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Multidisciplinary Disease Management Saves Money

Donna Young

A pharmacist-assisted disease management program for patients with heart failure decreased the hospitalization rate for enrollees, increased their clinic visits, and saved the health system money, researchers determined.

The study, "The Benefit of Implementing a Heart Failure Disease Management Program," conducted at Duke University Medical Center in Durham, N.C., was published in the Oct. 8 Archives of Internal Medicine.

"It was not a big battle to convince [the medical team] that a pharmacist should be involved," said Wendy A. Gattis, Pharm.D., a member of the Duke Heart Failure Program (DHFP). "They are pretty progressive here, and they welcome more people from various disciplines to be involved."

On completion of a pharmacy residency at the medical center, Gattis was hired by the university's medicine department to conduct clinical research.

Gattis, now an assistant clinical professor in medicine at Duke, said she reviewed data for about six months before the study began. She worked with nurse practitioners on the DHFP team to develop an education manual and drug information leaflets for the patients.

"I wrote a lot of drug protocols before we started," she said.

The protocols covered the use of angiotensin-converting-enzyme (ACE) inhibitors, beta-blockers, digoxin, diuretics, alternatives to ACE inhibitors for patients who cannot tolerate that type of agent, lipid-lowering agents, and other strategies targeted at optimizing the control of concomitant illnesses that may worsen congestive heart failure (CHF).

Gattis said the patient education manual included information on the purpose of each medication, the importance of adhering to the regimen, potential adverse effects and appropriate actions to take should an adverse effect occur, a low-salt and low-cholesterol, weight monitoring, physical activity, and resources available to patients with CHF.

The study enrolled 117 patients from July 1998 to April 1999.

In the early stages of the study, Gattis said she spent about 50 percent of her time reviewing medications and educational materials with the patients. Later on, with that work completed, she spent 15–25 percent of her time working directly with the patients.

The DHFP team found that the patients' hospitalization rates decreased while the number of clinic visits increased. Duke’s health system saved a median of $8,571 per patient year, the team determined.

This shift from inpatient care to outpatient care was expected, the team stated in its article, given the disease management program's emphasis on frequent clinic visits and close monitoring of patients.

The team suggested that the reduction in hospitalizations was likely due to two aspects of the disease management program: increased use of proven therapies, and close monitoring that included easy access to health care.

The program now has about 400 patients, and Gattis said she spreads her time between monitoring the outpatients and working on the next phase of the program: conducting clinical trials on medications and writing protocols for their use. Duke has hired a second pharmacist to monitor the program's inpatients.