
DATE: Sunday, July 27, 1997                 TAG: 9707270093

SECTION: LOCAL                   PAGE: B1   EDITION: FINAL 

SOURCE: BY DEBRA GORDON, STAFF WRITER 

                                            LENGTH:  164 lines

CLINIC HELPS PATIENTS MANAGE THEIR ILLNESS

Peggy Rudisill is no stranger to heart problems. The 72-year-old Virginia Beach woman has had several heart attacks and bypass surgeries in the past 30 years.

But after each hospitalization, she returned to an active lifestyle, gardening, working, caring for her husband and four kids.

That all changed in May.

What she thought was simple shortness of breath turned out to be one of the most common chronic medical conditions in elderly people - congestive heart failure.

Put simply, her heart is wearing out.

An estimated 4.8 million Americans suffer from heart failure, and nearly a million of them wind up in the hospital each year. In South Hampton Roads, heart failure is the most common reason people 65 and older are hospitalized.

Short of a transplant - available to a minuscule number of patients - there is no cure.

So Peggy Rudisill must learn to live with her condition. To take several different medications each day. To rest.

It's a hard education for this independent, active woman. But she has help.

The region's first outpatient heart-failure clinic, opened by Sentara Health System this month, is giving her what most heart-failure patients don't get: immediate access to medical care, extensive education and nearly daily oversight of her health.

The clinic, based at NDC medical center near Sentara Leigh Hospital, is modeled after similar programs around the country that, studies show, can significantly reduce hospitalization, lengthen life span and improve overall quality of life for heart-failure patients.

By the end of the summer, Sentara plans to open an inpatient heart failure clinic at Sentara Norfolk General Hospital.

The clinics represent a new philosophy in medicine today: disease management. Instead of focusing on the patient only during an acute medical episode, disease management emphasizes education, prevention and partnership with the patient to reduce complications and improve quality of life.

Says Rudisill, ``It helps you get over the hump and learn how to deal with your life.''

For Norfolk cardiologist John Herre, founder of the clinics, working for years in Sentara's heart transplant program was an eye-opener. The longer he spent with the transplant program, the more obvious it became to him that ``we did this backwards.''

Sentara performs about 25 heart transplants a year, he said, but he estimates the region has close to 20,000 heart-failure patients.

``The other 19,975 patients need to be taken care of,'' he says.

Heart failure occurs when the heart loses its ability to pump enough blood through the body. It usually develops slowly, over years, and has a variety of causes, including high blood pressure, diabetes and coronary disease.

In the past decade, a specific treatment regimen, composed primarily of multiple medications, salt-free diets and lifestyle changes, has emerged. But, says Herre, ``if you look out in the community, those treatments are not being applied universally or appropriately.''

It's not because community physicians - typically family practitioners and internists - don't know about them, Herre said, but because treating heart failure is a ``time consuming and sometimes tedious process.''

Medications must be continually adjusted depending on patients' symptoms. Patients need counseling on diet and lifestyle, as well as regular management of their weight and blood pressure.

It all takes more time than most doctors have.

So Sentara's program hands much of the treatment responsibility to nurse practitioner Lauren McGowan, who does have the time.

McGowan, who has the authority to write prescriptions, consults with cardiologists as necessary. But usually, she is the one examining the patient, developing the treatment plan and ensuring that it is followed.

For instance, Rudisill's first visit lasted more than an hour, and she's been seen several times since then. McGowan also calls several times a week to check Rudisill's weight and blood pressure, looking for any early signs of problems.

``With a doctor's appointment, you're always so rushed, there's nothing in-depth,'' Rudisill said of her visits with McGowan.

The Sentara program has three goals:

Ensure that the medical regimen is consistent with state-of-the-art clinical standards.

Increase patient compliance with diet and drugs. ``If we don't tell them what the drugs are designed to do, people can't be empowered to be responsible for taking them,'' McGowan says.

For instance, patients may stop taking a diuretic because it makes them go to the bathroom too often, not understanding that frequent urination is a desired effect.

Patients also consult with a nutritionist because ``one salty meal'' could put them back in the hospital, McGowan says.

The advice has already helped Rudisill. When she told McGowan about all the water she was drinking, the nurse practitioner warned her to stop. Too much fluid, McGowan said, puts more strain on the heart.

Monitor patients more closely after they leave the hospital.

Often, McGowan says, heart failure patients don't see a doctor for weeks after being discharged from the hospital. With the clinic, they'll be seen within a couple of days.

Patients also can be seen immediately at the five-day-a-week clinic, as opposed to the weeks they may have to wait for an appointment with a private physician.

``Typically, when their condition changes, the patient may call and get an appointment for three weeks from Thursday; but two weeks from Thursday they wind up in the emergency room and are admitted to the hospital,'' Herre says.

Several studies show that such close monitoring significantly benefits heart failure patients.

At Evanston Hospital outside Chicago, cardiologist John Williams has been running a similar heart-failure clinic for two years.

During that time, the clinic reduced the amount of time its patients spent in the hospital from 6.2 to four days; decreased re-admission rates within 30 days from 19 percent to 2.3 percent; and reported an overall admission rate of 0.6 admissions per patient per year, compared with the national average of 1.7 admissions per year.

Like the Evanston clinic, the Sentara program will keep the primary-care physician involved, educating community doctors about the best way to treat heart failure and eventually sending patients back to their regular doctor for continued treatment. In fact, patients can only enter the clinic with a referral from their primary doctor.

Norfolk internist Charles Kessler, who helped design the clinic, had his doubts at first.

``To be honest, like a lot of office-based physicians, I viewed it as an intrusion of our turf.'' The scientific data on the results of similar programs changed his mind.

``Most internists are very well-meaning, but they just don't have the time to go through this stuff,'' he said. And despite continuing education efforts, changes in the treatment of heart failure ``happen so fast that it's hard to keep up.'' ILLUSTRATION: Color photo

IAN MARTIN/The Virginian-Pilot

Dr. John Herre and nurse practitioner Lauren McGowan review a

patient's records at NDC medical center. A new program helps

patients become partners in their health care.

Peggy Rudisill

Graphics

FACT

AN ESTIMATED 4.8 MILLION AMERICANS HAVE HEART FAILURE, OFTEN A

SYMPTOM OF AN UNDERLYING PROBLEM. DETAILS, B4.

HEART FAILURE

What is heart failure?

Heart failure occurs when the heart loses its ability to pump