A broader paradigm for understanding and treating heart failure

Health System-Level Performance in Prescribing Guideline-Directed Medical Therapy for Patients with HFrEF: Results from the CONNECT-HF Trial

BACKGROUND

Health system-level interventions to improve use of guideline-directed medical therapy (GDMT) often fail in the acute care setting. We sought to identify factors associated with high performance in adoption of GDMT among health systems in CONNECT-HF.

METHODS AND RESULTS

Site-level composite quality scores were calculated at discharge and last follow-up. Site performance was defined as the average change in score from baseline to last follow-up and analyzed by performance tertile using a mixed-effects model with baseline performance as a fixed effect and site as a random effect. Among 150 randomized sites, mean 12-month improvement in GDMT was 1.8% (-26.4% to 60.0%). Achievement of ≥50% target dose for angiotensin-converting enzymes/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors and beta blockers at 12 months was modest, even at the highest performing sites (median 29.6% [23%, 41%] and 41.2% [29%, 50%]). Sites achieving higher GDMT scores had care teams that included social workers and pharmacists and patients able to afford medications and access medication lists in the electronic health record.

CONCLUSIONS

Substantial gaps in site-level use of GDMT were found even among highest performing sites. Failure of hospital-level interventions to improve quality metrics suggests that a team-based approach to care and improved patient access to medications are needed for post-discharge success.

Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized controlled trial

OBJECTIVE

The purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life.

METHODS

This is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3-4 follow-up phone calls by a nurse over 90 days.

RESULTS

A total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days.

CONCLUSION

Patients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care.

PRACTICE IMPLICATIONS

These data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes.

Self-reported health-related quality of life and sleep disturbances in Taiwanese people with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Health-related quality of life (HRQOL) has been viewed as the most important clinical outcome of heart failure (HF) management. However, information about the predictors of HRQOL in Taiwanese people with HF is limited, especially for the effects of sleep disturbances on HF.

PURPOSE

The purpose of this study was to identify predictors of HRQOL in Taiwanese people with HF, especially focusing on the extent to which sleep variables are related to HRQOL.

METHODS

A cross-sectional, descriptive correlational design was used. A nonprobability sample of 125 participants was recruited from the outpatient departments of 2 hospitals located in southern Taiwan. Participants were face-to-face individually interviewed to complete the Kansas City Cardiomyopathy Questionnaire, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Charlson Comorbidity Index. Data for concomitant health problems and HF characteristics were collected from the medical records.

RESULTS

The mean Kansas City Cardiomyopathy Questionnaire overall summary score for HRQOL in this sample was 70.50 (SD, 19.63). Health-related quality of life physical symptom had the highest score, and the psychological satisfaction domain had the lowest. Six predictors of the HRQOL were identified by using a 3-step hierarchical multiple regression analysis with forward method. The predictors were education (R² = 0.09), New York Heart Association functional class (R² = 0.398), Charlson Comorbidity Index number (R² = 2.6), subjective sleep quality (R² = 0.037), sleep disturbances (R² = 0.015), and sleep latency (R² = 0.018), and together they accounted for a total of 58.5% of the variance in HRQOL.

CONCLUSIONS

Nurses should use a holistic perspective to help patients understand and manage the impact of HF on their daily lives. Effective interventions for improving HRQOL should be designed based on patients' needs and lifestyles. The study findings could serve as a baseline for further longitudinal studies to explore the long-term effects of correlates and causal relationships among the variables in this Taiwanese population with HF.

Event-free survival in adults with heart failure who engage in self-care management

BACKGROUND

Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free.

METHODS

A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk.

RESULTS

The sample consisted of older (mean ± standard deviation=61.3 ± 11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364 ± 288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management.

CONCLUSION

Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.

Description of Symptom Severity in Heart Failure

The purpose of this article is to critically analyze research that describes symptom severity in heart failure. Medline, CINAHL, Psych Info, and Science Direct databases (2000 to July 2006) were searched to locate published studies that described or defined symptom severity or like terms in heart failure. A total of 323 publications were initially reviewed, from which 21 articles (6.51%) were selected based on the inclusion criteria for this article. Multiple terms are used synonymously, and inappropriately at times, to describe symptom severity. Rarely, symptom severity is adequately defined or fully described. Varying instruments and methods are used to measure symptom severity. The literature includes inappropriate measurement methods of symptom severity. Symptom severity should be clearly defined, differentiated from related terms, and measured appropriately. Comparisons across studies are impeded when terms are not clearly defined or inappropriately measured.

The nature of heart failure as a challenge to the integration of palliative care services

PURPOSE OF REVIEW

Despite its increasing prevalence and high mortality risk, heart failure is widely regarded as 'treatable'. Aggressive measures are employed even in its end stages. This review explores the clinical characteristics of heart failure, patterns of clinician response, and new data that may help to surmount current barriers to palliative approaches.

RECENT FINDINGS

The 'treatment imperative' that has helped to reduce overall cardiovascular mortality marginalizes palliative approaches in heart failure. The possibility of dying remains unacknowledged, and communication about palliative options tends not to occur. Both the apparently benign nature of heart failure and its inherent unpredictability discourage end-of-life considerations. Recent studies, however, provide evidence that these barriers may be surmountable, and also furnish tools to help with prognosis. A true heart failure continuum including palliative care would be desirable, although structural barriers exist.

SUMMARY

Therapeutic successes have encouraged clinicians to pursue heart failure treatment through the end stages of disease. These very successes, however, have made the course of advanced heart failure easier to predict. What is needed now is courage among clinicians to open early dialog about disease process, prognosis and palliative options with the growing number of patients with advanced disease.

Development and Testing of a Caring-based Intervention for Older Adults With Heart Failure

The clinical and cost burdens of heart failure (HF) continue to rise, creating an immediate need for cost-effective interventions geared toward improving health outcomes. This article describes the development and testing of a caring-based nursing intervention for older adults with advanced HF who have been recently discharged from acute care. The developmental process and components of the intervention are presented. A methodology for testing the intervention is also introduced. Through a phased development process including research, this intervention can be refined and used to guide clinicians, administrators, and policymakers in the provision of high-quality care to older adults with HF.

Nonpharmacological strategies for improving heart failure outcomes in the community: a systematic review

The purpose of this systematic review was to synthesize current evidence regarding nonpharmacological approaches to heart failure (HF) management. Following a literature search, identified studies were coded using the Heart Failure Study Assessment Scale (HFSAS) developed by the authors. Results included high-quality ratings, a predominance of multidisciplinary disease management studies, decreased readmission rates, and some improvement in quality of life. Implications for practice, leadership, education, and research are described.

Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure

OBJECTIVES

The purpose of this study was to assess whether depressive symptoms are independently associated with changes in heart failure (HF)-specific health status.

BACKGROUND

Depression is common in patients with HF, but the impact of depressive symptoms on the health status of these patients over time is unknown.

METHODS

We conducted a multicenter prospective cohort study of outpatients with HF. Data from 460 patients who completed a baseline Medical Outcomes Study-Depression Questionnaire and both a baseline and follow-up (6 +/- 2 weeks) Kansas City Cardiomyopathy Questionnaire (KCCQ) were analyzed. The KCCQ measures HF-specific health status, including symptoms, physical and social function, and quality of life. Multivariable regression was used to evaluate depressive symptoms as a predictor of change in KCCQ scores, adjusting for baseline KCCQ scores and other patient variables. The primary outcome was change in KCCQ summary scores (range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change).

RESULTS

Approximately 30% (139/460) of the patients had significant depressive symptoms at baseline. Depressed patients had markedly lower baseline KCCQ summary scores (beta = -19.6; p < 0.001). After adjustment for potential confounders, depressed patients were at risk for significant worsening of their HF symptoms, physical and social function, and quality of life (average change in KCCQ summary score = -7.1 points; p < 0.001). Depressive symptoms were the strongest predictor of decline in health status in the multivariable models.

CONCLUSIONS

Depressive symptoms are a strong predictor of short-term worsening of HF-specific health status. The recognition and treatment of depression may be an important component of HF care.