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C HAPTER 42 / Disease Management Models for Cardiovascular Care 923
not amenable to care and that patients are likely to lapse into old patient of $100 offset the costs associated with hypertension, in-
behaviors. cluding the time lost from work.
Disease management is also often provided by a group of indi- These early studies suggested that the convenience of helping
viduals focused on providing multidisciplinary care. Utilizing nu- individuals manage their health in settings conducive to work and
merous health care providers such as nurses, pharmacists, social home offered an optimal opportunity for disease management to
workers, dieticians, and others, multidisciplinary care teams may be brought to the patient. Since the 1970s, disease management
facilitate the transition from hospital to long-term care at home. 14 by nurses has been applied not only to hypertension, 17–26 but also
Each individual of the multidisciplinary team offers unique serv- to other aspects of cardiovascular management, including dyslipi-
ices to provide lifestyle interventions and health care. These teams demia, 27–30 tobacco dependence, 31–35 diabetes, 36–40 coronary ar-
may employ “coaching” a term coined in disease management to tery disease, 41–54 and heart failure. 55–71 Much of the early work
support behavior modification. before the term disease management was coined occurred in man-
Finally, Ed Wagner and colleagues at Group Health Coopera- aging patients after myocardial infarction using a multidiscipli-
tive of Puget Sound have developed the chronic care model em- nary approach to managing risk factors, adherence to diet, exer-
braced by large organizations such as Kaiser Permanente of cise, medications, and medical regimens to improve functioning
Northern California and Health Partners Medical Group in Min- and quality of life through the provision of individual and group
neapolis, Minnesota, which is the most comprehensive form of education, counseling, and behavioral interventions, which in-
disease management focused on changing an entire system of care cluded the patient and family as part of rehabilitation. 72
delivery. Operationalized, the chronic care model addresses the The largest number of studies related to disease management
community, health care system, and provider organization and are in heart failure, in which considerable interest has arisen about
ensures that six elements are in place to ensure optimal care. how to care for a large and growing population of high-risk pa-
These elements include (1) community resources and policies, tients with the most costly cardiovascular condition (see Chapter
(2) health care organization, (3) self-management support, (4) 24). The aforementioned body of work and the reviews conducted
delivery system design, (5) decision support, and (6) clinical in- by investigators in the area of heart failure, 73–77 diabetes, 78–80 and
81
formation systems. A large focus for this type of disease manage- hypertension offer insights and guidance to nurses on the appli-
ment is geared toward coordinating activities within primary cation of disease management systems for care delivery. Disease
care. 16 management systems have now also been used in randomized con-
trolled trials 21,27,28,39 and clinical practice settings, 11 which in-
28
Models of Disease Management in clude younger, older, 49,66,82 and minority populations, 83,84 clin-
Cardiovascular Care by Nurses ics, 41,59 hospitals, 32–34 work sites, 17 home-based 39,43 and cardiac
rehabilitation settings, 46,85 and the use of multidisciplinaryy 44,47,65
Since the early 1970s, unique models for delivering care to indi- or physician–nurse teams 41,71 to direct care delivery. Moreover,
viduals with chronic conditions by nurses have evolved. Much of these disease management programs have been shown to effectively
this early work in disease management occurred in hypertension reduce multiple risk factors, 36,43,46,47 improve quality of life, 41,62
control in the United States and Europe. 17,18 Most often, at- and functional status, 59 increase short-term compliance, 10 reduce
tempts were made to deliver high-quality care in various settings total admissions, and cardiovascular readmissions, 49,63,65,67 im-
that were convenient to the population being studied. In one of prove survival, 68 reduce days of hospitalizations, 55,68 and reduce
the first disease management programs, 18 patients with hyperten- rehospitalization costs. 49,86
sion, diabetes, or cardiac disease chose to be followed by specially
trained nurses in decentralized clinics close to their homes or in a Disease Management in
hospital-based outpatient clinic for chronic disease that was Low-Income Populations
staffed by internists. Patients had similar sociodemographic and
clinical characteristics. After 2 years, hypertension control rates Recent work has shown the benefit of disease management in low-
were superior in those patients cared for by specially trained income and minority populations who may be at greatest risk of
nurses, and they had 50% fewer hospital admission days. The au- cardiovascular disease. For example, Sisk et al. 83 randomly allo-
thors of this study attributed the success of the nurse-run clinics cated 406 Hispanic and Black patients with systolic dysfunction
to greater follow-up and time devoted to helping patients manage from four Harlem hospitals to receive usual care or nurse case
their chronic conditions. management over a period of 12 months. Bilingual nurse case
In another early trial, 17 nurses played a key role in the screen- managers counseled patients in the intervention group about
ing and follow-up of individuals within a work site setting in New sodium intake, fluid buildup, medication adherence, and self-
York City. Nurses screened and enrolled patients over an 11-day management symptoms, and in addition served as a bridge be-
period and followed up hypertensive individuals over 1 year. tween patients and physicians. At the end of 12 months, patients
Working closely with a medical director, they performed an initial who were managed by nurses had fewer hospitalizations (143 vs.
medical history, obtained preliminary laboratory data, and fol- 180, adjusted difference, 0.13 hospitalization/person year, 95%
lowed treatment algorithms, initiating and titrating medications CI 0.24 to 0.001 hospitalization/person year) than patients
for hypertension treatment. Diuretics were chosen as first-line receiving usual care. In addition, they had better functioning and
therapy for hypertension treatment, and after controlling blood quality of life based on the Minnesota Living with Heart Failure
pressure to goal, patients were seen for review of therapy and were Questionnaire 87 and the Medical Outcomes Study (MOS) short-
monitored for compliance every 3 months by the nurses. At the form. 88 Other investigators report challenges when working with
end of the year, 84% of the work site had been screened, 97% of minority populations, such as Mexican Americans who travel to
those followed up by the nurses remained in therapy, and 81% and from the United States to Mexico making interventions spo-
succeeded with optimal blood pressure lowering. The cost per radic and unsystematic in this population. 89 Stafford and Berra