Page 948 - Cardiac Nursing

0
0
6
9
/
/
6
2
009
009
/
/
2
32.
32.
qx
1-9
1-9
1-9
qx
2
9
9
d
d
2
e 9
24
24
g
g
e 9
Apt
ar
a
a
Apt
Apt
ar
1
1:1
1:1
009
1
1
1:1
M
Pa
Pa
3 P
3 P
M
0-c
K34
K34
42_
42_
0-c
p92
LWB
LWBK340-c42_42_p92p921-932.qxd 29/06/2009 11:13 PM Page 924 Aptara
p92
LWB
924 PA R T V / Health Promotion and Disease Prevention
highlight the barriers and facilitators of effective case manage- to disseminate and study the translation of these models into clin-
ment in multiethnic, low-income populations, and offer impor- ical practice settings.
tant suggestions for future work based on experiences with such Approaches to disease management have shown promise and
populations. 84 documented the leadership and contribution nurses can make in
the care of patients with cardiovascular health problems. Although
Is Disease Management the names of such models may differ, the specific components,
Cost-Effective? format, and distribution of health care professionals contributing
to the multidisciplinary approaches vary by setting and scope of
The majority of work in the area of the cost-effectiveness of dis- practice according to various health care professional practice acts,
ease management is still in its infancy. Due to the burden of geographic region, payors, and by nationality. Examples of bene-
heart failure and the high costs associated with 2.5 million read- ficial models have been cited from Europe, Australia, the United
missions annually, much of the evaluation of costs has been con- States, and Canada.
ducted in this population. Chan et al. 90 applied a Markov model
to assess the incremental life expectancy and cost of disease man-
agement to both low- and high-risk patients. They looked at the COMPONENTS OF DISEASE
cost of providing disease management to all patients for a period MANAGEMENT SYSTEMS
of 15 years and found that the average coverage at 15 years was
$12,882 per life-year saved with 95% CI of $6,486 to $29,293 Identifying a Patient Population
per life-year saved. The incremental cost-effectiveness ratio of
extending care to all patients was $9,700 per life-year gained and Effective disease management involves a process of identifying at-
having universal coverage quadrupled life-years saved as com- risk populations, coordinating systems of care delivery, obtaining
pared with only those at high risk. Disease management is likely outcomes, and managing outcomes most appropriately to im-
to be cost-effective in the long-term, with $50,000 per life-year prove care. The process is shown in Figure 42-2. Most often, dis-
gained as the benchmark for cost-effectiveness. 90 While one of ease management programs are developed for chronic conditions
the pitfalls of some disease management programs is the focus that are costly, such as coronary artery disease, diabetes, heart fail-
on a single disease condition, it has also been shown that few ure, renal failure, and chronic obstructive pulmonary disease.
studies have looked at the clustering of chronic conditions and Populations are moderate-risk to high-risk individuals. They may
the cost-effectiveness of managing multiple conditions. The be identified through hospital discharge records as high users of
work of Naylor et al. suggest that advance practice nurses may care, 49 through health plan databases when the aim is to reduce
not only be able to reduce costs associated with caring for pa- costs associated with a certain conditions, 36 or through a team of
tients with heart failure, but may significantly reduce the costs individuals such as nurses and physicians aiming to improve the
of caring for those patients who often have five to six comorbid quality of care through a quality-improvement process to meet na-
conditions. 91 tional guidelines. 44
Disease management is most effective when there are incen-
Future Research by Nurses tives tied to outcomes. For example, the goal of managed care or-
ganizations may be to reduce rehospitalizations for heart failure as
Research is still needed to determine the most cost-effective mod- reimbursement for patients readmitted within 30 days of hospi-
els, how to support long-term adherence including the frequency talization may be low. Thus, a program for patients with heart fail-
of interactions to ensure maintenance of health behavior changes, ure must consider a clear understanding of why patients are being
and if improved outcomes in reduction in rehospitalizations are admitted so frequently. For a health plan, the goal may be to en-
achieved through disease management programs. Nurses who sure that all individuals’ cardiovascular risk factors are screened
have conducted numerous successful trials are also well positioned and to focus on intensive disease management programs for those
Identification of Coordinated Outcomes Outcomes
at-risk care delivery data management
populations systems
Review
Low Resource &
Interventions utilization analysis
Moderate Algorithms and ■ Figure 42-2 The process of dis-
Education clinical ease management.
High outcomes Follow-up
Necessary
changes
Quality
improvement
Improved care