Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Journal of Cardiac Failure Vol. 8 No. 3 2002 Heart Failure Management: Multidisciplinary Care has Intrinsic Benefit Above the Optimization of Medical Care KENNETH MCDONALD, MD,1,2 MARK LEDWIDGE, PHD,1,2 JOHN CAHILL, MB,1 PETER QUIGLEY, MD,1 BRIAN MAURER, MD,1 BRONAGH TRAVERS, RN,1 MARY RYDER, RN,1 EMMA KIERAN, RN,1 LORNA TIMMONS, RN,1,2 AND ENDA RYAN, MB1 Dublin, Ireland ABSTRACT Purpose: This work addresses the unanswered question of whether multidisciplinary care (MDC) of heart failure (HF) can reduce readmissions when optimal medical care is applied in both intervention and control groups. Methods: In a randomized, controlled study, 98 patients (mean age, 70.8 ⫾ 10.5 years) admitted to hospital with left ventricular failure (New York Heart Association Class IV) were assigned to routine care (RC, n ⫽ 47) or MDC (n ⫽ 51). All patients received the same components of inpatient, optimal medical care of HF: specialist-led inpatient care; titration to maximum tolerated dose of angiotensin-converting enzyme inhibitor before discharge; attainment of predetermined discharge criteria (weight stable, off all intravenous therapy, and no change in oral regimen for 2 days). Only those in the MDC group received inpatient and outpatient education and close telephone and clinic follow-up. The primary study endpoint was rehospitalization or death for a HF-related issue at 3 months. Main findings: At 3 months, four people had events in the MDC group (7.8% rate over 3 months) compared with 12 people (25.5% rate over 3 months) in the RC group (P ⫽ 0.04). Conclusion: These data demonstrate for the first time the intrinsic benefit of MDC in the setting of protocol-driven, optimal medical management of HF. Moreover, the event rate of 7.8% at 3 months, as the lowest reported rate for such a high-risk group, underlines the value of this approach to the management of heart failure. Key Words: Multidisciplinary care, ACE Inhibition, readmission. medical care.1,4-6 Beginning with the index hospitalization for heart failure (HF), published work on multidisciplinary care (MDC) has shown significant reductions in rehospitalization rates,1,4-6 predominantly as a result of patient education, close clinical follow-up, and optimizing outpatient medical care. However, optimal medical care during the index hospitalization, which should comprise specialist management, applying maximal use of proven medical therapies and ensuring clinical stability at discharge, has not been a stated component of these studies. It is well-recognized that diagnosis and treatment of HF is significantly improved with specialist care.7,8 No study to date of multidisciplinary care of heart failure has shown the benefits to be independent of optimal From the 1St Vincent’s University Hospital Heart Failure Unit and Council on Heart Failure, Irish Heart Foundation, Dublin, Ireland Manuscript received November 6, 2001; revised manuscript received March 11, 2002; revised manuscript accepted April 2, 2002. Reprint requests: Dr. Ken McDonald, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland. This work is supported by unrestricted grants from the Irish Heart Foundation and Servier Laboratories Ireland. Copyright 2002, Elsevier Science (USA). All rights reserved. 1071-9164/02/0803-0006$35.00/0 doi:10.1054/jcaf.2002.124340 2 142 Heart Failure Management: Multidisciplinary Care has Intrinsic Benefit O McDonald Furthermore, achievement of target dose angiotensinconverting enzyme (ACE) inhibitor has been shown to reduce morbidity,3,9 and when applied before hospital discharge, significantly reduces rehospitalization over 3 months.3 Finally, Ashton and colleagues have demonstrated that achieving defined clinical stability criteria before discharge reduces readmission rates.2 Rich et al. were the first to demonstrate the benefits of MDC in reducing HF rehospitalizations.4,5 Cline et al. further emphasized the importance of a hospital based HF clinic after discharge.6 Recently, Stewart and colleagues have shown the benefits of a home-based program in reducing HF rehospitalizations.1 None of these studies counted maximization of medical therapy and clinical stability at discharge as mandatory components of care.1,4-6 Furthermore, as a home-based program initiated after hospital discharge, the work by Stewart et al. did not include predischarge specialist care of patients with HF.1 Because all the above components of optimal medical care will lead to reduced HF rehospitaliaation,2,3,7,8 the question unanswered by published work to date is whether MDC will still show benefit when these components are a standard part of the care program. By applying optimal medical care in both intervention and control groups, our study is the first to give a true estimation of the intrinsic benefit of regular patient education and support delivered as part of a MDC program for heart failure. Between November 1998 and April 2000, 337 patients were admitted to St. Vincent’s University Hospital through accident and emergency with a presumed diagnosis of HF. After review by the cardiology service, 64 patients had been incorrectly diagnosed, presenting with asthma, exacerbation of lung disease, pneumonia, or lung cancer (Fig. 1). A further 59 patients, although demonstrating some features of HF, were excluded because the primary reason for hospitalization was not related to HF. Therefore, it would be inappropriate for a HF service to take over their management. Two hundred and fourteen patients had a confirmed diagnosis of primary HF, 116 of whom were excluded for reasons outlined in Table 1, leaving a study population of 98. In-hospital Routine Care and Multidisciplinary Care RC Group Patients underwent investigations for HF, including echocardiography and right and left heart catheterization where indicated. Optimal medical therapy Methods Patient Selection The investigation conforms with the principles outlined in the Declaration of Helsinki and was approved by the St. Vincent’s University Hospital Ethics Committee. All patients older than 18 years of age admitted to St. Vincent’s University Hospital through injury with a diagnosis of HF were screened. Diagnosis of HF was confirmed or refuted by a cardiologist based on the presence of the following four criteria: history and examination compatible with HF, chest X-ray appearance of congestion, echocardiography evidenced left ventricular systolic or diastolic dysfunction, and response to initial therapy. Patients presenting with HF in the setting of myocardial infarction or unstable angina or in whom failure was not thought to be the primary problem were excluded. Also not considered were those with illnesses that could compromise survival over the duration of the study or with cognitive impairment. After they were stable and informed written consent was obtained, all eligible patients were randomized to routine care (RC) or MDC directly under the supervision of the cardiology service. 143 Fig. 1. Details of patient screening and inclusion. 144 Journal of Cardiac Failure Vol. 8 No. 3 June 2002 was administered (see the following section). Ancillary services such as dietary and social work consultation were provided as requested by the attending cardiologist. Clinical stability criteria outlined below had to be fulfilled before discharge. MDC Group Patients underwent similar investigation and treatment as outlined for the RC group. In addition, patients systematically received specialist nurse-led education and specialist dietitian consults on three or more occasions during the index admission. The education program focused on daily weight monitoring, disease and medication understanding, and salt restriction. Similar advice was given to the patient’s carer or next of kin where applicable. As in the RC group, stability criteria had to be fulfilled before discharge. Optimal Medical Therapy Both RC and MDC groups underwent echocardiography to determine left ventricular (LV) systolic function. Patients with an ejection fraction of <45% were categorized as having LV systolic dysfunction. In this subset, diuretic and digoxin therapy was prescribed in appropriate doses. Additionally ACE inhibitor therapy was prescribed at maximally tolerated doses. Perindopril was selected because it may be better tolerated on initiation and can be easily titrated to target doses.10,11 From a starting dose of 2 mg (low dose), patients were up-titrated to target dose of 4 mg daily. If tolerated and deemed clinically appropriate, higher doses (>4 mg) were used. Beta blockade was not routinely initiated for management in view of the unproven benefit in New York Heart Association (NYHA) Class IV HF during the course of this study. Because there is no defined approach to the management of HF and normal systolic function, patients with this type of HF were managed as deemed appropriate by the attending cardiologist. Table 1. Details of Screening and Reasons for Patient Exclusion Description Patients presenting with primary diagnosis of heart failure Not enrolled Nursing home Refused consent Cognitive impairment Active myocardial ischemia Died in hospital Significant hearing/visual impairment Living abroad Comorbidity compromising survival Immediate valve surgery Not English-speaking Enrolled n 214 116 28 25 20 16 7 7 5 5 2 1 98 Stability Criteria on Discharge Clinical and therapeutic criteria for stability at discharge were predefined and were a prerequisite for discharge in both groups. These were: O O O O Symptomatically improved and stable Off all intravenous therapy for 2 days Stable oral therapy with no dose change for 2 days Stable dry weight (no change > 1 kg) for 2 days Questionnaires Patients and carers received questionnaires to assess knowledge of HF and importance of diet at discharge and 3-month follow-up visit. In the absence of any broadly accepted, standard patient and carer questionnaires, we generated in-house knowledge of heart failure (20 questions) and diet (10 questions) questionnaires. These were administered by the nurse and used primarily to assess the success of the education component of the program and to identify areas of weakness. They were not pretested or validated in any way. Outpatient Routine Care and Multidisciplinary Care RC Group Patients were referred back to their primary physician with a letter stating participation in the study and that routine management of their condition can carry on as they see fit, including review by the hospital cardiology service, if required. Both the patient and their physician were asked to inform the study centre if admission to any hospital occurred before the 3-month follow-up period. All patients were reviewed at 3 months at the HF clinic. MDC Group In addition to the in-hospital MDC intervention (see previous), patients were discharged from hospital with a letter to the referring physician explaining the nature of the study and that management of HF-related issues should be referred to the clinic or the nurse. Telephone contact was made by the trained HF nurse specialist with the patient at 3 days after discharge and weekly thereafter until 12 weeks. The nurse making the phone call was the same nurse who attended the patient during the in-hospital MDC intervention, thus providing continuity of care. During the phone call clinical status was ascertained and any problems were discussed. Key education issues were also discussed as deemed necessary by the nurse. At weeks 2 and 6, patients and their next of kin attended the HF clinic to check clinical status and further revise key education issues. Patients were also asked to contact the HF clinic should they notice any clinical deterioration. This resulted in full clinical review. Advicewas given to the patient to increase diuretic therapy by 40 mg of frusemide or its equivalent if weight gain of2 kg or more occurred over 1 to 3 days in the absence of clinical Heart Failure Management: Multidisciplinary Care has Intrinsic Benefit O McDonald deterioration. The patient was also asked to attend the HF clinic for assessment of urea and electrolytes. Failure of this approach to bring body weight back to baseline resulted in full clinical review with options to use intravenous frusemide at the clinic to regain outpatient clinical stability. Criteria for Admission RC Group The decision to admit a patient was the responsibility of the physicians in charge of care and was not influenced by the persons involved in this study. MDC Group The decision to readmit a patient was made according to specific, predefined criteria. They were: NYHA class IV, potassium <2.8 mEq/L or >6.0 meq/L, failure of the tiered medical response (augmentation of oral diuretic, clinical review and use of intravenous diuretic on one occasion) to manage clinical deterioration, or weight gain. Endpoints and Data Analysis The endpoint in this study is the number of patients with death or readmission for HF within 12 weeks. Data were analyzed by intention to treat using Students t-test (normal distribution) and chi-squared analysis (with calculation of odds ratio and 95% confidence interval) for discrete variables. Results Demographics The RC and MDC groups were similar in all respects (Table 2). It is important to emphasize that this is an older population, more representative of community HF is than the majority of HF trials. Furthermore, this was an at-risk population because more than half the patients had a known history of HF and of these 85% had previously been admitted for this condition. Moreover, 38% of these had been admitted for HF in the 3 months previous to this index admission. In-hospital Course The discharge clinical stability criteria were applied in all cases, with the exception of one patient in the MDC group (Table 3). This may have contributed to the length of stay, which was similar in both groups, but longer than the average reported in the literature. Furthermore the majority of patients were not admitted under the cardiology service likely contributing to the increased length hospital stay. Of interest, 98% of patients in both groups with LV systolic dysfunction tolerated ACE inhibitor therapy with perindopril. All of these tolerated target or high dose therapy before discharge, with the exception of one Table 2. Baseline Demographic Characteristics of Total Population, Multidisciplinary Care (MDC) Group, and Routine Care (RC) Group Characteristic n Age ⫾ SD (years) Male (n):Female (n) Carer available—yes (n):no(n) Systolic dysfunction—yes (n):no(n) SBP/DBP on admission ⫾ SD (mmHg) HR (beats/min) on admission Sinus rhythm—yes (n):no(n) Etiology Ischemia—yes (n):no(n) Hypertension—yes (n):no(n) Valvular—yes (n):no(n) Idiopathic—yes (n):no(n) Previous HF—yes (n):no(n) Previous HF admissions—yes (n):no(n) Within 1 month—yes (n):no(n) Within 3 months—yes (n):no(n) Within 12 months—yes (n):no(n) Ejection fraction ⫾ SD (%) Total Population 98 70.80 ⫾ 10.47 145 MDC Group RC Group 47 ⫾ 70.83 ⫾ 10.69 65:33 88:10 71:27 136/77 87.9 ⫾ 19.1 52:46 51 70.76 10.37 32:19 47:4 39:12 138/79 87.0 ⫾ 17.6 24:27 46:42 9:89 18:80 8:90 53:45 45:53 5:40 12:33 24:21 37 ⫾ 13 23:28 4:47 10:41 6:45 29:22 23:28 2:21 6:17 13:10 36 ⫾ 12 23:24 5:42 8:39 2:45 24:23 22:25 3:19 6:16 11:11 38 ⫾ 15 SD, standard deviation; SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate; HF, heart failure. 33:24 41:6 32:15 134/75 88.9 ⫾ 20.7 28:19 146 Journal of Cardiac Failure Vol. 8 No. 3 June 2002 Table 3. In-hospital Course of Multidisciplinary Care (MDC) group and Routine Care (RC) group MDC Group N Length of stay ⫾ SD (day) Discharge medication EF <45%—yes(n):no(n) ACE inhibitor prescribed—yes(n):no(n) High dose—yes(n):no(n) Target dose—yes(n):no(n) Low dose—yes(n):no(n) Mean perindopril dose ⫾ SD (mg) Digoxin—yes(n):no(n) Mean digoxin dose ⫾ SD (mg) Diuretic—yes (n):no(n) Mean frusemide dose ⫾ SD (mg) HF specialist nurse interventions No. of visits (in-hospital) Time per patient, in hospital ⫾ SD (min) Time per patient, discharge ⫾ SD (min) HF Specialist Dietitian interventions No. of visits (in-hospital) Time per patient, in hospital ⫾ SD (min) Patient knowledge of HF ⫾ SD (n/20) Carer knowledge of HF ⫾ SD (n/10) Patient knowledge of diet ⫾ SD (n/10) Stability criteria on discharge, yes(n):no(n) RC Group P Value* 51 13.7 ⫾ 7.8 47 14.6 ⫾ 8.1 — .58 35:16 34:1 15:20 18:17 1:34 5.5 ⫾ 1.9 25:10 0.160 ⫾ 0.072 33:2 57.1 ⫾ 28.9 27:20 26:1 15:12 11:16 0:27 6.0 ⫾ 1.9 21:6 0.173 ⫾ 0.079 26:1 75.0 ⫾ 45.4 .25 .59 .32 .40 — .28 .57 .57 .71 .08 3.6 ⫾ 1.4 84.8 ⫾ 39.5 18.1 ⫾ 17.8 1.7 ⫾ 1 60.0 ⫾ 37.9 14.8 ⫾ 3.1 7.8 ⫾ 2.1 7.5 ⫾ 1.7 50:1 NA NA NA NA NA 11.6 ⫾ 3.1 5.8 ⫾ 1.5 6.3 ⫾ 1.6 47:0 — — — — — <.01 <.01 <.01 — SD, standard deviation; EF, ; ACE, angiotensin-converting enzyme; EF, ejection fraction; HF, heart failure. *Denotes statistical analyses of MDC versus RC groups. patient in the multidisciplinary arm. This rapid titration of ACE inhibitor was achieved without significant change in renal function. On discharge, there was an indication of difference between the two groups in terms of patient and carer understanding of heart failure as expressed by questionnaire scores (Table 4). In addition, patient understanding of the importance of diet and sodium restriction appeared to be superior in the MDC group on discharge. Endpoint and 3-Month Follow-Up The characteristics of patients after 3 months of follow-up are presented in Table 4 and Fig. 2. At 3 months, more patients suffered death or readmission for HF in the RC group (25.5%) compared with the MDC group (7.8%). There were three deaths in each group (the population 3-month mortality is 6.1%). Two patients in each group had an out-of-hospital sudden death. One in each group died during hospital admission for HF progression within the 3-month follow-up period. Overall, rehospitalization for heart failure was far more frequent in the RC group (25.5%) compared to the MDC group (3.9%). The superior knowledge regarding HF, medicines, and diet noted in patients in the MDC group at discharge was sustained at 3 months. No other differences in patient characteristics and outcomes were noted. Discussion This study provides original, conclusive evidence of the intrinsic benefits of multidisciplinary care in the setting of standardized optimal medical care of HF. Previous important contributions on the value of multidisciplinary care have demonstrated reductions in hospital admissions and improved quality of life with various forms of hospital or home-based programs.1,4-6 In general, these reports have initiated their intervention at an index hospital admission, and have focused on patient education and close clinical follow-up. However, standardized approaches to several aspects of optimal inpatient medical care were not a stated part of their protocols. These include referring all patients to a specialty service with a specific interest in heart failure, prescription of maximally tolerated therapy before discharge from hospital—especially with regard to ACE inhibitors—and attainment of predefined criteria for clinical stability before discharge. There is a wealth of data that supports the importance of these issues with regard to hospitalization for heart failure.2,3,7,8 Not least of these is the observation that the bulk of early readmissions tend to occur within the first month after discharge, suggesting lingering problems with the inpatient phase of management in current practice.1,13,14 It is our contention that the true, intrinsic value of multidisciplinary care cannot be determined until assessed in the setting of standardized optimal medical Heart Failure Management: Multidisciplinary Care has Intrinsic Benefit O McDonald 147 Table 4. Characteristics of the Multidisciplinary Care (MDC) group and Routine Care (RC) Group after 3 Months’ Follow-Up Characteristic Total Population MDC Group N NYHA class Ejection fraction (%) SBP/DBP ⫾ SD (mm Hg) 98 2.29 ⫾ 0.63 38.1 ⫾ 12.6 128/74 ⫾ 23/11 51 2.21 ⫾ 0.64 38.4 ⫾ 12.9 125/73 ⫾ 22/11 HR Potassium Urea Creatinine Quality of life Patient knowledge of HF Carer knowledge of HF Patient knowledge of diet Mean ACE inhibitor dose Mean frusemide dose Mean digoxin dose 75.7 ⫾ 12.4 4.16 ⫾ 0.59 10.7 ⫾ 6.2 134.3 ⫾ 59.9 34.1 ⫾ 27.1 14.7 ⫾ 3.0 6.5 ⫾ 2.8 7.5 ⫾ 2.2 4.6 ⫾ 3.2 42.1 ⫾ 26.0 0.128 0.105 12 76.3 ⫾ 12.3 4.18 ⫾ 0.50 10.0 ⫾ 4.1 134.1 ⫾ 98.5 28.8 ⫾ 23.0 16.3 ⫾ 2.7 7.1 ⫾ 3.3 8.3 ⫾ 2.1 4.5 ⫾ 3.3 44.4 ⫾ 25.2 0.107 0.099 1 Readmissions for HF in 3 months Patients with death and/or HF readmission in 3 months 16 ⫾ 4 RC Group 47 2.28 ⫾ 0.63 37.7 ⫾ 12.6 131/74 ⫾ 25/11 ⫾ 75.1 ⫾ 12.5 4.15 ⫾ 0.68 11.5 ⫾ 7.9 134.6 ⫾ 70.1 39.0 ⫾ 29.5 13.1 ⫾ 2.2 5.9 ⫾ 2.1 6.6 ⫾ 1.9 4.7 ⫾ 3.0 39.6 ⫾ 27.0 0.154 ⫾ 0.106 11 12 P* OR, 95% CI* — .53 .96 .28SBP .75DBP .83 .79 .23 .84 .11 <.01 .24 <.01 .71 .53 .06 — — — — — — — — — — — — — — — <.01 0.01-0.53 .04 0.07-0.84 NYHA, New York Heart Association; SBP, systolic blood pressure; DBP, diastolic blood pressure; SD, standard deviation; HR, heart rate; HF, heart failure; ACE, angiotensin-converting enzyme. *Denotes statistical analyses of MDC versus RCA groups. care. To address this issue we focused on the three aspects of care outlined above. Specialty care is associated with increased diagnostic accuracy of heart failure and is also associated with improved utilization of pharmacologic agents known to improve outcomes in this condition.7,8 There are no data to suggest that such specialty care has to be in a cardiology service, but clearly should be with a group of physicians with a stated interest in heart failure. Prescription of ACE inhibition at maximally tolerated dose before discharge could also be associated with reduced readmission at three months.3 The ATLAS multicenter study data points to the morbidity benefit of use of higher dose of ACE inhibitor agents Fig. 2. Number of patients with primary endpoints (death or readmission for heart failure) in multidisciplinary care (MDC) and routine care (RC) groups at 3 months. during follow-up management.9 However, ACE inhibitors are frequently underprescribed and underdosed at time of discharge.10 The complexity of titration with certain ACE inhibitors can also add to the difficulty in attaining target or high dose therapy. Finally, data from Ashton and colleagues underline the importance of attaining specific predefined criteria for clinical stability at discharge and thereby reducing 3-month readmission rates.2 To our knowledge no such approach has been a component of multidisciplinary care programs to date. In our study these three aspects of care were standardized in both the routine and multidisciplinary-managed groups, thus allowing for a true assessment of the value of multidisciplinary care. We report an event rate of patients with death or HF-related admission of 7.8% at 3 months after discharge in the multidisciplinary care group. This is the lowest event rate reported to date in such a high-risk population, characterized by hospital presentation of an elderly patient population with acute LV failure and a high incidence of prior hospitalization in those with a known history of HF. With such a low event rate it is important to note that all patients were cared for by a specialty service, that 99% of patients attained clinical stability at discharge, and that 97% of patients with LV systolic dysfunction were receiving at least target dose ACE inhibition with perindopril at discharge. The event rate of 7.8% within 3 months was significantly lower than that observed in the routine arm (25.5%) and was also lower than the 38% hospitalization rate within this 148 Journal of Cardiac Failure Vol. 8 No. 3 June 2002 particular group before index admission. It is possible that that this event rate could be further reduced with early systematic prescription of beta blockade to those with systolic dysfunction as indicated by the Copernicus study.12 Certain issues regarding the design and results of this study require further discussion. The study was designed to address the issue of multidisciplinary care in the setting of optimal medical care in a typical community HF population. The applicability of many studies in HF to management of the routine community patient can be questioned because of the younger age of the population compared with the typical community profile, and the high ratio of screened to enrolled patients. In this particular study the majority of those not randomized were already receiving 24-hour nursing care, refused consent, or had cognitive impairment; we cannot draw conclusions as to the potential benefit of the MDC program on these patients. However, the mean age of the population was more typical of the routine heart failure population, and just under half of patients fulfilling entry criteria were randomized making this study more generalizable than most. Secondly, this study placed increased focus on certain aspects of inpatient medical care. We have no data to support that the chosen components are what defines optimal medical care, but available data do underline their importance.2,3,7,8 Unlike certain other MDC of HF programs, a major part of the MDC intervention in this program was provided during the index hospitalization. Conclusion In summary, this study shows conclusively that, even in the setting of protocol-driven optimal medical care, multidisciplinary care of severe HF provides intrinsic and important additional benefits. Moreover, the event rate of 7.8% at 3 months, as the lowest reported rate for such a high-risk group, underlines the value of an integrated in-hospital and outpatient multidisciplinary approach to HF. Acknowledgments The authors gratefully acknowledge the support of the Irish Heart Foundation and Servier Laboratories Ireland. References 1. Stewart S, Marley JE, Horowitz JD: Effects of a multidisciplinary, home-based intervention on unplanned rea-- missions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999;354:1077–1083 2. Ashton CM, Kuykendall DH, Johnson ML, Wray NP, Wu L: The association between the quality of inpatient care and early readmission. Ann Intern Med 1995;122:415– 421 3. Luzier AB, Forrst A, Adelman M, Hawari FI, Schentag JJ, Izzo JL: Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol 1998;82;465–469 4. Rich MW, Beckham V, Wittenberg C, Levev CL, Freedland KE, Carney RM: A multidisciplinary intervention to prevent the readmission of elderly patients with heart failure. N Engl J Med 1995;333:1190–1195 5. Rich MW: Heart failure disease management: A critical review. J Cardiac Failure 1999;5:64–75 6. Cline CMJ, Israelsson BYA, Willenheimer RB, Boms K, Erhardt LR: Cost effective management for heart failure reduces hospitalisation. Heart 1998;80:442–446 7. Edep ME, Shah NB, Tateo IM, Massie BM: Differences between primary care physicians and cardiologists in management of congestive heart failure: Relation to practice guidelines. J Am Coll Cardiol 1997;30:518–526 8. Reis SE, Holubkov R, Edmundowicz D, McNamara DM, Zell KA, Detre KM, Feldman AM: Treatment of patients admitted to the hospital with congestive heart failure: Specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol 1997;30:733–738 9. Packer M, Poole-Wilson PA, Armstrong PW, Cleland JG, Horowitz JD, Massie BM, et al: Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation 1999; 100(23):2312–2318 10. Farnsworth A: Angiotensin converting enzyme inhibitors in heart failure: target dose prescription in elderly patients. Age Aging 1998:27:653–654 11. Squire IB, MacFadyen RJ, Reid JL, Devlin A, Lees KR: Differing early blood pressure and renin-angiotensin system responses to the first dose of angiotensin converting enzyme inhibitors in congestive heart failure. J Cardiovascular Pharmacol 1996:27:657–666 12. Moe G: Carvedilol in the treatment of chronic heart failure. Expert Opin Pharmacother 2001;2(5):831–843 13. Cardiology Preeminence Roundtable: Beyond four walls: Cost-effective management of chronic congestive heart failure. 1994; The Advisory Board Company:159 14. Riegel B, Carlson B, Glaser D, Hoagland P: Which patients with heart failure respond best to multidisciplinary disease management? J Cardiac Failure 2000;6: 290–299