Symptomatic improvement and reduced hospitalization for patients attending a cardiomyopathy clinic

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Simple Clinical Criteria to Determine the Prognosis of Heart Failure

Objective: To determine whether easily obtained clinical parameters serve as predictors of survival in patients with congestive heart failure. Several scoring systems to predict heart failure survival have been developed; however, many of these deal principally with transplant recipients or do not account for a patient’s response to therapy.

Methods: A total of 680 patients with an ejection fraction of less than 40% were included in the analysis. Baseline assessments were performed and treatment regimens were identified; patients were then followed for up to 5 years. Univariate and multivariate Cox regression models were used to determine clinically important predictors of survival. Kaplan-Meier survival functions for patients with and without the prognostic variable were constructed and mortality was calculated at 1 year and 5 years.

Results: Ejection fraction improvement at 6 months, diabetes mellitus, age, serum creatinine, and blood urea nitrogen (BUN) were significant predictors for survival in the univariate model. Ejection fraction improvement, age, and BUN were significant predictors in the multivariate model. These findings were used to construct a model for predicting patient mortality. Improved ejection fraction (>15 ejection fraction units) gave a 1-year mortality of 2% and a 5-year mortality of 11%. Mortality rates according to patient age and BUN levels were also calculated.

Conclusion: Ejection fraction improvement was the most important predictor for survival in patients with systolic dysfunction; monitoring ejection fraction changes through repeat echocardiograms has important prognostic value. In patients without ejection fraction improvement, age and renal function are important survival determinants.

Team-Based Care for Outpatients with Heart Failure

Management of heart failure requires a multidisciplinary team-based approach that includes coordination of numerous team members to ensure guideline-directed optimization of medical therapy, frequent and regular assessment of volume status, frequent education, use of cardiac rehabilitation, continued assessment for the use of advanced therapies, and advance care planning. All of these are important aspects of the management of this complex condition.

Impact of a dedicated cancer center surveillance program on guideline adherence for patients with stage II and III colorectal cancer

Surveillance after curative treatment for stage II/III colorectal cancer identifies surgically resectable disease and improves survival. We evaluated adherence to guidelines and outcomes for 408 patients enrolled in an innovative follow-up program at our cancer center. We found that a dedicated intensive surveillance program can impact adherence to guidelines for patients with colorectal cancer.

BACKGROUND

Our aims were to evaluate adherence to guidelines on colorectal cancer surveillance and outcomes for patients enrolled in an innovative follow-up program at our cancer center.

PATIENTS AND METHODS

A retrospective chart review was conducted at the Cross Cancer Institute in Edmonton, Canada. Patients with stage II/III colorectal cancer who completed treatment and who entered into the program from December 1, 2007, to December 31, 2009, were identified. The minimum standard of care follow-up was defined as (1) carcinoembryonic antigen (CEA) testing every 120 days for 3 years; (2) computed tomography of chest, abdomen, and pelvis at 10 to 14 months and 22 to 26 months after surgery; and (3) colonoscopy within 14 months of surgery.

RESULTS

A total of 408 patients met inclusion criteria. Two hundred (49.0%) patients were adherent to all 3 components of surveillance. Among all patients, 57 (14.0%) were nonadherent to computed tomography imaging, 135 (33.1%) were nonadherent to colonoscopy, and 96 (23.5%) were nonadherent to CEA testing. Determinants of nonadherence are described. In total, 192 (47.2%) patients had an abnormal surveillance investigation that led to 307 follow-up events. After a median of 1.6 years, 69 (16.9%) patients had documented tumor recurrence. Sixty-one (88.4%) of these 69 patients had recurrence diagnosed via surveillance, and 31 (44.9%) patients were considered potentially resectable.

CONCLUSIONS

Our study demonstrated an improvement in CEA testing since the program began; however, adherence rates for all components are not yet optimal. Alterations to surveillance program management are outlined. Further investigation will determine whether intense follow-up improves patient survival locally.

Flexible diuretic titration in chronic heart failure: where is the evidence?

BACKGROUND

Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload-related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients.

METHODS AND RESULTS

A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction.

CONCLUSIONS

To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials.

Epidemiologic analysis of racial/ethnic disparities: some fundamental issues and a cautionary example

Racial/ethnic health disparities are a primary focus of epidemiologic research, encompassing both sociological hypotheses about differential treatment as well as biomedical hypotheses about distinctive etiologic processes that might underlie observed disparities. These two main currents in disparities research are often pitted against one another as opposing paradigms. Despite contentious debate about the balance between these hypotheses in the etiology of existing disparities, one consideration that has been largely ignored is that there are important distinctions in the statistical justifications for these two types of inferences. In this article, I review the foundations of causal inference in etiologic epidemiology as applied to studies of racial/ethnic health disparities. I describe normative applications of quantitative techniques for causal inference as they are practiced in research on discrimination in health care and also for research on innate predisposition. I then show why the latter is an injudicious application of this statistical methodology, and illustrate this point with the example of an influential study in the biomedical literature that purported to demonstrate a lesser response to angiotensin-converting enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction.

Teleconsultation for cardiac patients: a comparison between nurses and physicians: the SHL experience in Israel

The absence of randomized studies on sufficiently large patient cohorts precludes the drawing of any firm conclusions on the comparative performance between nurses and physicians in transtelephonic triage and consultations and in diagnostic and management decision-making. We conducted such a comparative study at the SHL telemedicine facility. This facility also provides face-to-face medical management for its subscribers by means of mobile intensive care units (MICUs) staffed by physicians. The outcome of calls that came between 7:00 AM and 11:00 PM throughout the study year and that were handled at random by specially trained physicians (n = 15) or nurses (n = 35) were analyzed. Of 48,707 subscribers who fulfilled the study entry criteria 25,106 used the service at least once, producing 88,103 calls (81,817 handled by nurses and 6,286 by physicians). Teleconsultations were sufficient for most of the cases (80.13%). There were no significant differences between the performance of nurses and physicians regarding demographics (age, gender) and medical diagnoses of the applicants. The nurses' performance and decisions were comparable to those of physicians with respect to teleconsultations, medically justified dispatches of an MICU, repeated calls to the center and mortality during the week after the index call, although the duration of the physicians' telephone consultations was longer. Delegation of equal authority to nurses and physicians in triage and consultation in telecardiology results in equivalent and highly satisfactory medical care in a system in which subscribers receive service orchestrated from a single center of telecommunications.

Executive summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline

Heart failure (HF) is a syndrome characterized by high mortality, frequent hospitalization, reduced quality of life, and a complex therapeutic regimen. Knowledge about HF is accumulating so rapidly that individual clinicians may be unable to readily and adequately synthesize new information into effective strategies of care for patients with this syndrome. Trial data, though valuable, often do not give direction for individual patient management. These characteristics make HF an ideal candidate for practice guidelines. The 2006 Heart Failure Society of America comprehensive practice guideline addresses the full range of evaluation, care, and management of patients with HF.

Treating the right patient at the right time: access to specialist consultation and non-invasive testing

The Council of the Canadian Cardiovascular Society commissioned working groups to examine issues of access to, and wait times for, various aspects of cardiovascular care. The present article summarizes the deliberations on targets for medically acceptable wait times for access to cardiovascular specialist evaluation and on the performance of noninvasive testing needed to complete this evaluation. Three categories of referral indications were identified: those requiring hospitalization due to substantial ongoing risk of mortality and morbidity; those requiring an expedited early review in an ambulatory setting; and, finally, a larger category in which delays of two to six weeks can be justified. The proposed wait time targets will provide guidance on the timeliness of care to busy clinicians charged with the care of patients with cardiovascular disease, help policy makers appreciate the clinical challenges in providing access to high quality care, and highlight the critical need for a thoughtful review of cardiology human resource requirements. Wait time implementation suggestions are also included, such as the innovative use of disease management and special need clinics. The times proposed assume that available clinical practice guidelines are followed for clinical coronary syndrome management and for treatment of associated conditions such as hypertension, diabetes, renal disease, smoking cessation and lipid disorders. Although media attention tends to focus on wait times for higher profile surgical procedures and high technology imaging, it is likely that patients face the greatest wait-related risk at the earlier phases of care, before the disease has been adequately characterized.

Heart failure disease management: implementation and outcomes

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]

Background

Self-management programs for patients with heart failure can reduce hospitalizations and mortality. However, no programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care.

Methods

We performed a 12-month randomized controlled trial. From November 2001 to April 2003, we enrolled participants aged 30–80, who had heart failure and took furosemide. Intervention patients received education on self-care emphasizing daily weight measurement, diuretic dose self-adjustment, and symptom recognition and response. Picture-based educational materials, a digital scale, and scheduled telephone follow-up were provided to reinforce adherence. Control patients received a generic heart failure brochure and usual care. Primary outcomes were combined hospitalization or death, and heart failure-related quality of life.

Results

123 patients (64 control, 59 intervention) participated; 41% had inadequate literacy. Patients in the intervention group had a lower rate of hospitalization or death (crude incidence rate ratio (IRR) = 0.69; CI 0.4, 1.2; adjusted IRR = 0.53; CI 0.32, 0.89). This difference was larger for patients with low literacy (IRR = 0.39; CI 0.16, 0.91) than for higher literacy (IRR = 0.56; CI 0.3, 1.04), but the interaction was not statistically significant. At 12 months, more patients in the intervention group reported monitoring weights daily (79% vs. 29%, p < 0.0001). After adjusting for baseline demographic and treatment differences, we found no difference in heart failure-related quality of life at 12 months (difference = -2; CI -5, +9).

Conclusion

A primary care-based heart failure self-management program designed for patients with low literacy reduces the risk of hospitalizations or death.

Increasing self-management skills in heart failure patients: a pilot study

Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment-only pilot study examined whether a year-long group-based self-management intervention is feasible and improves self-management skills in patients with mild-to-moderate heart failure (ejection fraction < or =40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty-six (84%) completed the year-long self-management program. Compared with baseline, the intervention was associated with an increase in overall self-efficacy in practicing self-management skills (p<0.001) and in four of five specific self-management skills. Patients and their group leaders also reported an increase in actual use of self-management skills (p<0.001) and in several psychosocial outcomes. The success of this pilot study suggests the need for a randomized clinical trial to test the efficacy of group-based self-management training on medical outcomes.

They're watching you! Performance measurement, staffing, and facilities requirements

The aim of this article is to convey the importance of attention to performance measures, staffing, and facilities requirements when planning a heart failure management program in a short-stay area. Written performance measures that reflect care excellence and act as standards of care will ensure consistency in care delivery and lead to improved patient outcomes. Staffing can be carried out in many ways (physician led-program, physician-advanced practice nurse-led program, nurse-mediated care program, or multidisciplinary providers of care); however, a clinical leader willing to champion the program should be sought to promote performance achievement, negotiate for facilities resources, and guide staff through education and example. Facilities requirements include tools (forms that embed evidence-based practice to augment standards of care such as care algorithms, admission and discharge forms, and patient education materials) and devices that aide in patient assessment, diagnosis, management, and education. Minimal device resources needed to meet performance measures are access to echocardiography and B-type natriuretic peptide serum testing.

Telecardiology for patients with chronic heart failure: the 'SHL' experience in Israel

BACKGROUND

Patients with chronic heart failure characteristically have multiple hospital admissions for symptom control, deleteriously affecting their quality of life and imposing a burden on national healthcare costs. We assessed the effect of a novel transtelephonic monitoring and follow-up program on the admission rate and length of hospital stay as well as changes in their subjectively rated quality of life of patients with chronic heart failure.

METHODS

This prospective 1-year study was conducted on compliant subscribers to 'SHL', a telecardiological service with >60,000 subscribers, who were admitted > or = 2 times during the previous year for recurrent pulmonary edema or deterioration in heart failure. Their heart rate, blood pressure and body weight measurements were now automatically transmitted daily to 'SHL"s data bank and added to stored and updated medical records. A questionnaire survey acquired information on their quality of life.

RESULTS

The study cohort included 118 patients, mean age 75 years (range 49-89 years), 65% males, a II-IV class functional capacity and a 25% (range 10-39%) mean ejection fraction. There was a 66% reduction in the total hospitalization days (from 1623 in the year preceding study entry to 558 during the study period, p<0.0001). Although only 38/118 patients were hospitalized, most participants reported a significant subjective improvement in their quality of life.

CONCLUSIONS

Data are provided to demonstrate that a transtelephonic system allowing primary care at the patient's home can significantly reduce hospitalization rate and length of stay and significantly enhance the quality of life of patients with chronic heart failure.

The effect of a tailored message intervention on heart failure readmission rates, quality of life, and benefit and barrier beliefs in persons with heart failure

OBJECTIVE

The purpose of this study was to determine the effect of a tailored message intervention on heart failure readmission rates, quality of life, and health beliefs in persons with heart failure (HF).

DESIGN

This randomized control trial provided a tailored message intervention during hospitalization and 1 week and 1 month after discharge.Theoretic framework The organizing framework was the Health Belief Model.

SUBJECTS

Seventy persons with a primary diagnosis of chronic HF were included in the study.

RESULTS

HF readmission rates and quality of life did not significantly differ between the treatment and control groups. Health beliefs, except for benefits of medications, significantly changed from baseline in the treatment group in directions posited by the Health Belief Model.

CONCLUSIONS

A tailored message intervention changed the beliefs of the person with HF in regard to the benefits and barriers of taking medications, following a sodium-restricted diet, and self-monitoring for signs of fluid overload. Future research is needed to explore the effect of health belief changes on actual self-care behaviors.

Quality of life when living with heart failure

Heart failure is a chronic condition and consumes a huge portion of health care expenditures. Increased life expectancy combined with increasingly effective treatments for coronary artery disease and hypertension will increase the number of patients with heart failure. Efforts are aimed at helping patients better care for themselves. Nurses can design interventions that focus on education and self-management of complex treatments, spiritual support, and clinical relationships based on trust. It is essential that health care providers direct and evaluate interventions that promote improved QOL for patients and families. Nurses also need to continue to study the effects of education and self-care interventions so that care for heart failure patients is evidence based.

Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure

Hispanics are a growing ethnic minority in the United States and one at significant risk for heart failure. Health-related quality of life (HRQL) is poor in individuals with heart failure, especially during and immediately following hospitalization. No prior research into the HRQL of Hispanics with heart failure was located. A sample of 80 individuals with heart failure, evenly divided by primary language and matched on functional status using the New York Heart Association classification system and age, was studied for 6 months following hospital discharge. Data on HRQL were collected using Spanish and English versions of the Minnesota Living with Heart Failure Questionnaire. Scores improved over time in both groups but significantly more so in the Hispanics when compared to the non-Hispanics. Group differences in HRQL could not be explained by demographics, clinical characteristics, treatment received, perceived support, or instrument response characteristics. Further exploration of this naturally occurring phenomenon may provide insight into how HRQL can be improved in the general heart failure population.

BNP as discharge criteria for heart failure

BACKGROUND

Heart failure (HF) is a significant clinical and economic burden in the industrialized world. Advances in pharmaceutical compounds and various medical device technologies along with the use of sophisticated HF clinics have enhanced HF treatment and improved morbidity, mortality, and quality of life. However, hospital readmission rates remain stubbornly high. B-type natriuretic peptide (BNP) levels provide valuable information about a patient's chance of readmission within 30 days of discharge, making BNP a potentially useful tool for making discharge decisions and possibly reducing readmissions.

METHODS

This review examines the strength and level of evidence in key areas to determine if BNP levels could be used as a guide for discharge of HF patients. Although most of the literature describes nonrandomized studies, there is general agreement that BNP levels can be measured accurately and precisely, that BNP levels reflect varying physiologic states, and that they predict outcomes.

CONCLUSIONS

More studies are needed to determine extent of biologic variability. The further use of BNP as a potential discharge marker is promising but awaits additional randomized study that reflects use in a broad-based population.

Differences in psychosocial and behavioral profiles between heart failure patients admitted to cardiology and geriatric wards

BACKGROUND

Heart failure represents a growing epidemic, primarily in the elderly. Development and implementation of management programs designed for use in daily clinical practice remains a major challenge.

AIMS

This study aimed at profiling a hospitalized heart failure population in view of medical, behavioral, educational, psychosocial and health resources utilization parameters stratified by admission to cardiology and geriatric wards.

METHODS AND RESULTS

Using a descriptive comparative design, 109 European heart failure patients admitted to cardiology (42%) and geriatric wards (58%) were included. Significant differences (all P<0.0001) were identified between the two groups. Patients admitted to cardiology had a mean age of 68.5, 33% were women, and the mean ejection fraction was 38%. Patients admitted to geriatrics had a mean age of 85, 68% were women, and the mean ejection fraction was 56%. Sixty-six percent were admitted for cardiac reasons. Medical, educational, behavioral, psychosocial and health resources utilization data were retrieved from medical files as well as by patient and family interviews. Results showed significant differences between groups. Patients admitted to geriatric wards received significantly less ACE inhibition and beta-blockers. Moreover, these patients were significantly less knowledgeable, showed poorer self-management, poorer hearing, more cognitive impairment, a higher degree of depressive symptomatology, more problems with ADL and IADL, and used significantly more home health care services compared to patients admitted to cardiology wards.

CONCLUSION

The characteristics of the heart failure population at large are quite different from those of populations included in large-scale therapeutic trials. Findings from this study provide options for tailored management strategies for both profiled subgroups.

Adherence to angiotensin-converting enzyme inhibitor therapy for heart failure

This study examined adherence to angiotensin-converting enzyme inhibitor therapy among 171 heart failure clinic patients. Adherence was monitored over a 3-month period with an electronic event monitor housed in a medication bottle cap, which recorded the date and time the cap was opened and closed. The average percentage of days that the prescribed number of doses (regimen adherence) was taken over the observation period was 84%. Seventy-one percent of patients showed 85%-100% adherence with their daily regimen; 19% exhibited less than 70% adherence. The overall high rates of adherence to angiotensin-converting enzyme inhibitor therapy observed among heart failure clinic patients is consistent with research that shows improved outcomes for patients managed in heart failure clinics. Electronic medication monitoring can be useful in identifying a substantial fraction of patients who are poorly adherent so that interventions to improve adherence can be targeted toward them. Additional research is needed to develop and test adherence-enhancing interventions.

Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care

Ambulatory care by physicians especially devoted to the management of heart failure (HF) has been reported to have beneficial effects. The aim of this work was to assess the effect of outpatient management at a HF clinic, as compared with care by the usual assistant physician, on prognosis of HF patients. In this non-randomised study, we prospectively followed 339 patients after a hospitalisation index for HF, in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting: either a specific outpatient clinic (n=157) or the usual assistant physician (n=182). The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term. The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic (adjusted odds ratio 0.23; 95% CI 0.12-0.46). Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days (adjusted hazard ratio 0.52; 95% CI 0.34-0.81). The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients.

Underutilisation of ACE inhibitors in patients with congestive heart failure

Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.

Improved outcomes from a comprehensive management system for heart failure

AIMS

Congestive heart failure (CHF) is associated with a high readmission rate after diagnosis. We assessed the ability of a comprehensive management program (CMP) for CHF to reduce readmissions with secondary endpoints of improving quality of life, exercise capacity and targeted drug doses.

METHODS AND RESULTS

Patients (pts) with: New York Heart Association Class (NYHA) III or IV CHF; left ventricular ejection fraction <40%; and stable outpatient therapy were assigned to a CMP of cardiology assessment intensive education and referral to a tailored exercise program. Forty-two pts (35 M, 7 F, mean age 54 years, S.D. 12 years) were enrolled. Two pts were transplanted, two died during follow-up and two were lost to follow-up. Hospital admissions were reduced by 87.2%, (mean 1.05, S.D. 0.98, admissions per pt to mean 0.08, S.D. 0.28, admissions per pt at 6-month follow-up; P<0.0001). ACE-inhibitor dose increased by 42% (P<0.0008) and beta-blocker dose increased by 61% (P<0.0001). NYHA Class, 6-min walk and quality of life scores all improved significantly (P<0.0001).

CONCLUSION

A CMP improves QOL and exercise capacity as well as substantially reducing hospital admissions in CHF pts. This study validates the benefit of intensive outpatient care of CHF.

Predictors of self-care in persons with heart failure

OBJECTIVE

The objective of this study was to test a model of individual patient characteristics, covering symptom severity, comorbidity, social support, education, age, socioeconomic status, and gender, derived from Connelly's Model of Self-Care in Chronic Illness as predictors of self-care in heart failure.

DESIGN

This was a nonexperimental correlational study.

SETTING

The study took place in 6 hospitals in southern California.

PATIENTS

The study included 209 patients diagnosed with heart failure by their physicians. The typical study participant was age 73 years, Class III, married, grade-school educated, and earning an income of less than $20,000 per year. The genders were almost equally represented.

OUTCOME MEASURE

Self-care was measured by the Evaluating the Change subscale of the Self-Management of Heart Failure Instrument.

RESULTS

The model of 7 variables, analyzed by using multiple regression analysis, explained 10.3% of the variance in self-care. Only 2 of the variables were significant predictors of self-care: education (P =.009) and symptom severity (P =.046); 89.7% of the variance remained unexplained.

CONCLUSIONS

Persons with higher education and those who are symptomatic may be more likely to engage in self-care than those who are poorly educated or asymptomatic. Further research is needed to confirm these Results and identify other predictors of self-care.

Implementation strategies to manage heart failure outcomes

In the United States, chronic systolic heart failure causes a great economic burden. Pharmacologic and nonpharmacologic therapies must be tailored to the pathophysiologic cause with the ultimate goal of promoting regression or preventing progression of left ventricular remodeling. When this goal is met, symptoms are reduced, quality of life is improved, and morbidity and mortality are decreased. Specific objectives in a nurse-managed heart failure clinic are to improve exercise tolerance, decrease symptoms, and prevent or reduce emergency department visits and acute hospital admissions. Before a nurse-managed outpatient program for heart failure care is implemented, the team must address specific management issues and controversies in heart failure. Actions must focus on chronic disease management rather than just episodic care. Written protocols or algorithms provide guidance in pharmacologic and nonpharmacologic care and ensure that consensus guidelines that offer the best hope of reaching goals are followed.

Nonpharmacologic treatment of heart failure in the elderly

Nonpharmacologic therapy is an integral part of the management of elderly patients with heart failure. Reinforcement of dietary sodium restriction and other nutritional concerns are critical features of therapy. Quality standards for the management of patients with heart failure are being developed, and the implementation of these standards is a goal of clinicians. A multidisciplinary approach to elderly patients with heart failure is beneficial.

Effect of psychosocial factors on physiologic outcomes in patients with heart failure

Despite advances in its treatment, the epidemic of heart failure continues unabated in the United States and is escalating worldwide. The extremely high morbidity and mortality seen with heart failure demand creative approaches to this problem. Attention to nontraditional risk factors for rehospitalization and mortality, in addition to traditional medical risk factors, may yield improved outcomes. Psychosocial factors, particularly lack of social support and depression, are associated with poorer outcomes in cardiac patients. However, few studies have been conducted among patients with heart failure. In this article, the evidence relating poor quality of life, social isolation and lack of emotional support, anxiety and depression, and morbidity and mortality in patients with heart failure is discussed. Also explored are possible mechanisms for the association between psychosocial variables and physical outcomes and related clinical and research implications.

Impact of concurrent amiodarone treatment on the tolerability and efficacy of carvedilol in patients with chronic heart failure

OBJECTIVE

To assess the safety and efficacy of carvedilol when administered to heart failure patients already receiving amiodarone.

DESIGN

Retrospective analysis of the clinical outcome of 230 patients treated with carvedilol for chronic heart failure, stratified according to whether they were already receiving amiodarone (amiodarone group, 80 patients) or not (non-amiodarone group, 130 patients) at baseline.

SETTING

Heart failure clinic at a university affiliated public teaching hospital.

MAIN OUTCOME MEASURES

Incidence of adverse events; changes in functional status and echocardiographic dimensions at three months.

RESULTS

Adverse reactions to carvedilol occurred in 33 (41%) of the amiodarone group and 43 (29%) of the non-amiodarone group (p = 0.049). Carvedilol was discontinued in 21 (26%) of the amiodarone group and 37 (25%) of the non-amiodarone group (NS). The clinical outcome at three months did not differ significantly between the two groups; 31 (39%) of the amiodarone group improved their New York Heart Association status, 28 (35%) were unchanged, and 21 (26%) deteriorated compared with 67 (45%), 51 (34%), and 32 (21%), respectively, for the non-amiodarone group (NS). Both groups had highly significant decreases in heart rate and left ventricular end systolic dimension, and a significant increase in left ventricular ejection fraction after three months of carvedilol treatment, with no significant differences between the groups.

CONCLUSIONS

The beneficial effects of carvedilol on left ventricular remodelling, systolic function, and symptomatic status are not affected by concurrent treatment with amiodarone. Adverse reactions necessitating cessation of carvedilol are no more frequent in patients receiving amiodarone.

A review of quality-of-life evaluations in patients with congestive heart failure

The factors that may lead to an impaired quality of life in congestive heart failure (CHF) are physical symptoms, psychological problems, treatment adverse effects and social limitation. There are now several general and disease-specific quality-of-life (QOL) questionnaires which have been used to measure treatment effects in clinical trials in CHF. We review the design and validation of both generic and disease-specific QOL questionnaires which have been used in clinical trials in CHF. We then evaluate the performance of these QOL questionnaires in recent clinical trials in CHF in relation to other outcome measures. We conclude that there are important differences between these QOL questionnaires. The choice of a QOL questionnaire is relevant to both patient compliance and clinical outcomes in CHF trials. The 36-Item Short Form (SF-36) Health Survey, a generic QOL questionnaire, and the Minnesota Living with Heart Failure questionnaire, a disease-specific QOL questionnaire, have returned informative data in most trials in which they have been used. QOL questionnaires require further development if this important outcome is to be reliably measured in future clinical trials in CHF.

Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure

BACKGROUND

Heart failure (HF) is responsible for considerable mortality morbidity rates and resource utilization. Recently, several studies have reported improved outcomes when patients are managed by special HF clinics, but it is uncertain whether this improvement reflects differences in physician practices or other aspects of the operation of these clinics.

OBJECTIVES

This study was designed to identify differences in HF management practices between general cardiologists and cardiologists specializing in the treatment of patients with HF.

METHODS

A survey examining diagnostic and treatment practices in patients with HF was sent to a sample of cardiologists derived from the American Medical Association Masterfile and to HF specialists who were members of the Society of Transplant Cardiologists or principal investigators in HF trials. Responses were examined in relation to guidelines issued by the Agency for Health care Policy and Research released 9 months previously.

RESULTS

In general both groups practice in conformity with published guidelines. However, there were important differences between the practice patterns of general cardiologists and HF specialists. For instance, in patients being evaluated for the first time, cardiologists reported using a chest radiograph to assist in the diagnosis more than did HF specialists (47% vs 12%), whereas HF specialists were more likely to use an echocardiogram (73% vs 48%). Both groups were likely to evaluate their patients for ischemia and possible revascularization, even in patients not having angina. However, HF specialists tended to use coronary angiography as the initial diagnostic test, whereas cardiologists were more likely to use stress testing. HF specialists more often used angiotensin-converting enzyme inhibitors as part of their initial therapy in patients with mild to moderate HF (94% vs 86%) and during maintenance therapy (91% vs 80%). Also, HF specialists were more likely than cardiologists to titrate angiotensin-converting enzyme inhibitors to higher doses (75% vs 35%), even in the presence of renal dysfunction.

CONCLUSION

Cardiologists and HF specialists generally manage their patients in conformity with guidelines. However, in many areas, such as angiotensin-converting enzyme inhibitor use, HF specialists do so more aggressively. These approaches may, in part, explain the success of the HF clinic model and raise the possibility that some portion of the HF population may be more optimally managed by cardiologists with a special interest in and additional training or experience with this condition.

Heart failure disease management: a critical review

BACKGROUND

Despite major advances in the pharmacotherapy of heart failure, hospitalization rates remain high, owing in large part to a multitude of psychosocial, behavioral, and financial factors that serve as barriers to effective compliance with prescribed treatment. To deal with these issues, many centers have adopted a multidisciplinary approach to heart failure disease management.

METHODS AND RESULTS

A systematic review of the literature was conducted using the Medline database supplemented by reference lists from published articles. From 1983 to 1998, 16 studies describing multidisciplinary heart failure disease management programs were published in the English language literature. Of these, 10 were nonrandomized, observational studies and 6 were randomized clinical trials. All studies reported significant benefits in terms of reducing hospital utilization, and several studies reported improved quality of life, functional capacity, patient satisfaction, and compliance with diet and medications. In all studies in which a cost analysis was performed, heart failure disease management programs were found to be cost-effective. The limitations of the current data include concerns about the generalizability of published findings to the large and heterogenous population of patients with heart failure in the community, the feasibility of translating specific disease management programs into diverse practice environments, uncertainty about how to design and implement a maximally cost-effective heart failure disease management strategy, and how to best tailor the treatment program to the needs of each individual patient. The impact of heart failure disease management programs on survival is also unknown.

CONCLUSION

Based on currently available data, heart failure disease management programs appear to be a cost-effective approach to reducing morbidity and enhancing quality of life in selected patients with heart failure. However, additional study is needed involving larger and more diverse populations to define the optimal approach to heart failure disease management.