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Patient-Centered Multidisciplinary Approach Provides Clinic Based Treatment Historically Accessed By ED Visit

For patients with heart failure, hospitalizations can be a recurring part of life, affecting the lives of both patients and their caregivers. Driven by symptoms like shortness of breath or swelling of the feet, legs, and ankles, these are costly encounters, and historically, hospitalization is required when oral diuretic regimens fail. This changed when UNC’s Outpatient Diuresis Clinic opened in September 2017.

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Marie and Joe Costanzo with Dr. Mirnela Byku

An Expanding Care Team

In late 2019, Joe Costanzo drove from Fayetteville to see his life-long physician Patricia Rivera, MD, for pulmonary embolism and pneumonia. During that time, he learned about the new UNC Panther Creek Medical Office, which was closer and offered integrated primary and specialty care. All at one location, the 77-year-old Joe saw Claire West, MD (internal medicine), Kunal Patel, MD (pulmonary medicine), and Andrew Doorey, MD (cardiology).  Dr. West put him on an event heart monitor.

Access to Diuretic Therapy

In February 2020, tests showed Joe’s heart rate was dropping. He was experiencing three symptomatic events out of 20 episodes, and in June, he received a pacemaker at UNC Medical Center. Still, his left ventricle was weak, drug treatments weren’t working, and his health was declining. In January 2021, diuresis was recommended at the UNC Outpatient Diuresis Clinic. There, Joe would receive outpatient treatment during five visits, without having to go to the hospital.

“I was more than thrilled to use the clinic because I didn’t want to be admitted, and the nursing staff were very caring and responsive,” said Joe, a retired US Army Medical Service Officer and retired family practice administrator.

His wife Marie said the experience was amazing. “Before, Joe couldn’t eat or sleep. He had lost weight and couldn’t lie down flat. He went to the clinic every other day for 120mg of IV Lasix and improved with every visit. Halfway through the treatment he started eating again.”

Joe also praised Emily Baker, MSN, AGNP-C, lead APP for the clinic who scheduled his first appointment with Mirnela Byku, MD.  As one of the directors of the UNC Outpatient Diuresis Clinic, Byku specializes in advanced heart failure and mechanical circulatory support. She continues to follow Joe, who is now taking troponin and receiving cardiac rehabilitation several times a week.

“When oral medications are not enough, our trained cardiac team evaluates symptoms and designs a treatment plan specific to the patient’s needs at that time,” Byku said.  “In Joe’s case this outpatient approach relieved his symptoms and improved his quality of life, while preventing unnecessary emergency room visits and hospitalizations.”

Access to this outpatient treatment was especially valuable during the height of the pandemic. In Joe Costanzo’s case, making multiple ED visits would have been more difficult with COVID.

The success of the diuresis clinic is attributed to its design, built as a co-management model primarily managed by nurse practitioners and clinic nurses, the patient’s primary cardiologist is always in the loop and aware of status and progress with intervention. This gives patients more immediate access to care. The clinic can facilitate earlier hospital discharges by addressing the ongoing diuresis needs of patients in the outpatient setting, and it has enabled UNC to reduce some inpatient hospital stays by as much as two to three days. From a patient perspective, this results in helping heart failure symptoms become much better controlled in an ambulatory setting.

The UNC Outpatient Diuresis Clinic started as a Value-Care Action Group project in the Department of Medicine. Learn more.