an accepted treatment for selected patients with end-stage heart failure. Despite a successful transplant, denervated transplanted hearts respond differently to cardiac drugs than nontransplanted hearts. The treatments for bradycardia, tachycardia, and hypotension are different than for nontransplanted hearts. Despite the improvement in long-term survival, a number of complications may occur posttransplantation. These complications include, allograft rejection, infection, allograft coronary artery disease, and malignancy. Additionally, posttransplant patients may have complications from the immunosuppressive agents cyclosporine, prednisione, and azathioprine. Such complications include drug interactions with commonly prescribed medications, hypertension, hyperlipidemia, osteoporosis, and gastrointestinal complications. The purpose of this article is to discuss the management of the cardiac transplant recipient as it relates to the aforementioned complications. Management of the cardiac transplantation patient by the primary care physician will also be discussed, including indications for consultation by the primary care physician with the transplant center.

Publication Types:

• Review
• Review, tutorial

PMID: 9298043, UI: 97443182

Telemed Virtual Real 1997 Jun;2(6):72

Telehealth: nursing's urban frontier.

Publication Types:

• News

PMID: 10167779, UI: 97342423

Am J Med 1996 Oct 8;101(4A):4A76S-78S

Closing the treatment gap: in the community and at hospital discharge.

Greenland P

Northwestern University Medical School, Chicago, IL 60611-4402, USA.

Although most physicians agree on the value of risk reduction in patients with cardiovascular disease, preventive strategies are not being implemented as widely as they should be in current practice. Several obstacles may account for this trend: Preventive medicine is not widely encouraged or expected; urgency takes precedence over long-term severity; physicians' time per patient is severely limited; preventive services can be considered the responsibility of other healthcare professionals; and positive feedback is generally absent. Strategies for overcoming these obstacles include the systematic identification of appropriate candidates for preventive care, adequate communication with patients to increase their understanding of the need for therapy, clarification of how to take action, assistance in doing so, and reinforcement of preventive behaviors already being practiced by patients. The case-manager approach provides one effective method for implementing these strategies: Nurses assume responsibility for preventive services, working in concert with a multidisciplinary team of physicians and other specialists. Such an approach redefines risk management as a primary treatment goal, rather than an afterthought.

PMID: 8900341, UI: 97055996

Hosp Case Manag 1996 Nov;4(11):167-70

Published erratum appears in Hosp Care Manag 1997 Jan;5(1):6

Use interdisciplinary approach for coronary pathway.

Burke MM, Redick E

Mount Sinai Medical Center, Miami Beach, FL, USA.

PMID: 10164545, UI: 97155870

J Cardiovasc Nurs 1996 Oct;11(1):76-87

Home-based cardiac rehabilitation and lifestyle modification: the MULTIFIT model.

Miller NH, Warren D, Myers D

Stanford Cardiac Rehabilitation Program, School of Medicine, Stanford University, Palo Alto, California, USA.

Managed care has changed the way health care is delivered in the United States. Simultaneously, major changes in the management of patients with coronary heart disease has led to dramatic shifts in cardiac rehabilitation. Exercise training, education, and counseling to modify coronary risk factors has clearly been shown to benefit patients with coronary disease. Moreover, intensive risk factor modification has been shown to prevent progression of coronary atherosclerosis and to lower morbidity and mortality. Newer delivery models of rehabilitation are needed to improve health outcomes in a cost-effective way. A nursing case management model (MULTIFIT), illustrates one such innovative delivery model that meets the needs of a managed care plan for comprehensive cardiovascular risk reduction and surveillance of patients.

Comments:

• Comment in: J Cardiovasc Nurs 1996 Oct;11(1):v-vii
• Comment in: J Cardiovasc Nurs 1997 Jan;11(2):ix

PMID: 9069033, UI: 97221987

Int J Cardiol 1996 Jul 26;55(2):115-6

Management of subacute stent closure.

Hasdai D, Holmes DR

Mayo Clinic, Rochester, MN 55905, USA.

Publication Types:

• Review
• Review, tutorial

PMID: 8842779, UI: 96440468

Atherosclerosis 1994 Aug;108 Suppl:S127-35

Evaluating the effectiveness of dyslipidemia control strategies.

Kottke TE, Daida H

Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Minnesota, MN 55905.

While cost-effectiveness analyses of anti-hyperlipidemia programs featuring drug treatment suggest that the best use of public dollars is to delay treatment until an individual develops coronary heart disease, a comprehensive hyperlipidemia treatment policy must take a broader perspective. The high case-fatality rates of patients exhibiting first manifestations of coronary heart disease, the limited population impact of interventions aimed solely at high risk groups, the cost of testing to identify the high risk segment of the population, the social origins of the behavioral risk factors for coronary heart disease, and the perspective of the individual must also be considered. Available data suggest that the best public policy to control the burden of heart disease is one with two components: On the one hand, all individuals without clinically manifest heart disease would be encouraged to adopt healthy behaviors without an attempt to sort the population into 'high' and 'not high' risk groups. On the other hand, the risk factors of individuals who already have coronary heart disease would be treated aggressively with a case-management system of follow-up. The data that support this conclusion are presented in this paper.