The Stanford Chronic Care Management System

Progress Report

November 1, 2007 Interim Progress Report

The progress report shown below is abstracted from an actual report summarizing progress in an ongoing clinical trial conducted by the Stanford Cardiac Rehabilitation Program. These reports provide clinicians, administrators and others involved in the implementation of the Care Management System with information that helps to document the safety, efficacy and costs of the system and points out systems issues requiring further attention.

Interim Progress Report
10/30/07
Ongoing Clinical Trial Conducted at a Public Hospital

Summary

The ongoing clinical trial of the Care Management System, conducted at a public hospital in San Francisco, CA, has enrolled 47 patients to date. These patients have spent an average of 3 months in the program. The characteristics of the study population are shown in Table 1, which indicates that as many as 19% of the 308 patients undergoing screening met the eligibility criterion of documented coronary artery disease. Most of the 47 enrolled patients had experienced an acute coronary syndrome on one or more occasions prior to enrollment, which was carried out during or soon after hospitalization. The more recent table includes 49 enrolled patients.

Table 1

Status of All Patients

49

15%

Enrolled

9

3%

Status Pending

268

82%

Ineligible

326

100%

 

 

 

 

Ineligible Reasons

19

7%

Cabg

14

5%

Medical

34

13%

Mental

4

1%

SNF

81

30%

Language

37

14%

Other-Misc

28

10%

Other-Pt Refusal

16

6%

Other-no phone

11

4%

Other-homeless

19

7%

Other-drugs

5

2%

Other-unable to reach

268

100%

 

 

 

 

The most common reason for ineligibility for the study was the lack of facility with the English language sufficient to permit reliable communication with the nurse care manager. The 80 patients excluded on this basis were otherwise eligible. Including them in the study would have nearly tripled the enrolled population. Other substantial categories of exclusion included mental disease, substance abuse and logistical problems such as homelessness. Thus, except for language facility, the enrolled population reflects the attributes of the patient population.

Enrolled patients were provided with the toll-free telephone number of the Stanford-based Nurse Care Manager and advised to call during clinic hours to discuss any symptoms of concern. As shown in Table 2, the baseline risk established at enrollment, based on the extent of myocardial ischemia and left ventricular dysfunction, was classified as low in 26 patients (55%), moderate in 13 patients (28%) and high in 8 patients (17%).

Table 2

Summary of Patient-Initiated Telephone Contacts

 

Baseline Risk Status (n)

Phone Contacts

Advice Provided by CMS

 

 

 

Stay Home

Visit Clinic

Call 911

Low

26

8

8

0

0

Moderate

13

5

5

0

0

High

8

4

4

0

0

Total

47

17

17

0

0

A total of 6 of the 47 enrolled patients (13%) initiated one or more telephone contacts. All 6 patients were advised to remain at home, awaiting a followup telephone contact from the nurse the following day or, in the case of patients calling on a Friday, 72 hours later. None of these followup telephone contacts by the nurse care manager disclosed persistent symptoms and none of these patients was hospitalized or went to the ER. How many of these 6 patients would have sought ER care in the absence of the Care Management System cannot be known with certainty. However, avoidance of even half of these potential 6 ER admissions (3 patients) would have equaled the three patients who came to the ER during non-clinic hours.

The reasons for patient-initiated telephone contacts, shown in Table 3, were to report symptoms (64% of contacts) or to discuss administrative problems encountered at SFGH (36% of contacts). Symptoms reflected primarily chest pain (6 calls), and dizziness, nausea, palpitation and back pain (1 call each).

Table 3

Reasons for Patient-Initiated Phone Calls

 

Baseline Risk Status (n)

Report            Symptoms

Administrative Reasons

Total Phone Contacts

Low

26

4

4

8

Moderate

13

3

2

5

High

8

4

0

4

Total

47

11

6

17

Patients were telephoned on a routine basis by the Nurse Care Manager at 1, 2 and 3 months or once, at 4 months, by the Research Assistant as part of the close-out process. These contacts revealed the clinical events shown in Table 4.

Table 4

Clinical Events

Deaths

1

Rehosp ( failure to call CMS)

2

ER/Rehosp (called CMS or weekend)

4

Total

7

There was one death, in a 72-year old woman, due to progression of Lupus Erythematosis, without evident cardiac etiology. Two patients were rehospitalized without first initiating telephone contact with the Stanford-based Nurse Care Manager. Three additional patients underwent ER evaluation or hospitalization for cardiovascular complaints during evenings or weekends. One patient who telephoned the Nurse Care Manager during clinic hours to report symptoms of atypical chest pain was ultimately referred to the ER because the staff in the Urgent Care Clinic declined to evaluate his blood pressure. The patient had been seen in the ER during the previous month for treatment of a hypertensive crisis. Review of ER and hospital records revealed no evidence of myocardial infarction in these 4 patients. None of the 6 patients who initiated telephone contact with the Nurse Care Manager during clinic hours was rehospitalized or evaluated in the ER.

A range of needs emerged during the single baseline telephone contact with the Nurse Care Manager during enrollment or during the three followup telephone contacts initiated by the Nurse Care Manager. As shown in Table 5, these needs fell into two main groups: medication issues and administrative issues. Intervention into these issues by the Nurse Care Manager occurred in 28 of the 47 patients (60%).

Table 5

CMS Baseline and Follow-up (Outbound) Calls

Intervention by the Nurse Care Manager was needed in 28/47 (60%) of patients

Medication Issues (13 pts)
  • Need Rx for Lipitor
  • Need to restart Carvedilol prior to GI series
  • Need initial Rx for ACE (5)
  • Needs refills for Plavix and Lipitor
  • Needs refills for Benazapril and Plavix
  • Misunderstood appropriate dose of Niacin (1500 versus 500 mg)
  • Taking both Plavix and Clopidogrel
  • Taking both Toprol XL and metoprolol
  • Off Plavix 5 days---call if unable to get Rx that day

Need initial Rx for Nitro (12 pts)
Needs refill for outdated Rx (5 pts)

Administrative Issues (2 pts)
  • Billing items related to medications
  • Missed lab appt so MD can determine re-challenge of Zocor
Scheduling of Appts (7 pts)
  • Obtain PCP for pt (1)
  • Obtain PCP appts for pts (2)
  • Obtain cardiology appt for pt (1)
  • Obtain PCP or cardiologist appt following hosp. (1)
  • Obtain Diabetic clinic appt. (1)
  • Obtain lipid clinic appt. (1)

This experience reflects discontinuities in care during the transition from hospital to home. These discontinuities are ubiquitous in all medical care systems. The intervention of the nurse, which occurred in 60% of the patients, contributed substantially to the continuity of care and, in some cases, possibly to the prevention of adverse drug reactions, as in the case of the two patients who were taking both a generic and a brand-name formulation of the same drug.

Clinical implications

Prior to initiation of the present clinical trial, some physicians expressed concern that CMS could compromise patients’ welfare by delaying or withholding needed care or diffusing the responsibility of caring for these patients. These preliminary results do not substantiate these concerns. It appears that CMS permitted medical responses to patient-initiated contacts to be matched appropriately to the needs of patients. Moreover, the Nurse Care Manager coordinated non-urgent needs of patients so as to enhance the continuity of care. Finally, 6 of the 8 patients who experienced cardiovascular symptoms during clinic hours (75%) telephoned the Nurse Care Manager to report their symptoms and all were advised to remain at home; none was advised to visit a same-day clinic or to call 911 for transportation to the ER.