Strategies to reduce hospitalization in the management of heart failure.

Progressive and debilitating heart failure (HF) affects almost 5 million, mostly elderly, individuals in the United States. As the elderly population grows in coming decades, the prevalence of HF is expected to increase substantially. In addition to its human toll, HF yields a substantial economic burden, with direct and indirect cost estimates ranging from $27 to $56 billion annually. It is associated with an unacceptably high rehospitalization rate--50% within 6 months--which not only drives burgeoning costs but also provides a signal that current management approaches to HF are less than optimal. Evidence-based treatment approaches, which include the use of beta-blockers, angiotensin-converting enzyme inhibitors, spironolactone, and nesiritide, may offer opportunities for reducing mortality and rehospitalization rates in HF. Yet, because of inadequate discharge guidance and follow-up, many patients with HF are caught in a "revolving door" process that ultimately culminates in exacerbation and rehospitalization. Hospital-based disease management programs have consistently been shown to optimize care and reduce rehospitalization rates in patients with HF. The Hackensack University Medical Center HF program is discussed as an example of a successful HF program. This program represents a multidisciplinary, multifaceted approach to care that emphasizes case management. The core goal of this program is to provide a continuum of care that extends through hospitalization and into the patients' home environment.