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Background: beta-blockers (BB) in the treatment of heart failure (HF) are frequently underprescribed and underdosed, perhaps because of recommendations for office visits at each dose change. In previous work, we demonstrated the feasibility of remote telephonically assisted BB titration and found favorable effects on morbidity, time to target dose, and low withdrawal rates. In the current expanded evaluation, we reasoned that a structured remote telephonic titration protocol would achieve outcomes comparable to US Carvedilol Trials in regard to optimal dose, titration time, and morbidity., Methods: Seventy HF patients were initiated on BB therapy (carvedilol). Before therapy, patients were instructed on BB side effects, pulse taking, and weight monitoring. Patients reported weights, vital signs, and symptoms 3 times per week by phone. Advanced practice nurses counseled, educated, and reminded patients to increase their dose every 2 weeks until target doses were reached., Results: A total of 96% reached a therapeutic dose (6.25 mg twice daily). Moreover, 71% of patients reached target doses of 25 mg twice weekly in approximately 8 weeks. No HF hospitalizations occurred during remote titration., Conclusions: The use of advanced practice nurses, titration protocols, and telemanagement technologies may improve the number of HF patients initiated and treated with appropriate doses of BB.

Congestive heart failure (CHF) is the most common reason for a hospital admission in the Medicare age group and is nearly double the rate of pneumonia, the next highest volume diagnosis. The economic burden of this debilitating, chronic disease demands a mechanism to improve quality of care while preventing unnecessary hospitalizations. Beginning in 1995, Evanston Northwestern Healthcare (ENH) created a disease management program involving a multidisciplinary team designed to decrease length of stay (national average = 6.2 days; ENH = 4 days), reduce costs, prevent readmissions (national 30-day readmission rate = 23%; ENH CHF Program = 2.3%), and improve compliance with the treatment regimen. Compliance monitoring through an automated telemanagement program reinforces education, identifies early warning signs and reduces the likelihood of hospitalization. After 18 months, telemanagement participants' compliance rate averages 89.5%. CHF hospitalization rates are 0.6/patient/year compared with the national benchmark of 1.7/patient/year. A disease management program consists of inpatient consultation, education, outpatient CHF clinic, cardiac home care, and compliance monitoring. Throughout this continuum, education must be communicated consistently by all team members. A CHF Assessment Guide assists the multidisciplinary team to thoroughly complete all education and address unique solutions to patients' needs.

One hundred eighty-four consecutive patients who underwent heart transplantation from January 1987 to December 1994 have been reviewed. Patients who were 60 years of age or older at the time of transplant (Group A, n = 50) showed improved overall survival when compared with younger patients (Group B, n = 134), though this was not statistically significant. Survivals in groups A and B were 94% and 90%, respectively, at 1 year; 86% and 80% at 5 years; and 86% and 78% at 8 years. Overall survival of older patients in the U.S. and worldwide is inferior when compared with younger patients. More thorough pretransplant evaluation of the older patient and improved compliance post-transplantation may be factors in the good results obtained in this group at our own center.