Effectiveness of the clinical pathway in the management of congestive heart failure. (Review Article).

Background: The prevalence of congestive heart failure (CHF) in the United States is approximately 4 million, with associated annual health care expenditures exceeding $8 billion. Clinical pathways for CHF have been developed, but they have not been rigorously evaluated regarding efficacy and improvement in the quality of care. We sought to evaluate the effect of a GHF clinical pathway on hospital charges, length of stay, and use of angiotensin-converting enzyme (ACE) inhibitors in patients with CHF in a retrospective cohort study.

Methods: We studied 371 patients (age range, 44-92 yr) with discharge diagnoses of CHF in a 376-bed community hospital between July 1996 and December 1997. We conducted chart reviews to determine length of stay, hospital charges, and use of ACE inhibitors.

Results: Of the 371 patients, 174 were assigned to the clinical pathway and 197 were not. Baseline characteristics of the two groups were similar. The benchmark of less than 4 days' in-hospital stay was achieved in 65% of patients on the pathway and 42% who were not on the pathway (odds ratio, 2.6; 95% confidence interval, 1.67-4.05; P < 0.001). The median hospital charges were lower in the group on the clinical pathway ($3,000 versus $5,500, P < 0.001). In addition, 81% of the patients on the clinical pathway were administered ACE inhibitors, compared with 48% of equally eligible patients from the non-pathway group (odds ratio, 4.68; 95% confidence interval, 2.85-7.72; P < 0.001).

Conclusion: The clinical pathway for CHF was associated with increased use of ACE inhibitors as well as reduced length of stay and hospital charges.

Key Words: clinical pathway, congestive heart failure, cost control, quality of care

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In the United States, the prevalence of congestive heart failure (CHE) is approximately 4 million, and 400,000 new cases are diagnosed yearly. (1-3) Currently, CHF is the most frequent admission diagnosis in the Medicare population. (4-6) Heart failure claims the lives of more than 200,000 Americans annually, with 50% of the patients dying within 5 years of onset. (7)

The cost of caring for patients with CHF exceeds $8 billion/yr and continues to increase. (8,9) To control costs, medical centers have adopted various strategies. A 1993 survey of U.S. hospitals performed by the Cardiology Advisory Board Co. (Washington, DC) identified several strategies: heart failure clinics, home health cardiac specialists, community-based service coordinators, patient telemanagement, hospital-sponsored cardiac rehabilitation, emergency department observation units, and CHF subacute care. (10) In the hospital setting, the most common strategy is the clinical pathway. However, none of these clinical pathways has been studied rigorously for efficacy.

In 1995, our institution developed and implemented a clinical pathway for patients with CHF. The goal was to decrease hospital charges while maintaining efficiency and quality of care. Two years after implementation, we wanted to determine the effectiveness of the program. Our study was designed primarily to ascertain whether the pathway reduced length of stay and hospital charges; a secondary aim was to determine whether the pathway increased the use of angiotensin-converting enzyme (ACE) inhibitors.

Methods

The diagnosis of CHF was made on the basis of clinical examinations and echocardiography performed for all patients selected for the study. The data collected regarding existing comorbid conditions also were used to stratify patients with CHF into three groups by severity (0-1, 2-4, and 5 or more comorbid states as mild, moderate, and severe comorbidity index, respectively). The baseline characteristics of the patients in the two groups (pathway and nonpathway) were found to be similar.

Statistical Analysis

Clinical data were collected by performing chart reviews in the medical records department with the management information systems database. The three major outcomes considered were length of in-hospital stay (benchmark, <4 d), hospital charges incurred for that particular stay, and use of ACE inhibitors. The data were analyzed with the Epi-Info software (version 6.1; Centers for Disease Control and Prevention, Atlanta, GA). A two-sided [chi square] test mainly was used to evaluate variables. ACE inhibitors and length of stay at the 95% confidence interval (CI) and the Mantel-Haenszel method were used to adjust for a few confounding factors. The Mann-Whitney rank-sum test was used to analyze hospital charges. Odds ratios (ORs) and 95% CIs were obtained for the variables analyzed. These comparisons of the two groups of patients were first performed for the entire study population and then in the subgroups stratified according to comorbidity.

Results

Of the total of 371 patients admitted with the clinical diagnosis of CHF and meeting the criteria for inclusion in this analysis, 174 patients (47%) were assigned to the clinical pathway and 197 (53%) were not. A total of 152 (41%) of 371 patients belonged in the moderate comorbidity subgroup, 219 (59%) were in the severe comorbidity group, and there were no patients in the mild comorbidity subgroup.

Unstratified Data among Patients with CHF

A total of 113 (65%) of 174 patients on the clinical pathway fulfilled the benchmark regarding length of in-hospital stay (<4 d), compared with 82 (42%) of 197 patients who were not on the pathway (OR, 2.6; 95% CI, 1.67-4.05; P < 0.001). The median charge incurred during hospitalization was $3,000 (25th-75th percentiles, $2000-$5,000) among patients on the pathway and $5,500 (25th-75th percentiles, $3,000-$9,000) for the group not on pathway (P < 0.001). Costs ranged from $1,000 to $20,000 in the clinical pathway group and from $1,000 to $42,000 in the nonpathway group. A total of 141 (81%) of 174 patients on the clinical pathway were administered ACE inhibitors, compared with 94 (48%) of 197 patients who were not on the pathway (OR, 4.68; 95% CI, 2.85-7.72; P < 0.001) (Table 1).

Stratified Data According to Comorbidity among Patients with CHF

The same three variables discussed above were reanalyzed after stratification of patients into two subgroups: moderate and severe comorbidity. Among patients with moderate comorbidity (two to four comorbid states), 70 (46%) of 152 patients were on the clinical pathway and 82 (54%) were not on the pathway. A total of 53 (76%) of 70 patients on the pathway achieved the benchmark length of in-hospital stay (<4 d), compared with 40 (49%) of 82 patients who were not on the pathway (OR, 3.27; 95% CI, 1.54-7.00, P < 0.001). The median length of stay was 3 days (range, 1-10 d) among patients on the pathway and 5 days (range, 1-13 d) for patients not on the pathway. The median cost of hospitalization was $2,250 for patients on the pathway (25th-75th percentiles, $2,000-$4,050) and $4,500 (25th-75th percentiles, $2,650-$7,050) for patients who were not on the pathway (P < 0.001). The range of hospital charges was $1,000 to $17,000 in the pathway group and $1,500 to $42,000 in the nonpathway group. A total of 54 (77%) o f 70 patients on the pathway were administered ACE inhibitors, compared with 35 (43%) of 82 patients who were not on the pathway (OR, 4.23; 95% CI, 2.11-9.83; P < 0.001).

Among patients with severe comorbidity (more than five comorbid states), 104 (47%) of 219 patients were on the clinical pathway and 115 (53%) patients were not. A total of 60 (5 8%) of 104 patients on the pathway achieved the benchmark length of in-hospital stay (<4 d), compared with 42 (37%) of 115 patients who were not on the pathway (OR, 2.37; 95% CI, 1.376-4.082; P < 0.005). The median length of stay was 4 days (range, 1-11 d) among patients on the pathway and 6 days (range, 1-29 d) among patients not on the pathway. The median cost of hospitalization was $4,000 for patients on the pathway (25th-75th percentiles, $2,000-$5,350) and $7,000 (25th-75th percentiles, $4,000-$10,000) for patients who were not on the pathway (P < 0.001). The range of hospital charges was $1,000 to $20,000 in the pathway group and $1,000 to $30,000 in the nonpathway group. A total of 87 (84%) of 104 patients who were on the pathway were administered ACE inhibitors, compared with 59 (51%) of 115 patients who were not on the pathwa y (OR, 4.86; 95% CI, 2.46-9.66; P < 0.001).

Discussion

Our results show that the patients assigned to the CHF clinical pathway had a shorter length of stay and reduced hospital charges compared with those who were not on the pathway. The study also shows that 81% of patients on the pathway were administered ACE inhibitors, compared with 48% of the patients who were not. ACE inhibitors have been shown to reduce symptoms and prolong survival in patients with CHF. (11) Despite its proved efficacy, ACE inhibitor therapy is provided for fewer than 31% of eligible patients, according to other studies. (12) In our study, the clinical pathway for CHF served as a reminder to physicians and helped to increase the use of ACE inhibitors significantly.

Previous studies have shown that patients who are managed according to CHF clinical pathways have a slightly shorter length of stay and lower hospital costs. However, the results of the previous studies were not analyzed for statistical significance. Moreover, none of the studies showed increased use of ACE inhibitors among patients on the clinical pathway. Our study shows that the quality of care delivered (as measured by administration of ACE inhibitors) was not compromised by the reduction in length of hospital stay in patients on the clinical pathway. In fact, more patients in the clinical pathway group than in the nonpathway group were administered ACE inhibitors.

The limitations of our study include those intrinsic to all observational, retrospective study designs, such as the absence of randomization and blinding and the confinement of the findings to a single community hospital. A randomized trial of the effectiveness of clinical pathways for patients with CHF would be difficult because of logistical problems and difficult decisions about issues such as unit of randomization and maintenance of blinding. Even without randomization, our patients were not significantly different in their baseline characteristics. Also, because of the nature of our study, we were unable to include readmission data in our analysis. Undoubtedly, this information would have been useful in validating our findings.

Conclusions

Our study shows that the clinical pathway for CHF was associated with increased use of ACE inhibitors as well as reduced length of stay and hospital charges. Because our hospital admits approximately 300 patients with CHF annually and because the clinical pathway in our study saved $2,500/patient, universal use of the pathway could save the hospital approximately $750,000/yr. Considering the growing prevalence of CHF in the United States and the billions of dollars spent each year in its management, the use of clinical pathways seems to be a promising means of significant cost savings while improving the quality of care.

Table 1

Patient characteristics

Characteristic       Data

No. of patients      371
Age range (mean)     44-92 yr (mean age, 67 yr)
Sex ratio            1:1 (178 males, 193 females)
Time frame           July 1996-December 1997 (18 mo)
Discharge diagnosis  Congestive heart failure
Comorbid diagnoses   Chronic lung disease, pneumonia, coronary
                      artery disease, anemia, renal insufficiency,
                      diabetes, hypertension
Exclusion criteria   Peripartum cardiomyopathy, hemodialysis,
                      intolerance to angiotensin-converting
                      enzyme inhibitors, readmission for
                      congestive heart failure

Accepted January 9, 2003.

References

(1.) Ho KK, Anderson KM. Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88:107-115.

(2.) Agency for Health Care Policy and Research (AHCPR). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction (AHCPR Publication No. 94-0612). Rockville, MD, AHCPR, 1994.

(3.) Committee on Evaluation and Management of Heart Failure. Guidelines for the evaluation and management of heart failure: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1995;26:1376-1398.

(4.) Graves EJ. Detailed diagnoses and procedures, National Hospital Discharge Survey, 1990. Vital Health Stat 13 1992;113:l-225.

(5.) Ghali JK, Cooper R, Ford E. Trends in hospitalization rates for heart failure in the United States, 1973-1986: Evidence for increasing population prevalence. Arch Intern Med 1990;150:769-773.

(6.) Agency for Health Care Policy and Research (AHCPR). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction (AHCPR Publication No. 94-0613). Rockville, MD, AHCPR, 1994.

(7.) Graves EJ. National Hospital Discharge Survey: Annual summary, 1993. Vital Health Stat 13 1995;121:1-63.

(8.) Levit KR, Lazenby HC, Cowan CA, Letsch SW. National health expenditures, 1990. Health Care Financ Rev 1991;13:29-54.

(9.) O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: Time for a different approach. J Heart Lung Transplant 1994;13:S107-S112.

(10.) Venner GH, Seelbinder JS. Team management of congestive heart failure across the continuum. J Cardiovasc Nurs 1996;l0:71-84.

(11.) Stafford RS, Saglam D, Blumenthal D. National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure, Arch intern Med 1997;157:2460-2464.

(12.) Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure: Collaborative Group on ACE Inhibitor Trials, JAMA 1995;273:1450-1456.

RELATED ARTICLE: Key Points

* The use of the clinical pathway in patients with moderate to severe congestive heart failure was associated with shorter hospital stay and lower costs.

* Compared with patients who were not on the clinical pathway, the pathway patients were statistically more likely to be administered angiotensin-converting enzyme inhibitors.

* The use of the clinical pathway in patients with congestive heart failure was associated with both a reduction in hospital costs and an improvement in the quality of care.

From the Greater Baltimore Medical Center, Baltimore, MD, and the National Institute on Aging, National Institutes of Health, Bethesda, MD.

Reprint requests to Eugene Obah, MD, Greater Baltimore Medical Center, Physicians Pavilion East, Suite 203, 6565 N. Charles Street, Baltimore, MD 21204.

Copyright (c) 2003 by The Southern Medical Association

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