A Quality Improvement Project to Reduce Congestive Heart Failure Mortality With Intensive Case Management

Abstract

PURPOSE: As part of a multidisciplinary collaboration to improve the follow-up care of our veterans with congestive heart failure (CHF), we implemented an initiative for our cardiology nurse practioner (NP) to provide intensive case management. We hypothesized this would reduce the frequency of hospitalizations, lengths of stay (LOS), and overall mortality. METHODS: We developed a clinic for our NP to provide intensive case management for our veterans with CHF alongside their primary care physicians and cardiologists. Successful enrollment was anyone who participated in at least 4 clinic visits or phone-calls in one year with our NP. We accommodated them with either encounter, during which our NP discussed medications, the presence of new symptoms, and changes in weight. He made medication adjustments in response to new findings and referred anyone to the ER for concerns such as acute chest pain. We measured our program outcomes with a cohort study comparing frequency of hospitalizations, LOS, and mortality rates between 116 veterans enrolled in our clinic (enrolled cohort) and 274 veterans not enrolled (standard cohort) from 2008-2012. Each cohort consisted of equal proportions of admissions for DRG 291, 292, or 293. RESULTS: The yearly hospitalization rate between the enrolled cohort (3.4%) and standard cohort (2.89%) was statistically significant (t-test p=0.023). The average LOS between the enrolled cohort (5.13 days) and standard cohort (7.8%) was not statistically significant (t-test p=0.369). The mortality rate between the enrolled cohort (37%) and standard cohort (53%) was statistically significant (Fischer Exact Test p=0.0039). CONCLUSIONS: We found a significantly higher yearly hospitalization rate among those enrolled. We attribute this to earlier recognition of decompensated CHF or failing outpatient regimens, resulting in an admission for timely treatment and rapid resolution. This led to an ostensible decrease in LOS, which is clinically relevant due to the morbidity and mortality associated with prolonged hospitalizations. This was particularly held true by the significant decrease in mortality among those enrolled.