Page 945 - Cardiac Nursing

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CHAPTER
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D D D D Disease Management Models for
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C C C Cardiovascular Care
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Nancy Houston Miller / Erika S. Sivarajan Froelicher
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Si Since the mid-1990ss disease management programs have served byy the coexistence off multipple medical conditions and the social
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as an important method of caring for patients with chronic illness and psychological seqquelae that accompany them. 5
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to improve patient outcomess, increasee qualityy fof life, a d de- It It is estimmated that three quarters of all health care expendi-
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crease health care utilization and cost. Disease management has tures go to caring for individuals with chronic conditions. With
been adopted on the basis of results of numerous randomized health care expenditures exceeding $1.7 trillion and 15% of the
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controlled trials showing that patients with cardiovascular condi- gross domestic product, numerous health care plans, including
tions such as heart failure, coronary heart disease, diabetes, and Medicaid and Medicare have implemented disease management
hypertension are better supported through methods involving a programs to improve high-cost care. Whether disease manage-
team approach, coordinated delivery of care, systematic educa- ment programs will succeed in significantly lowering the costs as-
tion, and documentation of outcomes directed at improving pro- sociated with managing chronic disease remains to be seen as the
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gram delivery. The trend toward caring for patients through dis- evidence of cost-effectiveness remains limited. Advanced Prac-
ease management programs has spread rapidly and now involves tice Nurses are well positioned to take on the challenge of disease
not only researchers, but also numerous health care organiza- management, as they constitute the largest group of health care
tions, the government, and for-profit organizations that are at- professionals, with more than 2.4 million employed in the United
tempting to improve chronic disease care and reduce costly emer- States. 8
gency department visits and hospitalizations. Data from The resources to manage those with an acute illness are quite
managed care organizations indicate that at least 88% of such or- different from those with a chronic condition. Acute care services
ganizations have implemented at least one disease management are provided primarily by physicians and nurses, often in inten-
program. 1 sive, hospital-based care requiring the use of expensive technology.
In a health care system faced with an overburden of chronic ill- In contrast, effective chronic care requires a comprehensive ap-
nesses, disease management is a concept likely to enable Ameri- proach that combines social, educational, vocational, and medical
cans to live differently in the future. It is necessary in any society services provided in a variety of settings that increasingly focus on
whose population is growing older and a health care system that the home as the setting of care. The scope of chronic care is broad,
is focused on managing the acute aspects of illness. By 2030 it is encompassing social, community, and personal services as well as
expected that one in five Americans will enter the age group older medical and rehabilitative care. The management of chronic con-
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than 65 years. Moreover, life expectancy has increased 44% be- ditions also requires a network of health care professionals includ-
tween 1900 and 1950, 13% between 1950 and 2000, and is pro- ing nurses, social workers, family, and caregivers. Finally, much of
jected to increase by 9% between 2000 and 2050. In 1997, the av- chronic care requires education and support of patients and fam-
erage life expectancy was 79 years for women and 74 years for ily members to maximize self-management.
men. As of 2005, only 8 years later, life expectancy was 80 years In the late 1990s, in a review of the literature, Wagner et al. 9
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for women and 75 years for men. Life expectancy at ages 65 and identified five important elements associated with improved out-
85 years has also increased substantially over the past 50 years; comes for those with chronic conditions such as hypertension and
women who survive to age 65 years can expect to live to age diabetes. Successful programs tended to be those that (1) incor-
84 years, and those who survive to age 85 years can expect to live porated guidelines and protocols in practice; (2) used a multidis-
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to age 92 years. Although the average American then can expect ciplinary team with careful allocation of tasks and ongoing patient
to live much longer, will their quality of life enable them to enjoy contact; (3) provided counseling, education, information feed-
both independence and function? back, and other support to patients; (4) offered access to necessary
In 2005 more than 133 million Americans had one or more clinical expertise such as referral to specialists, collaborative care
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chronic conditions. This figure is expected to increase by 1% per models, and computer-decision support; and (5) used supportive
year through the year 2030, where the number will increase by information systems that offer reminders for preventive care and
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46 million Americans. Moreover, women will experience the ma- follow-up as well as feedback to providers on patient compliance
jor burden of chronic diseases. Many of these conditions are re- and service use. Various disease management models have been
lated to the vascular system including hypertension, which is the developed to meet the needs of those with chronic conditions, in-
leading chronic condition in those younger and older than 65 corporating many of these elements associated with chronic care
years and heart disease, which is the leading cause of death in both delivery. Moreover, a systems approach to care delivery is needed
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men and women. Other chronic conditions most prevalent in to enhance long g-term adherence (see Chapter 40). This chapter
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those older than 65 years include pulmonary disease, diabetes, focuses on various models of disease management, including
arthritis, and chronic mental disorders. Treatment is complicated clinic and nurse case management approaches developed for
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