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Pedroni C, Djuric O, Bassi MC, Mione L, Caleffi D, Testa G, Prandi C, Navazio A, Giorgi Rossi P. Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review. Healthcare (Basel) 2023; 11:1227. [PMID: 37174769 PMCID: PMC10178532 DOI: 10.3390/healthcare11091227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.
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Affiliation(s)
- Cristina Pedroni
- Direzione delle Professioni Sanitarie, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
- Laurea Magistrale in Scienze Infermieristiche e Ostetriche, University of Modena and Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Olivera Djuric
- Epidemiology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
- Centre for Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Maria Chiara Bassi
- Medical Library, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Lorenzo Mione
- Laurea Magistrale in Scienze Infermieristiche e Ostetriche, University of Modena and Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Dalia Caleffi
- Cardiology Division, Azienda Ospedaliera Universitaria di Modena, 41124 Modena, Italy;
| | - Giacomo Testa
- UO Medicina, Ospedale Giuseppe Dossetti, Azienda Unità Sanitaria Locale di Bologna, 40053 Bologna, Italy;
| | - Cesarina Prandi
- Department of Business Economics, Health & Social Care, University of Applied Sciences & Arts of Southern Switzerland, CH-6928 Manno, Switzerland;
| | - Alessandro Navazio
- Cardiology Division, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
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Jasińska-Stroschein M, Waszyk-Nowaczyk M. Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists. J Clin Med 2023; 12:3037. [PMID: 37109373 PMCID: PMC10142526 DOI: 10.3390/jcm12083037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists. METHODS articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test. RESULTS a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.
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Affiliation(s)
| | - Magdalena Waszyk-Nowaczyk
- Pharmacy Practice Division, Chair and Department of Pharmaceutical Technology, Poznan University of Medical Sciences, 6 Grunwaldzka Street, 60-780 Poznan, Poland
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Hafkamp FJ, Tio RA, Otterspoor LC, de Greef T, van Steenbergen GJ, van de Ven ART, Smits G, Post H, van Veghel D. Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure. Heart Fail Rev 2022; 27:1683-1748. [PMID: 35239106 PMCID: PMC8892116 DOI: 10.1007/s10741-021-10212-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.
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Affiliation(s)
| | - Rene A. Tio
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Luuk C. Otterspoor
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Tineke de Greef
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | | | - Arjen R. T. van de Ven
- Netherlands Heart Network, Veldhoven, The Netherlands
- St. Anna Hospital, Geldrop, The Netherlands
| | - Geert Smits
- Netherlands Heart Network, Veldhoven, The Netherlands
- Primary care group Pozob, Veldhoven, The Netherlands
| | - Hans Post
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Dennis van Veghel
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
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Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease. Am J Prev Med 2022; 62:e202-e222. [PMID: 34876318 PMCID: PMC8863641 DOI: 10.1016/j.amepre.2021.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management. METHODS Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars. RESULTS The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management. DISCUSSION The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.
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Perera R, Stevens R, Aronson JK, Banerjee A, Evans J, Feakins BG, Fleming S, Glasziou P, Heneghan C, Hobbs FDR, Jones L, Kurtinecz M, Lasserson DS, Locock L, McLellan J, Mihaylova B, O’Callaghan CA, Oke JL, Pidduck N, Plüddemann A, Roberts N, Schlackow I, Shine B, Simons CL, Taylor CJ, Taylor KS, Verbakel JY, Bankhead C. Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Long-term monitoring is important in chronic condition management. Despite considerable costs of monitoring, there is no or poor evidence on how, what and when to monitor. The aim of this study was to improve understanding, methods, evidence base and practice of clinical monitoring in primary care, focusing on two areas: chronic kidney disease and chronic heart failure.
Objectives
The research questions were as follows: does the choice of test affect better care while being affordable to the NHS? Can the number of tests used to manage individuals with early-stage kidney disease, and hence the costs, be reduced? Is it possible to monitor heart failure using a simple blood test? Can this be done using a rapid test in a general practitioner consultation? Would changes in the management of these conditions be acceptable to patients and carers?
Design
Various study designs were employed, including cohort, feasibility study, Clinical Practice Research Datalink analysis, seven systematic reviews, two qualitative studies, one cost-effectiveness analysis and one cost recommendation.
Setting
This study was set in UK primary care.
Data sources
Data were collected from study participants and sourced from UK general practice and hospital electronic health records, and worldwide literature.
Participants
The participants were NHS patients (Clinical Practice Research Datalink: 4.5 million patients), chronic kidney disease and chronic heart failure patients managed in primary care (including 750 participants in the cohort study) and primary care health professionals.
Interventions
The interventions were monitoring with blood and urine tests (for chronic kidney disease) and monitoring with blood tests and weight measurement (for chronic heart failure).
Main outcome measures
The main outcomes were the frequency, accuracy, utility, acceptability, costs and cost-effectiveness of monitoring.
Results
Chronic kidney disease: serum creatinine testing has increased steadily since 1997, with most results being normal (83% in 2013). Increases in tests of creatinine and proteinuria correspond to their introduction as indicators in the Quality and Outcomes Framework. The Chronic Kidney Disease Epidemiology Collaboration equation had 2.7% greater accuracy (95% confidence interval 1.6% to 3.8%) than the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate. Estimated annual transition rates to the next chronic kidney disease stage are ≈ 2% for people with normal urine albumin, 3–5% for people with microalbuminuria (3–30 mg/mmol) and 3–12% for people with macroalbuminuria (> 30 mg/mmol). Variability in estimated glomerular filtration rate-creatinine leads to misclassification of chronic kidney disease stage in 12–15% of tests in primary care. Glycaemic-control and lipid-modifying drugs are associated with a 6% (95% confidence interval 2% to 10%) and 4% (95% confidence interval 0% to 8%) improvement in renal function, respectively. Neither estimated glomerular filtration rate-creatinine nor estimated glomerular filtration rate-Cystatin C have utility in predicting rate of kidney function change. Patients viewed phrases such as ‘kidney damage’ or ‘kidney failure’ as frightening, and the term ‘chronic’ was misinterpreted as serious. Diagnosis of asymptomatic conditions (chronic kidney disease) was difficult to understand, and primary care professionals often did not use ‘chronic kidney disease’ when managing patients at early stages. General practitioners relied on Clinical Commissioning Group or Quality and Outcomes Framework alerts rather than National Institute for Health and Care Excellence guidance for information. Cost-effectiveness modelling did not demonstrate a tangible benefit of monitoring kidney function to guide preventative treatments, except for individuals with an estimated glomerular filtration rate of 60–90 ml/minute/1.73 m2, aged < 70 years and without cardiovascular disease, where monitoring every 3–4 years to guide cardiovascular prevention may be cost-effective. Chronic heart failure: natriuretic peptide-guided treatment could reduce all-cause mortality by 13% and heart failure admission by 20%. Implementing natriuretic peptide-guided treatment is likely to require predefined protocols, stringent natriuretic peptide targets, relative targets and being located in a specialist heart failure setting. Remote monitoring can reduce all-cause mortality and heart failure hospitalisation, and could improve quality of life. Diagnostic accuracy of point-of-care N-terminal prohormone of B-type natriuretic peptide (sensitivity, 0.99; specificity, 0.60) was better than point-of-care B-type natriuretic peptide (sensitivity, 0.95; specificity, 0.57). Within-person variation estimates for B-type natriuretic peptide and weight were as follows: coefficient of variation, 46% and coefficient of variation, 1.2%, respectively. Point-of-care N-terminal prohormone of B-type natriuretic peptide within-person variability over 12 months was 881 pg/ml (95% confidence interval 380 to 1382 pg/ml), whereas between-person variability was 1972 pg/ml (95% confidence interval 1525 to 2791 pg/ml). For individuals, monitoring provided reassurance; future changes, such as increased testing, would be acceptable. Point-of-care testing in general practice surgeries was perceived positively, reducing waiting time and anxiety. Community heart failure nurses had greater knowledge of National Institute for Health and Care Excellence guidance than general practitioners and practice nurses. Health-care professionals believed that the cost of natriuretic peptide tests in routine monitoring would outweigh potential benefits. The review of cost-effectiveness studies suggests that natriuretic peptide-guided treatment is cost-effective in specialist settings, but with no evidence for its value in primary care settings.
Limitations
No randomised controlled trial evidence was generated. The pathways to the benefit of monitoring chronic kidney disease were unclear.
Conclusions
It is difficult to ascribe quantifiable benefits to monitoring chronic kidney disease, because monitoring is unlikely to change treatment, especially in chronic kidney disease stages G3 and G4. New approaches to monitoring chronic heart failure, such as point-of-care natriuretic peptide tests in general practice, show promise if high within-test variability can be overcome.
Future work
The following future work is recommended: improve general practitioner–patient communication of early-stage renal function decline, and identify strategies to reduce the variability of natriuretic peptide.
Study registration
This study is registered as PROSPERO CRD42015017501, CRD42019134922 and CRD42016046902.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Julie Evans
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin G Feakins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Susannah Fleming
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD, Australia
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - FD Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louise Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Milena Kurtinecz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel S Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise Locock
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Julie McLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Pidduck
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annette Plüddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, Knowledge Centre, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire L Simons
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- National Institute for Health Research (NIHR) Community Healthcare MedTech and In Vitro Diagnostics Co-operative (MIC), Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Schumacher PM, Becker N, Tsuyuki RT, Griese-Mammen N, Koshman SL, McDonald MA, Bouvy M, Rutten FH, Laufs U, Böhm M, Schulz M. The evidence for pharmacist care in outpatients with heart failure: a systematic review and meta-analysis. ESC Heart Fail 2021; 8:3566-3576. [PMID: 34240570 PMCID: PMC8497358 DOI: 10.1002/ehf2.13508] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Aims Patients with heart failure (HF) have poor outcomes, including poor quality of life, and high morbidity and mortality. In addition, they have a high medication burden due to the multiple drug therapies now recommended by guidelines. Previous reviews, including studies in hospital settings, provided evidence that pharmacist care improves outcomes in patients with HF. Because most HF is managed outside of hospitals, we aimed to synthesize the evidence for pharmacist care in outpatients with HF. Methods and results We conducted a systematic literature search in PubMed of randomized controlled trials (RCTs) and integrated the evidence on patient outcomes in a meta‐analysis. We found 24 RCTs performed in 10 countries, including 8029 patients. The data revealed consistent improvements in medication adherence (independent of the measuring instrument) and knowledge, physical function, and disease and medication management. Sixteen RCTs were included in meta‐analyses. Differences in all‐cause mortality (odds ratio (OR) = 0.97 [95% CI, 0.84–1.12], Q‐statistic, P = 0.49, I2 = 0%), all‐cause hospitalizations (OR = 0.86 [0.73–1.03], Q‐statistic, P = 0.01, I2 = 45.5%), and HF hospitalizations (OR = 0.89 [0.77–1.02], Q‐statistic, P = 0.11, I2 = 0%) were not statistically significant. We also observed an improvement in the standardized mean difference for generic quality of life of 0.75 ([0.49–1.01], P < 0.01), with no indication of heterogeneity (Q‐statistic, P = 0.64; I2 = 0%). Conclusions Results indicate that pharmacist care improves medication adherence and knowledge, symptom control, and some measures of quality of life in outpatients with HF. Given the increasing complexity of guideline‐directed medical therapy, pharmacists' unique focus on medication management, titration, adherence, and patient teaching should be considered part of the management strategy for these vulnerable patients.
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Affiliation(s)
- Pia M Schumacher
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany
| | - Nicolas Becker
- Personality Psychology and Psychological Assessment, Saarland University, Saarbrücken, Germany
| | - Ross T Tsuyuki
- Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nina Griese-Mammen
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany
| | - Sheri L Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A McDonald
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Marcel Bouvy
- Department of Pharmacoepidemiology & Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Michael Böhm
- Internal Medicine III - Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Martin Schulz
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany.,Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
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Arunmanakul P, Kengkla K, Chaiyasothi T, Phrommintikul A, Ruengorn C, Permsuwan U, Thakkinstian A, Page RL, Munger MA, Nathisuwan S, Chaiyakunapruk N. Effects of pharmacist interventions on heart failure outcomes: A systematic review and
meta‐analysis. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1442] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Poukwan Arunmanakul
- Department of Pharmaceutical Care, Faculty of Pharmacy Chiang Mai University Chiang Mai Thailand
| | - Kirati Kengkla
- School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Thanaputt Chaiyasothi
- Department of Clinical Pharmacy, Faculty of Pharmacy Srinakharinwirot University Nakhon Nayok Thailand
| | - Arintaya Phrommintikul
- Cardiology Division, Department of Internal Medicine, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy Chiang Mai University Chiang Mai Thailand
| | - Unchalee Permsuwan
- Department of Pharmaceutical Care, Faculty of Pharmacy Chiang Mai University Chiang Mai Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital Mahidol University Bangkok Thailand
| | - Robert L. Page
- Department of Clinical Pharmacy, School of Pharmacy University of Colorado Colorado USA
| | - Mark A. Munger
- Department of Pharmacotherapy, College of Pharmacy University of Utah Salt Lake City Utah USA
- Department of Internal Medicine, School of Medicine University of Utah Salt Lake City Utah USA
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy Mahidol University Bangkok Thailand
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy University of Utah Salt Lake City Utah USA
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8
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Li Y, Fu MR, Fang J, Zheng H, Luo B. The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship. Int J Nurs Stud 2021; 117:103902. [PMID: 33662861 DOI: 10.1016/j.ijnurstu.2021.103902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/06/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transitional care interventions that bridge the care gap from hospital to home have proven to be effective in lessening the burden of healthcare systems by reducing hospital readmissions. Yet, the effects of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress remains unclear. OBJECTIVES To evaluate the effectiveness and dose-response of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress among individuals with heart failure and to identify the trial-level characteristics potentially affecting the overall effectiveness. DESIGN Systematic review with random-effects meta-analysis, meta-regression, and dose-response analysis of randomized controlled trials comparing transitional care interventions with usual care in adult people hospitalized with heart failure. DATA SOURCES Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL were systematically searched from January 1, 2000 to June 31, 2020. REVIEW METHODS Authors independently reviewed the retrieved articles based on inclusion and exclusion criteria, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2.0. We pooled data from each study using random-effects meta-analysis and performed meta-regression to explore the impact of pre-specified trial-level factors. Dose-response meta-analysis was conducted to examine the relationship between the intensity (i.e., frequency and duration of interventions) and complexity (i.e., number of intervention components) of transitional care interventions and the treatment effects. RESULTS Data were synthesized from 42 trials covering a total of 10,784 people with heart failure. Comparing to usual care, transitional care interventions achieved pooled evidence of a mean 18% risk reduction on mortality (0.82, 95% CI 0.71 to 0.95, P = 0.009) and better improvement in quality of life (-4.37, 95% CI -7.20 to -1.54, P = 0.002). There were insufficient data to determine with certainty the effects on anxiety and depression. Meta-regression showed greater efficacy in trials that delivered the intervention by a multidisciplinary team. Dose-response analyses demonstrated that mortality and quality of life were improved with increased intensity and complexity of the transitional care interventions. CONCLUSIONS Transitional care interventions were effective in reducing mortality and improving quality of life for adult people with heart failure. The effects on emotional distress were inconclusive due to insufficient data, highlighting the need for further research. REGISTRATION NUMBER CRD42019132732.
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Affiliation(s)
- Yuan Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China; West China School of Nursing, Sichuan University, Chengdu 610041, China
| | - Mei R Fu
- William F. Connell School of Nursing, Boston College, Chestnut Hill 02467, MA, United States
| | - Jinbo Fang
- West China School of Nursing, Sichuan University, Chengdu 610041, China
| | - Hong Zheng
- Nursing Department, West China Second University Hospital, Sichuan University, Chengdu 610041, China
| | - Biru Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China; Nursing Department, West China Second University Hospital, Sichuan University, Chengdu 610041, China.
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9
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Veenis JF, Radhoe SP, Hooijmans P, Brugts JJ. Remote Monitoring in Chronic Heart Failure Patients: Is Non-Invasive Remote Monitoring the Way to Go? SENSORS (BASEL, SWITZERLAND) 2021; 21:887. [PMID: 33525556 PMCID: PMC7865348 DOI: 10.3390/s21030887] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022]
Abstract
Heart failure (HF) is a major health care issue, and the incidence of HF is only expected to grow further. Due to the frequent hospitalizations, HF places a major burden on the available hospital and healthcare resources. In the future, HF care should not only be organized solely at the clinical ward and outpatient clinics, but remote monitoring strategies are urgently needed to guide, monitor, and treat chronic HF patients remotely from their homes as well. The intuitiveness and relatively low costs of non-invasive remote monitoring tools make them an appealing and emerging concept for developing new medical apps and devices. The recent COVID-19 pandemic and the associated transition of patient care outside the hospital will boost the development of remote monitoring tools, and many strategies will be reinvented with modern tools. However, it is important to look carefully at the inconsistencies that have been reported in non-invasive remote monitoring effectiveness. With this review, we provide an up-to-date overview of the available evidence on non-invasive remote monitoring in chronic HF patients and provide future perspectives that may significantly benefit the broader group of HF patients.
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Affiliation(s)
- Jesse F. Veenis
- Erasmus MC, University Medical Center Rotterdam, Thorax Center, Department of Cardiology, 3000 Rotterdam, The Netherlands; (S.P.R.); (P.H.); (J.J.B.)
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10
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Mackintosh NJ, Davis RE, Easter A, Rayment-Jones H, Sevdalis N, Wilson S, Adams M, Sandall J. Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings. Cochrane Database Syst Rev 2020; 12:CD012829. [PMID: 33285618 PMCID: PMC8406701 DOI: 10.1002/14651858.cd012829.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns. OBJECTIVES To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response. DATA COLLECTION AND ANALYSIS Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice. MAIN RESULTS We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies. AUTHORS' CONCLUSIONS Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.
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Affiliation(s)
- Nicola J Mackintosh
- SAPPHIRE, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Rachel E Davis
- Health Service & Population Research Department, King's College London, London, UK
| | - Abigail Easter
- Health Service & Population Research Department, King's College London, London, UK
| | - Hannah Rayment-Jones
- Department of Women and Children's Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, London, UK
| | - Sophie Wilson
- Health Service & Population Research Department, King's College London, London, UK
| | - Mary Adams
- Health Service & Population Research Department, King's College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King's College London, London, UK
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11
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Li Y, Fu MR, Luo B, Li M, Zheng H, Fang J. The Effectiveness of Transitional Care Interventions on Health Care Utilization in Patients Discharged From the Hospital With Heart Failure: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2020; 22:621-629. [PMID: 33158744 DOI: 10.1016/j.jamda.2020.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Heart failure (HF) heavily burdens the global health system. Transitional care interventions attempt to streamline the hospital-to-home transition to ease the burden. This systematic review and meta-analysis aimed to evaluate the effectiveness of transitional care interventions on health care utilization after hospitalization for HF. DESIGN Systematic review and meta-analysis including dose-response relationship. SETTING AND PARTICIPANTS Randomized controlled trials (RCTs) of transitional care interventions vs usual care in older patients discharged from the hospital with HF. METHODS Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL, were systematically searched from January 2009 to October 2019 to locate relevant systematic reviews or meta-analyses. The original RCTs included in the review articles were identified, and an additional search for recently published RCTs was performed from January 2014 to June 2020. This systematic review focused on health care utilization outcomes, including hospital readmissions for HF or any cause, emergency department (ED) visits, and length of hospital stay (LOS). RESULTS Data were summarized from 38 RCTs covering 10,871 patients. Pooled evidence suggested a mean 11% [risk ratio (RR) 0.89, 95% confidence interval (CI) 0.82, 0.97] and 22% (RR 0.78, 95% CI 0.68, 0.89) risk reduction on all-cause and HF-specific readmissions, but no significant reduction (RR 0.94, 95% CI 0.83, 1.07) on ED visits. Findings were mixed for LOS. Subgroup analysis by different types of transitional care interventions indicated that multidisciplinary interventions currently have the best evidence for reducing readmissions up to 6 months post the index HF hospitalization. In addition, we observed an inverse linear dose-response relationship between intervention intensity (ie, frequency and duration of interventions) and complexity (ie, number of intervention components) and the risk of HF readmissions. CONCLUSIONS AND IMPLICATIONS Transitional care interventions for hospitalized patients with HF reduced all-cause and HF-specific readmissions, but did not decrease ED visits. Multidisciplinary interventions are highly recommended if adequate resources are available.
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Affiliation(s)
- Yuan Li
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Mei R Fu
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
| | - Biru Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China; Nursing Department, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Minlu Li
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, China
| | - Hong Zheng
- Nursing Department, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jinbo Fang
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, China.
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12
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You H, Su X, Su G. Novel thiazole-pyrazolone hybrids as potent ACE inhibitors and their cardioprotective effect on isoproterenol-induced myocardial infarction. Arch Pharm (Weinheim) 2020; 353:e2000140. [PMID: 32841430 DOI: 10.1002/ardp.202000140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/23/2020] [Accepted: 07/11/2020] [Indexed: 11/09/2022]
Abstract
A facile synthesis of a group of novel thiazole-pyrazolone hybrids and their investigation for angiotensin-converting enzyme (ACE) inhibition are reported in this study. These compounds were synthesized using a well-known approach, based on the condensation of ethyl acetoacetate with thiazolylhydrazines, and characterized by various spectroscopic and analytical techniques. The entire set of compounds displayed a moderate-to-excellent inhibitory activity against ACE. In particular, compound 4i was found to be the most potent ACE inhibitor and was further studied for cardioprotective effects against isoproterenol (ISO)-induced myocardial infarction (MI) in rats. Compound 4i improved the cardiac function and prevented cardiac injury induced by ISO in Sprague Dawley rats. The levels of oxidative stress and proinflammatory cytokines were also restored to near normal by 4i as compared with the ISO group. In the Western blot analysis, compound 4i prevented mitochondrial apoptosis after MI by downregulating the expression of cleaved caspase-3 and Bax, with the upregulation of Bcl-2, as compared with the ISO group.
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Affiliation(s)
- Hongwen You
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xinyou Su
- Department of Oncology, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Guoying Su
- Department of Cardiology, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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13
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Bonetti AF, Reis WC, Mendes AM, Rotta I, Tonin FS, Fernandez-Llimos F, Pontarolo R. Impact of Pharmacist-led Discharge Counseling on Hospital Readmission and Emergency Department Visits: A Systematic Review and Meta-analysis. J Hosp Med 2020; 15:52-59. [PMID: 30897055 DOI: 10.12788/jhm.3182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transitions of care can contribute to medication errors and other adverse drug events. PURPOSE The aim of this study was to evaluate the impact of pharmacist-led discharge counseling on hospital readmission and emergency department visits through a systematic review and meta-analysis. EDATA SOURCES Lectronic searches were performed in PubMed, Scopus, and DOAJ (Directory of Open Access Journals), along with a manual search (July 2017). PROSPERO registration no. CRD42017068444. STUDY SELECTION Two independent reviewers performed all the steps of the systematic review process (screening of titles and abstracts, full-text appraisal, data extraction, and quality assessment), with contributions from a third researcher. We included randomized controlled trials (RCTs) reporting data on pharmacist-led discharge counseling. DATA EXTRACTION Primary extracted outcomes were emergency department visits and hospital readmission rates. DATA SYNTHESIS Meta-analyses of intervention versus usual care for hospital readmission and emergency department visit rates were performed using the inverse variance method. Results are reported as risk ratios (RRs) with 95% confidence intervals (CIs). Prediction intervals (PIs) were also calculated. Sensitivity and subgroup analyses were performed. A total of 21 RCTs were included in the qualitative synthesis and 18 in the meta-analyses (n = 7,244 patients). The original meta-analysis revealed a significant difference in the impact between pharmacist-led discharge counseling and usual care on overall hospital readmission (RR = 0.864 [95% CI 0.763-0.997], P = .020) and emergency department (RR = 0.697 [95% CI 0.535-0.907], P = .007) visits. However, the small number of included studies, the high heterogeneity among trials (I2 between 40% and 60%), and the wide PIs (hospital readmission: PI 0.542-1.186; emergency department visits: PI 0.027-1.367) prevented drawing further conclusions. CONCLUSIONS Insufficient evidence exists regarding the effect of pharmacist-led discharge counseling on hospital readmission and emergency department visits. Further well-designed clinical trials with defined core outcome sets are needed.
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Affiliation(s)
- Aline F Bonetti
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Walleri C Reis
- Department of Pharmacy, Federal University of Paraiba, João Pessoa, Brazil
| | - Antonio M Mendes
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Inajara Rotta
- Pharmacy Service, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Department of Social Pharmacy, College of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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14
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Blood AJ, Fischer CM, Fera LE, MacLean TE, Smith KV, Dunning JR, Bosque-Hamilton JW, Aronson SJ, Gaziano TA, MacRae CA, Matta LS, Mercurio-Pinto AA, Murphy SN, Scirica BM, Wagholikar K, Desai AS. Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. Clin Cardiol 2019; 43:4-13. [PMID: 31725920 PMCID: PMC6954374 DOI: 10.1002/clc.23291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Alexander J Blood
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina M Fischer
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana E Fera
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor E MacLean
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline R Dunning
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Samuel J Aronson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Thomas A Gaziano
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lina S Matta
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ana A Mercurio-Pinto
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Benjamin M Scirica
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kavishwar Wagholikar
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Effectiveness of the Pharmacist-Involved Multidisciplinary Management of Heart Failure to Improve Hospitalizations and Mortality Rates in 4630 Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Card Fail 2019; 25:744-756. [DOI: 10.1016/j.cardfail.2019.07.455] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 12/28/2022]
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16
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Toukhsati SR, Jaarsma T, Babu AS, Driscoll A, Hare DL. Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2019; 13:1179546819856855. [PMID: 31217696 PMCID: PMC6563392 DOI: 10.1177/1179546819856855] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/17/2019] [Indexed: 12/12/2022]
Abstract
Unplanned hospital readmissions are the most important, preventable cost in heart failure (HF) health economics. Current professional guidelines recommend that patient self-care is an important means by which to reduce this burden. Patients with HF should be engaged in their care such as by detecting, monitoring, and managing their symptoms. A variety of educational and behavioural interventions have been designed and implemented by health care providers to encourage and support patient self-care. Meta-analyses support the use of self-care interventions to improve patient self-care and reduce hospital readmissions; however, efficacy is variable. The aim of this review was to explore methods to achieve greater clarity and consistency in the development and reporting of self-care interventions to enable ‘change agents’ to be identified. We conclude that advancement in this field requires more explicit integration and reporting on the behaviour change theories that inform the design of self-care interventions and the selection of behaviour change techniques. The systematic application of validated checklists, such as the Theory Coding Scheme and the CALO-RE taxonomy, will improve the systematic testing and refinement of interventions to enable ‘change agent/s’ to be identified and optimised.
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Affiliation(s)
- S R Toukhsati
- School of Health and Life Sciences, Psychology, Federation University Australia, Berwick, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia.,Department of Cardiology, Austin Health, Heidelberg, VIC, Australia
| | - T Jaarsma
- Faculty of Health Sciences, University of Linköping, Linköping, Sweden.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - A S Babu
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia.,Department of Cardiology, Austin Health, Heidelberg, VIC, Australia.,Department of Physiotherapy, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, India
| | - A Driscoll
- Department of Cardiology, Austin Health, Heidelberg, VIC, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - D L Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia.,Department of Cardiology, Austin Health, Heidelberg, VIC, Australia
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17
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Blizzard S, Verbosky N, Stein B, Hale G, Patel N, Chau Y, Cave B. Evaluation of Pharmacist Impact Within an Interdisciplinary Inpatient Heart Failure Consult Service. Ann Pharmacother 2019; 53:905-915. [PMID: 30961358 DOI: 10.1177/1060028019842656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Heart failure (HF) is highly prevalent in the Veterans Affairs (VA) health care system and the leading cause of hospital discharges in the VA. Despite guideline-specific recommendations of drug therapy, many patients are not on optimal medication regimens. Objective: To examine and quantify pharmacist impact in an interdisciplinary HF consult (IC) service on increasing use of guideline-directed medical therapy (GDMT). The 30-day readmission rates before and after the implementation of an IC service are reported. Methods: This was a single-center retrospective analysis of veterans admitted with a HF diagnosis between August 2008 and August 2015 in 2 distinctive cohorts: pre-IC (August 2008 to November 2011) and IC (November 2011 to August 2015). Results: Four-hundred patients were included, with 200 in each cohort. All-cause readmissions at 30 days were not different between pre-IC and IC groups: 33.5% versus 28.5%, respectively. Secondary outcomes of HF readmission and 1-year mortality were not different between groups. Significant increases in medication use rates were observed from admission to discharge in both cohorts; however, greater increases were observed in the IC group in which the pharmacist role was clearly defined in recommending GDMT optimization, especially in patients with HF with reduced ejection fraction. Conclusion and Relevance: Although the implementation of an IC service did not significantly change 30-day readmission rates, increases in GDMT use are evident with increased pharmacist involvement. Longer-term outcomes associated with this intervention warrant future investigation.
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Affiliation(s)
| | | | | | - Genevieve Hale
- 2 Nova Southeastern University College of Pharmacy, Davie, FL, USA
| | - Nitin Patel
- 3 Veterans Health Administration, Office of Community Care, Denver, CO, USA
| | - Yen Chau
- 1 James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Brandon Cave
- 4 Methodist University Hospital, Memphis, TN, USA
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Tsuyuki RT, Lockwood EE, Shibata MC, Simpson SH, Tweden KL, Gutierrez R, Reddy MC, Rowe BH, Villa-Roel C, Fradette M. A Randomized Trial of Video-based Education in Patients With Heart Failure: The Congestive Heart Failure Outreach Program of Education (COPE). CJC Open 2019; 1:62-68. [PMID: 32159085 PMCID: PMC7063627 DOI: 10.1016/j.cjco.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/12/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Heart failure (HF) exacerbations often relate to poor self-care. Education programs improve outcomes, but are resource-intensive. We developed a video-based educational intervention and evaluated it in patients with HF. METHODS Congestive Heart Failure Outreach Program of Education was a pragmatic multicenter randomized trial. We included subjects with HF if they were hospitalized, seen in the emergency department (ED), or high-risk outpatients, and randomized them to intervention or control. Intervention included a 20-minute video, supplementary booklet, and 3 bimonthly newsletters focusing on salt and fluid restriction, daily weights, and medications. Subjects watched the video and were encouraged to review it at home, along with the booklet/newsletters. Control subjects received the booklet only. The primary outcome was the difference in cardiovascular hospitalizations or ED visits between groups at 6 months. Secondary outcomes included clinical events and in-hospital days. RESULTS We recruited 539 subjects from 22 centers in Canada and the United States. Baseline characteristics were similar in both groups: 64% were male and had a mean age of 66 (± 13) years, mean ejection fraction 31% (± 13.5), and 65% New York Heart Association Functional Classification III/IV. The primary outcome occurred in 57 subjects (21%) in the intervention group compared with 61 subjects (23%) in the control group (P = 0.66). There were no significant differences in prespecified secondary outcomes; however, death occurred in 18 subjects (7%) in the intervention group and 33 subjects (12%) in the control group (P = 0.03). CONCLUSION Video education on self-care did not reduce hospitalizations or ED visits in patients with HF. Of note, mortality was lower in the intervention group.
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Affiliation(s)
- Ross T. Tsuyuki
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Evan E. Lockwood
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Marcelo C. Shibata
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Misericordia Hospital, Edmonton, Alberta, Canada
| | - Scot H. Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Rosa Gutierrez
- Capital Health Authority/Alberta Health Services, Edmonton, Alberta, Canada (now retired)
| | - Maria C. Reddy
- Capital Health Authority/Alberta Health Services, Edmonton, Alberta, Canada (now retired)
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Fradette
- EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012. OBJECTIVES To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness. MAIN RESULTS We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective. AUTHORS' CONCLUSIONS We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.
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Affiliation(s)
- Andrea Takeda
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Nicole Martin
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Rod S Taylor
- University of Exeter Medical SchoolInstitute of Health ResearchSouth Cloisters, St Luke's Campus, Heavitree RoadExeterUKEX2 4SG
| | - Stephanie JC Taylor
- Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonCentre for Primary Care and Public Health and Asthma UK Centre for Applied ResearchYvonne Carter Building58 Turner StreetLondonUKE1 2AB
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Abstract
The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.
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Affiliation(s)
- Asrul Akmal Shafie
- Discipline of Social Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Minden, Penang, Malaysia.
| | - Yui Ping Tan
- Discipline of Social Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Minden, Penang, Malaysia
| | - Chin Hui Ng
- Discipline of Social Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Minden, Penang, Malaysia
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21
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Penney LS, Nahid M, Leykum LK, Lanham HJ, Noël PH, Finley EP, Pugh J. Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review. BMC Health Serv Res 2018; 18:894. [PMID: 30477576 PMCID: PMC6260570 DOI: 10.1186/s12913-018-3712-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/14/2018] [Indexed: 11/13/2022] Open
Abstract
Background Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes. Methods We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness. Results Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005). Conclusions Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission. Electronic supplementary material The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lauren S Penney
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA. .,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Musarrat Nahid
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Luci K Leykum
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Information, Risk and Operations Management, McCombs School of Business, The University of Texas at Austin, 2110 Speedway Stop B6500, Austin, TX, 78712-1277, USA
| | - Holly Jordan Lanham
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Information, Risk and Operations Management, McCombs School of Business, The University of Texas at Austin, 2110 Speedway Stop B6500, Austin, TX, 78712-1277, USA.,Department of Family & Community Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Polly H Noël
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Family & Community Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Erin P Finley
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Psychiatry, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Jacqueline Pugh
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
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22
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Aronow WS, Shamliyan TA. Comparative Effectiveness of Disease Management With Information Communication Technology for Preventing Hospitalization and Readmission in Adults With Chronic Congestive Heart Failure. J Am Med Dir Assoc 2018; 19:472-479. [PMID: 29730178 DOI: 10.1016/j.jamda.2018.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/15/2018] [Accepted: 03/16/2018] [Indexed: 12/28/2022]
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Verloo H, Chiolero A, Kiszio B, Kampel T, Santschi V. Nurse interventions to improve medication adherence among discharged older adults: a systematic review. Age Ageing 2017; 46:747-754. [PMID: 28510645 DOI: 10.1093/ageing/afx076] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 04/24/2017] [Indexed: 01/09/2023] Open
Abstract
Background discharged older adult inpatients are often prescribed numerous medications. However, they only take about half of their medications and many stop treatments entirely. Nurse interventions could improve medication adherence among this population. Objective to conduct a systematic review of trials that assessed the effects of nursing interventions to improve medication adherence among discharged, home-dwelling and older adults. Method we conducted a systematic review according to the methods in the Cochrane Collaboration Handbook and reported results according to the PRISMA statement. We searched for controlled clinical trials (CCTs) and randomised CCTs (RCTs), published up to 8 November 2016 (using electronic databases, grey literature and hand searching), that evaluated the effects of nurse interventions conducted alone or in collaboration with other health professionals to improve medication adherence among discharged older adults. Medication adherence was defined as the extent to which a patient takes medication as prescribed. Results out of 1,546 records identified, 82 full-text papers were evaluated and 14 studies were included-11 RCTs and 2 CCTs. Overall, 2,028 patients were included (995 in intervention groups; 1,033 in usual-care groups). Interventions were nurse-led in seven studies and nurse-collaborative in seven more. In nine studies, adherence was higher in the intervention group than in the usual-care group, with the difference reaching statistical significance in eight studies. There was no substantial difference in increased medication adherence whether interventions were nurse-led or nurse-collaborative. Four of the 14 studies were of relatively high quality. Conclusion nurse-led and nurse-collaborative interventions moderately improved adherence among discharged older adults. There is a need for large, well-designed studies using highly reliable tools for measuring medication adherence.
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Affiliation(s)
- Henk Verloo
- School of Health sciences, HES-SO Valais - Wallis, University of Applied sciences Western Switzerland, Chémin de l'Agasse 6, Sion, Switzerland
- La Source, School of Nursing Sciences, University of Applied Sciences Western Switzerland, Lausanne, Switzerland
| | - Arnaud Chiolero
- IUMSP, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Blanche Kiszio
- La Source, School of Nursing Sciences, University of Applied Sciences Western Switzerland, Lausanne, Switzerland
| | - Thomas Kampel
- La Source, School of Nursing Sciences, University of Applied Sciences Western Switzerland, Lausanne, Switzerland
| | - Valérie Santschi
- La Source, School of Nursing Sciences, University of Applied Sciences Western Switzerland, Lausanne, Switzerland
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
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Riegel B, Moser DK, Buck HG, Dickson VV, Dunbar SB, Lee CS, Lennie TA, Lindenfeld J, Mitchell JE, Treat-Jacobson DJ, Webber DE. Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association. J Am Heart Assoc 2017; 6:e006997. [PMID: 28860232 PMCID: PMC5634314 DOI: 10.1161/jaha.117.006997] [Citation(s) in RCA: 260] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.
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25
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McNeely EB. Treatment Considerations and the Role of the Clinical Pharmacist Throughout Transitions of Care for Patients With Acute Heart Failure. J Pharm Pract 2017; 30:441-450. [PMID: 27129914 PMCID: PMC5524196 DOI: 10.1177/0897190016645435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Heart failure is associated with increased risk of morbidity and mortality, resulting in substantial health-care costs. Clinical pharmacists have an opportunity to reduce health-care costs and improve disease management as patients transition from inpatient to outpatient care by leading interventions to develop patient care plans, educate patients and clinicians, prevent adverse drug reactions, reconcile medications, monitor drug levels, and improve medication access and adherence. Through these methods, clinical pharmacists are able to reduce rates of hospitalization, readmission, and mortality. In addition, care by clinical pharmacists can improve dosing levels and adherence to guideline-directed therapies. A greater benefit in patient management occurs when clinical pharmacists collaborate with other members of the health-care team, emphasizing the importance of heart failure treatment by a multidisciplinary health-care team. Education is a key area in which clinical pharmacists can improve care of patients with heart failure and should not be limited to patients. Clinical pharmacists should provide education to all members of the health-care team and introduce them to new therapies that may further improve the management of heart failure. The objective of this review is to detail the numerous opportunities that clinical pharmacists have to improve the management of heart failure and reduce health-care costs as part of a multidisciplinary health-care team.
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Affiliation(s)
- Elizabeth B McNeely
- 1 TriStar Centennial Medical Center, Department of Pharmacy, University of Tennessee Health Science Center College of Pharmacy, Nashville, TN, USA
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26
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Clinical Outcomes Used in Clinical Pharmacy Intervention Studies in Secondary Care. PHARMACY 2017; 5:pharmacy5020028. [PMID: 28970440 PMCID: PMC5597153 DOI: 10.3390/pharmacy5020028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/30/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022] Open
Abstract
The objective was to investigate type, frequency and result of clinical outcomes used in studies to assess the effect of clinical pharmacy interventions in inpatient care. The literature search using Pubmed.gov was performed for the period up to 2013 using the search phrases: “Intervention(s)” and “pharmacist(s)” and “controlled” and “outcome(s)” or “effect(s)”. Primary research studies in English of controlled, clinical pharmacy intervention studies, including outcome evaluation, were selected. Titles, abstracts and full-text papers were assessed individually by two reviewers, and inclusion was determined by consensus. In total, 37 publications were included in the review. The publications presented similar intervention elements but differed in study design. A large variety of outcome measures (135) had been used to evaluate the effect of the interventions; most frequently clinical measures/assessments by physician and health care service use. No apparent pattern was established among primary outcome measures with significant effect in favour of the intervention, but positive effect was most frequently related to studies that included power calculations and sufficient inclusion of patients (73% vs. 25%). This review emphasizes the importance of considering the relevance of outcomes selected to assess clinical pharmacy interventions and the importance of conducting a proper power calculation.
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Wan TTH, Terry A, Cobb E, McKee B, Tregerman R, Barbaro SDS. Strategies to Modify the Risk of Heart Failure Readmission: A Systematic Review and Meta-Analysis. Health Serv Res Manag Epidemiol 2017; 4:2333392817701050. [PMID: 28462286 PMCID: PMC5406120 DOI: 10.1177/2333392817701050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/07/2017] [Accepted: 02/07/2017] [Indexed: 12/21/2022] Open
Abstract
Background: Human factors play an important role in health-care outcomes of heart failure (HF) patients. A systematic review and meta-analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies. Purpose: To investigate how the 8 guiding principles of choice, rest, environment, activity, trust, interpersonal relationships, outlook, and nutrition reduce HF readmissions. Basic Procedures: Appropriate keywords were identified related to the (1) independent variable of hospitalization and treatment, (2) the moderating variable of care management principles, (3) the dependent variable of readmission, and (4) the disease of HF to conduct searches in 9 databases. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ERIC, MEDLINE, PubMed, PsycInfo, Science Direct, and Web of Science. Only prospective studies associated with HF hospitalization and readmissions, published in English, Chinese, Spanish, and German journals between January 1, 1990, and August 31, 2015, were included in the systematic review. In the meta-analysis, data were collected from studies that measured HF readmission for individual patients. Main Findings: The results indicate that an intervention involving any human factor principles may nearly double an individual’s probability of not being readmitted. Participants in interventions that incorporated single or combined principles were 1.4 to 6.8 times less likely to be readmitted. Principal Conclusions: Interventions with human factor principles reduce readmissions among HF patients. Overall, this review may help reconfigure the design, implementation, and evaluation of clinical practice for reducing HF readmissions in the future.
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Affiliation(s)
- Thomas T H Wan
- College of Health and Public Affairs, University of Central Florida, Orlando, FL, USA
| | - Amanda Terry
- College of Health and Public Affairs, University of Central Florida, Orlando, FL, USA
| | - Enesha Cobb
- Florida Hospital Translational Research Institute, Orlando, FL, USA
| | - Bobbie McKee
- College of Health and Public Affairs, University of Central Florida, Orlando, FL, USA
| | - Rebecca Tregerman
- College of Health and Public Affairs, University of Central Florida, Orlando, FL, USA
| | - Sara D S Barbaro
- College of Health and Public Affairs, University of Central Florida, Orlando, FL, USA
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Le Berre M, Maimon G, Sourial N, Guériton M, Vedel I. Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review. J Am Geriatr Soc 2017; 65:1597-1608. [PMID: 28403508 DOI: 10.1111/jgs.14828] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.
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Affiliation(s)
- Mélanie Le Berre
- Lady Davis Institute of the Jewish General Hospital, Montreal, Québec, Canada
| | - Geva Maimon
- Lady Davis Institute of the Jewish General Hospital, Montreal, Québec, Canada
| | - Nadia Sourial
- Lady Davis Institute of the Jewish General Hospital, Montreal, Québec, Canada
| | - Muriel Guériton
- Lady Davis Institute of the Jewish General Hospital, Montreal, Québec, Canada
| | - Isabelle Vedel
- Lady Davis Institute of the Jewish General Hospital, Montreal, Québec, Canada.,Department of Family Medicine, McGill University, Montreal, Québec, Canada
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Lin MH, Yuan WL, Huang TC, Zhang HF, Mai JT, Wang JF. Clinical effectiveness of telemedicine for chronic heart failure: a systematic review and meta-analysis. J Investig Med 2017; 65:899-911. [PMID: 28330835 DOI: 10.1136/jim-2016-000199] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 11/04/2022]
Abstract
Telemedicine interventions may be associated with reductions in hospital admission rate and mortality in patients with heart failure (HF). The present study is an updated analysis (as of June 30, 2016) of randomized controlled trials, where patients with HF underwent telemedicine care or the usual standard care. Data were extracted from 39 eligible studies for all-cause and HF-related hospital admission rate, length of stay, and mortality. The overall all-cause mortality (pooled OR=0.80, 95% CI 0.71 to 0.91, p<0.001), HF-related admission rate (pooled OR=0.63, 95% CI 0.53 to 0.76, p<0.001), and HF-related length of stay (pooled standardized difference in means=-0.37, 95% CI -0.72 to -0.02, p=0.041) were significantly lower in the telemedicine group (teletransmission and telephone-supported care), as compared with the control group. In subgroup analysis, all-cause mortality (pooled OR=0.69, 95% CI 0.56 to 0.86, p=0.001), HF-related admission rate (OR=0.61, 95% CI 0.42 to 0.88, p=0.008), HF-related length of stay (pooled standardized difference in means=-0.96, 95% CI -1.88 to -0.05, p=0.039) and HF-related mortality (OR=0.68, 95% CI 0.54 to 0.85, p=0.001) were significantly lower in the teletransmission group, as opposed to the standard care group, whereas only HF-related admission rate (OR=0.64, 95% CI 0.52 to 0.79, p<0.001) was lower in the telephone-supported care group. Overall, telemedicine was shown to be beneficial, with home-based teletransmission effectively reducing all-cause mortality and HF-related hospital admission, length of stay and mortality in patients with HF.
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Affiliation(s)
- Mao-Huan Lin
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Wo-Liang Yuan
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Tu-Cheng Huang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Hai-Feng Zhang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jing-Ting Mai
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jing-Feng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
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Bartlett Ellis RJ, Knisely MR, Boyer K, Pike C. Pillbox intervention fidelity in medication adherence research: A systematic review. Nurs Outlook 2017; 65:464-476. [PMID: 28187900 DOI: 10.1016/j.outlook.2016.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 11/04/2016] [Accepted: 12/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pillboxes are widely available, have evidence of effectiveness, but translating pillboxes in self-management interventions requires an understanding of intervention components. PURPOSE To review components of intervention design, interventionist training, delivery, receipt, enactment, and targeted behaviors in adherence studies. METHODS Five multidisciplinary databases were searched to find reports of controlled trials testing pillboxes and medication adherence interventions in adults managing medications. Details of treatment fidelity, that is, design, training, delivery, receipt, and enactment, were abstracted. FINDINGS A total of 38 articles reporting 40 studies were included. Treatment fidelity descriptions were often lacking, especially reporting receipt and enactment, important for both control and intervention groups. Clearly reported details are needed to avoid making assumptions when translating evidence. CONCLUSION These findings serve as a call to action to explicitly state intervention details. Lack of reported intervention detail is a barrier to translating which components of pillboxes work in influencing medication adherence behaviors and outcomes.
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Affiliation(s)
| | - Mitchell R Knisely
- Department of Health Promotion & Development, University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Kiersten Boyer
- Science of Nursing Care Department, Indiana University School of Nursing, Indianapolis, IN
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Murphy TM, Waterhouse DF, James S, Casey C, Fitzgerald E, O'Connell E, Watson C, Gallagher J, Ledwidge M, McDonald K. A comparison of HFrEF vs HFpEF's clinical workload and cost in the first year following hospitalization and enrollment in a disease management program. Int J Cardiol 2016; 232:330-335. [PMID: 28087180 DOI: 10.1016/j.ijcard.2016.12.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 12/04/2016] [Accepted: 12/16/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Admission with heart failure (HF) is a milestone in the progression of the disease, often resulting in higher intensity medical care and ensuing readmissions. Whilst there is evidence supporting enrolling patients in a heart failure disease management program (HF-DMP), not all reported HF-DMPs have systematically enrolled patients with HF with preserved ejection fraction (HFpEF) and there is a scarcity of literature differentiating costs based on HF-phenotype. METHODS 1292 consenting, consecutive patients admitted with a primary diagnosis of HF were enrolled in a hospital based HF-DMP and categorized as HFpEF (EF≥45%) or HFrEF (EF<45%). Hospitalizations, primary care, medications, and DMP workload with associated costs were evaluated assessing DMP clinic-visits, telephonic contact, medication changes over 1year using a mixture of casemix and micro-costing techniques. RESULTS The total average annual cost per patient was marginally higher in patients with HFrEF €13,011 (12,011, 14,078) than HFpEF, €12,206 (11,009, 13,518). However, emergency non-cardiovascular admission rates and average cost per patient were higher in the HFpEF vs HFrEF group (0.46 vs 0.31 per patient/12months) & €655 (318, 1073) vs €584 (396, 812). In the first 3months of the outpatient HF-DMP the HFrEF population cost more on average €791 (764, 819) vs €693 (660, 728). CONCLUSION There are greater short-term (3-month) costs of HFrEF versus HFpEF as part of a HF-DMP following an admission. However, long-term (3-12month) costs of HFpEF are greater because of higher non-cardiovascular rehospitalisations. As HFpEF becomes the dominant form of HF, more work is required in HF-DMPs to address prevention of non-cardiovascular rehospitalisations and to integrate hospital based HF-DMPs into primary healthcare structures.
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Affiliation(s)
- T M Murphy
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - D F Waterhouse
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - S James
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - C Casey
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - E Fitzgerald
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - E O'Connell
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - C Watson
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland; Centre for Experimental Medicine, Queen's University Belfast, Northern Ireland
| | - J Gallagher
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - M Ledwidge
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - K McDonald
- Heart Failure Unit, St Vincent's University Hospital, Dublin 4, Ireland.
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Information needs of older people with heart failure: listening to their own voice. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:435-8. [PMID: 27594872 PMCID: PMC4984572 DOI: 10.11909/j.issn.1671-5411.2016.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? An Individual Patient Data Meta-analysis. J Card Fail 2016; 22:861-871. [PMID: 27374838 DOI: 10.1016/j.cardfail.2016.06.422] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/22/2016] [Accepted: 06/28/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND To identify those characteristics of self-management interventions in patients with heart failure (HF) that are effective in influencing health-related quality of life, mortality, and hospitalizations. METHODS AND RESULTS Randomized trials on self-management interventions conducted between January 1985 and June 2013 were identified and individual patient data were requested for meta-analysis. Generalized mixed effects models and Cox proportional hazard models including frailty terms were used to assess the relation between characteristics of interventions and health-related outcomes. Twenty randomized trials (5624 patients) were included. Longer intervention duration reduced mortality risk (hazard ratio 0.99, 95% confidence interval [CI] 0.97-0.999 per month increase in duration), risk of HF-related hospitalization (hazard ratio 0.98, 95% CI 0.96-0.99), and HF-related hospitalization at 6 months (risk ratio 0.96, 95% CI 0.92-0.995). Although results were not consistent across outcomes, interventions comprising standardized training of interventionists, peer contact, log keeping, or goal-setting skills appeared less effective than interventions without these characteristics. CONCLUSION No specific program characteristics were consistently associated with better effects of self-management interventions, but longer duration seemed to improve the effect of self-management interventions on several outcomes. Future research using factorial trial designs and process evaluations is needed to understand the working mechanism of specific program characteristics of self-management interventions in HF patients.
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Unverzagt S, Meyer G, Mittmann S, Samos FA, Unverzagt M, Prondzinsky R. Improving Treatment Adherence in Heart Failure. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:423-30. [PMID: 27397013 PMCID: PMC4941608 DOI: 10.3238/arztebl.2016.0423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite improved treatment options, heart failure remains the third most common cause of death in Germany and the most common reason for hospitalization. The treatment recommendations contained in the relevant guidelines have been incompletely applied in practice. The goal of this systematic review is to study the efficacy of adherence-promoting interventions for patients with heart failure with respect to the taking of medications, the implementation of recommended lifestyle changes, and the improvement in clinical endpoints. METHODS We performed a meta-analysis of pertinent publications retrieved by a systematic literature search. RESULTS 55 randomized controlled trials were identified, in which a wide variety of interventions were carried out on heterogeneous patient groups with varying definitions of adherence. These trials included a total of 15 016 patients with heart failure who were cared for as either inpatients or outpatients. The efficacy of interventions to promote adherence to drug treatment was studied in 24 trials; these trials documented improved adherence in 10% of the patients overall (95% confidence interval [CI]: [5; 15]). The efficacy of interventions to promote adherence to lifestyle recommendations was studied in 42 trials; improved adherence was found in 31 trials. Improved adherence to at least one recommendation yielded a long-term absolute reduction in mortality of 2% (95% CI: [0; 4]) and a 10% reduction in the likelihood of hospitalization within 12 months of the start of the intervention (95% CI: [3; 17]). CONCLUSION Many effective interventions are available that can lead to sustained improvement in patient adherence and in clinical endpoints. Longterm success depends on patients' assuming responsibility for their own health and can be achieved with the aid of coordinated measures such as patient education and regular follow-up contacts.
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Affiliation(s)
- Susanne Unverzagt
- Institute for Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale):
| | - Gabriele Meyer
- Institute of Health and Nursing Sciences, Martin-Luther-University Halle-Wittenberg, Halle (Saale)
| | - Susanne Mittmann
- Institute for Medical Epidemiology, Biostatistics and Informatics, Section for General Practice, Martin-Luther-University Halle-Wittenberg, Halle (Saale):
| | - Franziska-Antonia Samos
- Institute for Medical Epidemiology, Biostatistics and Informatics, Section for General Practice, Martin-Luther-University Halle-Wittenberg, Halle (Saale):
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Ruppar TM, Cooper PS, Mehr DR, Delgado JM, Dunbar-Jacob JM. Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials. J Am Heart Assoc 2016; 5:e002606. [PMID: 27317347 PMCID: PMC4937243 DOI: 10.1161/jaha.115.002606] [Citation(s) in RCA: 202] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/28/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Poor adherence to medications is a common problem among heart failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function, and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown. METHODS AND RESULTS We conducted a comprehensive search and systematic review of intervention studies testing interventions to improve adherence to HF medications. Mortality and readmission outcome effect sizes (ESs) were calculated from the reported data. ESs were combined using random-effects model meta-analysis methods, because differences in true between-study effects were expected from variation in study populations and interventions. ES differences attributed to study design, sample, and intervention characteristics were assessed using moderator analyses when sufficient data were available. We assessed publication bias using funnel plots. Comprehensive searches yielded 6665 individual citations, which ultimately yielded 57 eligible studies. Overall, medication adherence interventions were found to significantly reduce mortality risk among HF patients (relative risk, 0.89; 95% CI, 0.81, 0.99), and decrease the odds for hospital readmission (odds ratio, 0.79; 95% CI, 0.71, 0.89). Heterogeneity was low. Moderator analyses did not detect differences in ES from common sources of potential study bias. CONCLUSIONS Interventions to improve medication adherence among HF patients have significant effects on reducing readmissions and decreasing mortality. Medication adherence should be addressed in regular follow-up visits with HF patients, and interventions to improve adherence should be a key part of HF self-care programs.
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Affiliation(s)
- Todd M Ruppar
- Sinclair School of Nursing, University of Missouri, Columbia, MO
| | - Pamela S Cooper
- Sinclair School of Nursing, University of Missouri, Columbia, MO
| | - David R Mehr
- Department of Family and Community Medicine, University of Missouri, Columbia, MO
| | - Janet M Delgado
- Sinclair School of Nursing, University of Missouri, Columbia, MO
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Kang JE, Han NY, Oh JM, Jin HK, Kim HA, Son IJ, Rhie SJ. Pharmacist-involved care for patients with heart failure and acute coronary syndrome: a systematic review with qualitative and quantitative meta-analysis. J Clin Pharm Ther 2016; 41:145-57. [DOI: 10.1111/jcpt.12367] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/01/2016] [Indexed: 11/27/2022]
Affiliation(s)
- J. E. Kang
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
- Department of Pharmacy; National Medical Center; Seoul Korea
| | - N. Y. Han
- College of Pharmacy; Seoul National University; Seoul Korea
| | - J. M. Oh
- College of Pharmacy; Seoul National University; Seoul Korea
| | - H. K. Jin
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
| | - H. A. Kim
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
| | - I. J. Son
- Department of Pharmacy; National Medical Center; Seoul Korea
| | - S. J. Rhie
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
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Salas CM, Miyares MA. Implementing a pharmacy resident run transition of care service for heart failure patients: Effect on readmission rates. Am J Health Syst Pharm 2016; 72:S43-7. [PMID: 25991595 DOI: 10.2146/sp150012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Heart failure (HF) is a leading cause of hospital readmissions adversely affecting resources and hospital reimbursements. The purpose of this study was to optimize medication therapy, provide patient education and facilitate discharge and follow-up through the creation of a pharmacy resident managed HF transition service with the intention of decreasing readmission rates. METHODS A 6-month prospective, single center pilot study was conducted by a pharmacy resident to decrease readmission rates in patients with HF. Patients were identified through emergency department admission reports and direct requests from discharge nurses. The pharmacy resident provided patients with tailored medication and disease state counseling, ensured obtainment of discharge medications and performed follow up telephone calls for appointment reminders and further counseling. The primary outcome measured was readmission rate at 30 days. Secondary outcomes were number of patients requesting safety net medications, reason for readmission(s), and appointment compliance. RESULTS Thirty patients were enrolled in the program. The 30-day heart failure readmission rate decreased from 28.1% to 16.6%. Eighty-eight percent of patients attended their follow up appointments. CONCLUSION A reduction in readmission rate was achieved through this pharmacy resident-run HF transition service. The majority of patients attended follow-up visits and financial appointments after discharge.
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Affiliation(s)
| | - Marta A Miyares
- Clinical Hospital Pharmacist, Internal Medicine, PGY-1 Residency Program Director, Jackson Memorial Hospital, Miami, FL
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38
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Jonkman NH, Westland H, Groenwold RHH, Ågren S, Atienza F, Blue L, Bruggink-André de la Porte PWF, DeWalt DA, Hebert PL, Heisler M, Jaarsma T, Kempen GIJM, Leventhal ME, Lok DJA, Mårtensson J, Muñiz J, Otsu H, Peters-Klimm F, Rich MW, Riegel B, Strömberg A, Tsuyuki RT, van Veldhuisen DJ, Trappenburg JCA, Schuurmans MJ, Hoes AW. Do Self-Management Interventions Work in Patients With Heart Failure? An Individual Patient Data Meta-Analysis. Circulation 2016; 133:1189-98. [PMID: 26873943 DOI: 10.1161/circulationaha.115.018006] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Self-management interventions are widely implemented in the care for patients with heart failure (HF). However, trials show inconsistent results, and whether specific patient groups respond differently is unknown. This individual patient data meta-analysis assessed the effectiveness of self-management interventions in patients with HF and whether subgroups of patients respond differently. METHODS AND RESULTS A systematic literature search identified randomized trials of self-management interventions. Data from 20 studies, representing 5624 patients, were included and analyzed with the use of mixed-effects models and Cox proportional-hazard models, including interaction terms. Self-management interventions reduced the risk of time to the combined end point of HF-related hospitalization or all-cause death (hazard ratio, 0.80; 95% confidence interval [CI], 0.71-0.89), time to HF-related hospitalization (hazard ratio, 0.80; 95% CI, 0.69-0.92), and improved 12-month HF-related quality of life (standardized mean difference, 0.15; 95% CI, 0.00-0.30). Subgroup analysis revealed a protective effect of self-management on the number of HF-related hospital days in patients <65 years of age (mean, 0.70 versus 5.35 days; interaction P=0.03). Patients without depression did not show an effect of self-management on survival (hazard ratio for all-cause mortality, 0.86; 95% CI, 0.69-1.06), whereas in patients with moderate/severe depression, self-management reduced survival (hazard ratio, 1.39; 95% CI, 1.06-1.83, interaction P=0.01). CONCLUSIONS This study shows that self-management interventions had a beneficial effect on time to HF-related hospitalization or all-cause death and HF-related hospitalization alone and elicited a small increase in HF-related quality of life. The findings do not endorse limiting self-management interventions to subgroups of patients with HF, but increased mortality in depressed patients warrants caution in applying self-management strategies in these patients.
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Affiliation(s)
- Nini H Jonkman
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.). n.jonkman@umcutrecht
| | - Heleen Westland
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Rolf H H Groenwold
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Susanna Ågren
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Felipe Atienza
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Lynda Blue
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Pieta W F Bruggink-André de la Porte
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Darren A DeWalt
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Paul L Hebert
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Michele Heisler
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Tiny Jaarsma
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Gertrudis I J M Kempen
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Marcia E Leventhal
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Dirk J A Lok
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Jan Mårtensson
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Javier Muñiz
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Haruka Otsu
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Frank Peters-Klimm
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Michael W Rich
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Barbara Riegel
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Anna Strömberg
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Ross T Tsuyuki
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Dirk J van Veldhuisen
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Jaap C A Trappenburg
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Marieke J Schuurmans
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
| | - Arno W Hoes
- From Department of Rehabilitation, Nursing Science and Sports (N.H.J., H.W., J.C.A.T., M.J.S.) and Julius Center for Health Sciences and Primary Care (R.H.H.G., A.W.H.), University Medical Center Utrecht, The Netherlands; Departments of Medical and Health Sciences and Department of Cardiothoracic Surgery (S.Å.), Department of Medical and Health Sciences, Division of Nursing Science (S.Å., A.S.), Department of Social and Welfare Studies (T.J.), and Department of Cardiology (A.S.), Linköping University, Sweden; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain (F.A.); British Heart Foundation, Glasgow, UK (L.B.); Department of Cardiology, Deventer Hospital, The Netherlands (P.W.F.B.-A.d.l.P., D.J.A.L.); Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill (D.A.D.); Department of Health Services, University of Washington, Seattle (P.L.H.); Department of Internal Medicine, University of Michigan, Ann Arbor (M.H.); Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands (G.I.J.M.K.); Institute of Nursing Science, University of Basel, Switzerland (M.E.L.); Department of Nursing Science, Jönköping University, Sweden (J. Mårtensson); Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña and INIBIC, A Coruña, Spain (J. Muñiz); Graduate School of Health Sciences, Hirosaki University, Aomori, Japan (H.O.); Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany (F.P.-K.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.W.R.); School of Nursing, University of Pennsylvania, Philadelphia (B.R.); Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (R.T.T.); and Department of Cardiology, University Medical Center Groningen, The Netherlands (D.J.v.V.)
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Bos-Touwen I, Jonkman N, Westland H, Schuurmans M, Rutten F, de Wit N, Trappenburg J. Tailoring of self-management interventions in patients with heart failure. Curr Heart Fail Rep 2016; 12:223-35. [PMID: 25929690 PMCID: PMC4424272 DOI: 10.1007/s11897-015-0259-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The effectiveness of heart failure (HF) self-management interventions varies within patients suggesting that one size does not fit all. It is expected that effectiveness can be optimized when interventions are tailored to individual patients. The aim of this review was to synthesize the literature on current use of tailoring in self-management interventions and patient characteristics associated with self-management capacity and success of interventions, as building blocks for tailoring. Within available trials, the degree to which interventions are explicitly tailored is marginal and often limited to content. We found that certain patient characteristics that are associated with poor self-management capacity do not influence effectiveness of a given intervention (i.e., age, gender, ethnicity, disease severity, number of comorbidities) and that other characteristics (low: income, literacy, education, baseline self-management capacity) in fact are indicators of patients with a high likelihood for success. Increased scientific efforts are needed to continue unraveling success of self-management interventions and to validate the modifying impact of currently known patient characteristics.
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Affiliation(s)
- Irene Bos-Touwen
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Nini Jonkman
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Heleen Westland
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marieke Schuurmans
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frans Rutten
- />Julius Center, Department of General Practice, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Niek de Wit
- />Julius Center, Department of General Practice, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Jaap Trappenburg
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Vedel I, Khanassov V. Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis. Ann Fam Med 2015; 13:562-71. [PMID: 26553896 PMCID: PMC4639382 DOI: 10.1370/afm.1844] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 06/30/2015] [Accepted: 07/10/2015] [Indexed: 02/04/2023] Open
Abstract
PURPOSE We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration. RESULTS We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious. CONCLUSIONS Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.
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Affiliation(s)
- Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Canada
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Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JGF. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev 2015; 2015:CD007228. [PMID: 26517969 PMCID: PMC8482064 DOI: 10.1002/14651858.cd007228.pub3] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness. OBJECTIVES To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care. SEARCH METHODS We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits. SELECTION CRITERIA We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up. DATA COLLECTION AND ANALYSIS We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age). MAIN RESULTS We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours. AUTHORS' CONCLUSIONS For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.
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Affiliation(s)
- Sally C Inglis
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Maru S, Byrnes J, Carrington MJ, Chan YK, Thompson DR, Stewart S, Scuffham PA. Cost-effectiveness of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort - The WHICH? study (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care). Int J Cardiol 2015; 201:368-75. [PMID: 26310979 DOI: 10.1016/j.ijcard.2015.08.066] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/02/2015] [Accepted: 08/03/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the long-term cost-effectiveness of two multidisciplinary management programs for elderly patients hospitalized with chronic heart failure (CHF) and how it is influenced by patient characteristics. METHODS A trial-based analysis was conducted alongside a randomized controlled trial of 280 elderly patients with CHF discharged to home from three Australian tertiary hospitals. Two interventions were compared: home-based intervention (HBI) that involved home visiting with community-based care versus specialized clinic-based intervention (CBI). Bootstrapped incremental cost-utility ratios were computed based on quality-adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed based on incremental net monetary benefit (NMB). We performed multiple linear regression to explore which patient characteristics may impact patient-level NMB. RESULTS During median follow-up of 3.2 years, HBI was associated with slightly higher QALYs (+0.26 years per person; p=0.078) and lower total healthcare costs (AU$ -13,100 per person; p=0.025) mainly driven by significantly reduced duration of all-cause hospital stay (-10 days; p=0.006). At a willingness-to-pay threshold of AU$ 50,000 per additional QALY, the probability of HBI being better-valued was 96% and the incremental NMB of HBI was AU$ 24,342 (discounted, 5%). The variables associated with increased NMB were HBI (vs. CBI), lower Charlson Comorbidity Index, no hyponatremia, fewer months of HF, fewer prior HF admissions <1 year and a higher patient's self-care confidence. HBI's net benefit further increased in those with fewer comorbidities, a lower self-care confidence or no hyponatremia. CONCLUSIONS Compared with CBI, HBI is likely to be cost-effective in elderly CHF patients with significant comorbidity.
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Affiliation(s)
- Shoko Maru
- Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia.
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia
| | - Melinda J Carrington
- Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Yih-Kai Chan
- Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - David R Thompson
- Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Simon Stewart
- Centre for Research Excellence to Reduce Inequality in Heart Disease, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia
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Yu M, Chair SY, Chan CWH, Choi KC. A health education booklet and telephone follow-ups can improve medication adherence, health-related quality of life, and psychological status of patients with heart failure. Heart Lung 2015; 44:400-7. [PMID: 26054444 DOI: 10.1016/j.hrtlng.2015.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 05/12/2015] [Accepted: 05/13/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure is an increasing public health problem globally. Interventions are imperative in managing the disease. OBJECTIVE To examine the effectiveness of a health education booklet and telephone follow-ups on patients' medication adherence, health-related quality of life, and psychological status. METHODS One hundred and sixty heart failure patients were assigned to either the experimental group (health education booklet and telephone follow-ups) or the control group (usual care). An independent t-test and the generalized estimating equation (GEE) model were used to compare the differences in the study outcomes. The statistical tests were two-sided and a p value below 0.05 was considered statistically significant. RESULTS The patients in the experimental group showed greater improvement throughout the study period compared with those in the control group regarding all the study outcomes. CONCLUSIONS The study provided clues for healthcare professionals to develop interventions while undertaking clinical work with limited resources in China.
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Affiliation(s)
- Mingming Yu
- School of Nursing, Peking Union Medical College, Beijing, PR China.
| | - Sek Ying Chair
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, PR China
| | - Carmen W H Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, PR China
| | - Kai Chow Choi
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, PR China
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Avaldi VM, Lenzi J, Castaldini I, Urbinati S, Di Pasquale G, Morini M, Protonotari A, Maggioni AP, Fantini MP. Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy. PLoS One 2015; 10:e0127796. [PMID: 26010223 PMCID: PMC4444393 DOI: 10.1371/journal.pone.0127796] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/18/2015] [Indexed: 01/25/2023] Open
Abstract
Background Primary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF. Methods The study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners’ monodisciplinary organizational arrangement, and implementation of a specific HF care pathway). Results The 1873 study patients had a median age of 83 years (interquartile range 77–87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35–0.92; medium-term: IRR=0.70, 95%CI=0.51–0.96; mid-long-term: IRR=0.79, 95%CI=0.64–0.98; long-term: IRR=0.82, 95%CI=0.67–0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57–0.94). Conclusion Our study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.
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Affiliation(s)
- Vera Maria Avaldi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Ilaria Castaldini
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | | | - Mara Morini
- Department of Primary Care, Bologna Local Healthcare Authority, Bologna, Italy
| | - Adalgisa Protonotari
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
- * E-mail:
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45
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Leung AW, Chan CY, Yan BP, Yu CM, Lam YY, Lee VW. Management of heart failure with preserved ejection fraction in a local public hospital in Hong Kong. BMC Cardiovasc Disord 2015; 15:12. [PMID: 25887230 PMCID: PMC4364510 DOI: 10.1186/s12872-015-0002-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/05/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Heart failure (HF) is one of the most debilitating chronic illnesses. The prevalence is expected to increase due to aging population. The current study aimed to examine the management of heart failure with preserved ejection fraction (HFpEF) including drug use pattern, direct medical cost and humanistic outcome in a local public hospital in Hong Kong. METHODS The current study adopted the retrospective observational study design. Subjects were recruited from the Heart Failure Registry of the Prince of Wales Hospital in Hong Kong between 2006 and 2008 and completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ) at 3 designated time-points conferred eligibility. Patients with significant valvular disorder were excluded. Each patient's medical record was reviewed for 12 months after the date of admission. Heart failure related admissions, clinic visits, cardiovascular drugs, laboratory tests and diagnostic tests were documented. Costs and MLHFQ scores in patients with or without hypertension, diabetes and renal impairment were compared. RESULTS A total of 73 HFpEF patients were included. It was found that loop diuretics (93.1%, 78.1%) was the most frequently used agent for HFpEF management in both in-patient and out-patient settings. The mean 1-year direct medical cost was USD$ 19969 (1 US $ = 7.8 HK$), with in-patient ward care contributing to the largest proportion (72.2%) of the total cost. Patients with diabetes or renal impairment were associated with a higher cost of HFpEF management. Significant difference was found in the renal impairment group (median cost: USD$ 24604.2 versus USD$ 12706.8 in no impairment group, p = 0.023). The MLHFQ scores of the subjects improved significantly during the study period (p < 0.0005). CONCLUSIONS The cost of management of HFpEF was enormous and further increased in the presence of comorbidities.
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Affiliation(s)
- Angel W Leung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Cherise Y Chan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Bryan P Yan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Cheuk Man Yu
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Yat Yin Lam
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Vivian W Lee
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
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46
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Ruppar TM, Delgado JM, Temple J. Medication adherence interventions for heart failure patients: A meta-analysis. Eur J Cardiovasc Nurs 2015; 14:395-404. [DOI: 10.1177/1474515115571213] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/15/2015] [Indexed: 01/28/2023]
Affiliation(s)
- Todd M Ruppar
- Sinclair School of Nursing, University of Missouri, Columbia, USA
| | - Janet M Delgado
- Sinclair School of Nursing, University of Missouri, Columbia, USA
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47
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Conn VS, Ruppar TM, Chan KC, Dunbar-Jacob J, Pepper GA, De Geest S. Packaging interventions to increase medication adherence: systematic review and meta-analysis. Curr Med Res Opin 2015; 31:145-60. [PMID: 25333709 PMCID: PMC4562676 DOI: 10.1185/03007995.2014.978939] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. RESEARCH DESIGN AND METHODS Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. RESULTS Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. CONCLUSIONS Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.
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48
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Maru S, Byrnes J, Carrington MJ, Stewart S, Scuffham PA. Systematic review of trial-based analyses reporting the economic impact of heart failure management programs compared with usual care. Eur J Cardiovasc Nurs 2014; 15:82-90. [PMID: 25322749 DOI: 10.1177/1474515114556031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/27/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The cost-effectiveness of heart failure management programs (HF-MPs) is highly variable. We explored intervention and clinical characteristics likely to influence cost outcomes. METHODS A systematic review of economic analyses alongside randomized clinical trials comparing HF-MPs and usual care. Electronic databases were searched for English peer-reviewed articles published between 1990 and 2013. RESULTS Of 511 articles identified, 34 comprising 35 analyses met the inclusion criteria. Eighteen analyses (51%) reported a HF-MP as more effective and less costly; four analyses (11%), and five analyses (14%) also reported they were more effective but with no significant or an increased cost difference, respectively. Alternatively, five analyses (14%) reported no statistically significant difference in effects or costs, and one analysis (3%) reported no statistically significant effect difference but was less costly. Finally, two analyses (6%) reported no statistically significant effect difference but were more costly. Interventions that reduced hospital admissions tended to result in favorable cost outcomes, moderated by increased resource use, intervention cost and/or the durability of the intervention effect. The reporting quality of economic evaluation assessed by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist varied substantially between 5% and 91% (median 45%; 34 articles) of the checklist criteria adequately addressed. Overall, none of the study, patient or intervention characteristics appeared to independently influence the cost-effectiveness of a HF-MP. CONCLUSION The extent that HF-MPs reduce hospital readmissions appears to be associated with favorable cost outcomes. The current evidence does not provide a sufficient evidence base to explain what intervention or clinical attributes may influence the cost implications.
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Affiliation(s)
- Shoko Maru
- Centre for Applied Health Economics, Griffith University, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, Griffith University, Australia
| | - Melinda J Carrington
- NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
| | - Simon Stewart
- NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, Griffith University, Australia
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Gorthi J, Hunter CB, Mooss AN, Alla VM, Hilleman DE. Reducing Heart Failure Hospital Readmissions: A Systematic Review of Disease Management Programs. Cardiol Res 2014; 5:126-138. [PMID: 28348710 PMCID: PMC5358117 DOI: 10.14740/cr362w] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2014] [Indexed: 11/30/2022] Open
Abstract
The recent enactment of the Patient Protection and Affordable Care Act which established the federal Hospital Readmissions Reduction Program (HRRP) has accelerated efforts to develop heart failure (HF) disease management programs (DMPs) that reduce readmissions in patients hospitalized for HF. This systematic review identified randomized controlled trials of HF DMPs which included home care, outpatient clinic interventions, structured telephone support, and non-invasive and invasive telemonitoring. These different types of DMPs have been associated with conflicting results. No specific type of DMP has produced consistent benefit in reducing HF hospitalizations. Although probably effective at reducing readmissions, home visits and outpatient clinic interventions have substantial limitations including cost and accessibility. Telemanagement has the potential to reach a large number of patients at a reasonable cost. Structured telephone support follow-up has been shown to significantly reduce HF readmissions, but does not significantly reduce all-cause mortality or all-cause hospitalization. A meta-analysis of 11 non-invasive telemonitoring studies demonstrated significant reductions in all-cause mortality and HF hospitalizations. Invasive telemonitoring is a potentially effective means of reducing HF hospitalizations, but only one study using pulmonary artery pressure monitoring was able to demonstrate a reduction in HF hospitalizations. Other studies using invasive hemodynamic monitoring have failed to demonstrate changes in rates of readmission or mortality. The efficacy of HF DMPs is associated with inconsistent results. Our review should not be interpreted to indicate that HF DMPs are universally ineffective. Rather, our data suggest that one approach applied to a broad spectrum of different patient types may produce an erratic impact on readmissions and clinical outcomes. HF DMPs should include the flexibility to meet the individualized needs of specific patients.
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Affiliation(s)
- Janardhana Gorthi
- The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA
| | - Claire B Hunter
- The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA
| | - Ayran N Mooss
- The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata M Alla
- The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA
| | - Daniel E Hilleman
- The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA
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50
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Burke RE, Guo R, Prochazka AV, Misky GJ. Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res 2014; 14:423. [PMID: 25244946 PMCID: PMC4180324 DOI: 10.1186/1472-6963-14-423] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions. METHODS Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework. RESULTS 66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0). CONCLUSIONS Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.
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Affiliation(s)
- Robert E Burke
- Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, USA.
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