Team management of patients with heart failure: A statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association

Impact of Heart Failure Team on Inpatient Rapid Sequencing of Heart Failure Therapy

The management of heart failure (HF) has undergone a paradigm shift from conventional stepwise methods of initiation and the up-titration of HF therapy towards an early, more intensive initiation of pharmacotherapy to improve the prognosis. The aim of this study was to compare the outcomes of patients at the Liverpool Heart and Chest Hospital (LHCH), with new diagnosis of HF, who were reviewed by the inpatient heart failure team (HFT), compared to patients that were not reviewed. A retrospective review of the electronic records of patients admitted with a new diagnosis of HF to the LHCH from May to December 2023 was performed. Admission drugs were similar, apart from betablockers, which were more frequent in the non-HFT group (58% vs. 24.2%; p = 0.002). The length of inpatient stay was longer in the HFT group (median 5.5 days vs. 3 days; p = 0.001) and more likely to be on all four pillars of HF medical therapy (96.8% vs. 0; p < 0.001) within 30 days of discharge. The 30-day and 6-month mortality outcomes were not significantly different. Patients reviewed by the HFT were significantly more likely to receive the four pillars of HF therapy within 30 days of their diagnosis compared to their counterparts at the expense of a longer length of stay.

The association of workforce configurations with length of stay and charges in hospitalized patients with congestive heart failure

Introduction

Clinicians are the conduits of high-quality care delivery. Clinicians have driven advancements in pharmacotherapeutics, devices, and related interventions and improved morbidity and mortality in patients with congestive heart failure over the past decade. Yet, the management of congestive heart failure has become extraordinarily complex and has fueled recommendations from the American Heart Association and the American College of Cardiology to optimize the composition of the care team to reduce the health, economic, and the health system burden of high lengths of stay and hospital charges. Therefore, the purpose of this study was to identify the extent to which specific care team configurations were associated with high length of stay and high-charge hospitalizations of patients with congestive heart failure.

Methods

This study performed a retrospective analysis of data extracted from the electronic health records of 3,099 patients and their hospitalizations from the Arkansas Clinical Data Repository. The data was analyzed using binomial logistic regression in which adjusted odds ratios reflected the association of specific care team configurations (i.e., combination of care roles) with length of stay and hospital charges.

Results

Team configurations that included a nurse practitioner, registered nurse, care manager, and social worker were generally above the median length of stay and median charges when compared to team configurations that did not collectively include all of these roles. Patients with larger configurations (i.e., four or more different care roles) had higher length of stays and charges than smaller configurations (i.e., two to three different care roles). The results also validated the Van Walraven Elixhauser Comorbidity Score by finding that its quartiles were associated with length of stay and charges, an indicator of care demand based on patient morbidity.

Conclusions

Cardiologists, alone, cannot shoulder the burden of improving patient outcomes. Care team configuration data within electronic health record systems of hospitals could be an effective method of isolating and tracking high-risk patients. Registered nurses may be particularly effective in advancing real-time risk stratification by applying the Van Walraven Elixhauser Comorbidity Score at the point of care, improving the ability of health systems to match care demand with workforce availability.

Fluid Restriction for Patients with Heart Failure: Current Evidence and Future Perspectives

Fluid restriction has long been believed to benefit patients with heart failure by counteracting the activated renin-angiotensin aldosterone system and sympathetic nervous activity. However, its effectiveness remains controversial. In this paper, we summarized the current recommendations and reviewed the scientific evidence on fluid restriction in the setting of both acute decompensated heart failure and compensated heart failure. While a recent meta-analysis demonstrated the beneficial effects of fluid restriction on both all-cause mortality and hospitalization compared to usual care, several weaknesses were identified in the assessment of the methodological quality of the meta-analysis using AMSTAR 2. Further randomized controlled trials with larger sample sizes are needed to elucidate the benefits of fluid restriction for both clinical outcomes and patient-reported outcomes in patients with heart failure.

Health Status in Heart Failure and Cancer: Analysis of the Medicare Health Outcomes Survey 2016-2020

BACKGROUND

People with heart failure (HF) and cancer experience impaired physical and mental health status. However, health-related quality of life (HRQOL) has not been directly compared between these conditions in a contemporary population of older people.

OBJECTIVES

The authors sought to compare HRQOL in people with HF vs those with lung, colorectal, breast, and prostate cancers.

METHODS

The authors performed a pooled analysis of Medicare Health Outcomes Survey data from 2016 to 2020 in participants ≥65 years of age with a self-reported history of HF or active treatment for lung, colon, breast, or prostate cancer. They used the Veterans RAND-12 physical component score (PCS) and mental component score (MCS), which range from 0-100 with a mean score of 50 (based on the U.S. general population) and an SD of 10. The authors used pairwise Student's t-tests to evaluate for differences in PCS and MCS between groups.

RESULTS

Among participants with HF (n = 71,025; 54% female, 16% Black), mean PCS was 29.5 and mean MCS 47.9. Mean PCS was lower in people with HF compared with lung (31.2; n = 4,165), colorectal (35.6; n = 4,270), breast (37.7; n = 14,542), and prostate (39.6; n = 17,670) cancer (all P < 0.001). Participants with HF had a significantly lower mean MCS than those with lung (31.2), colon (50.0), breast (52.0), and prostate (53.0) cancer (all P < 0.001).

CONCLUSIONS

People with HF experience worse HRQOL than those with cancer actively receiving treatment. The pervasiveness of low HRQOL in HF underscores the need to implement evidence-based interventions that target physical and mental health status and scale multidisciplinary clinics.

Assessing and Improving the Care of Patients With Heart Failure in Ghana: Protocol for a Prospective Observational Study and the Ghana Heart Initiative-Heart Failure Registry

BACKGROUND

Heart failure (HF) is a leading cause of morbidity and mortality globally, with a high disease burden. The prevalence of HF in Ghana is increasing rapidly, but epidemiological profiles, treatment patterns, and survival data are scarce. The national capacity to diagnose and manage HF appropriately is also limited. To address the growing epidemic of HF, it is crucial to recognize the epidemiological characteristics and medium-term outcomes of HF in Ghana and improve the capability to identify and manage HF promptly and effectively at all levels of care.

OBJECTIVE

This study aims to determine the epidemiological characteristics and medium-term HF outcomes in Ghana.

METHODS

We conducted a prospective, multicenter, multilevel cross-sectional observational study of patients with HF from January to December 2023. Approximately 5000 patients presenting with HF to 9 hospitals, including teaching, regional, and municipal hospitals, will be recruited and evaluated according to a standardized protocol, including the use of an echocardiogram and an N-terminal pro-brain natriuretic peptide (NT-proBNP) test. Guideline-directed medical treatment of HF will be initiated for 6 months, and the medium-term outcomes of interventions, including rehospitalization and mortality, will be assessed. Patient data will be collated into a HF registry for continuous assessment and monitoring.

RESULTS

This intervention will generate the necessary information on the etiology of HF, clinical presentations, the diagnostic yield of various tools, and management outcomes. In addition, it will build the necessary capacity and support for HF management in Ghana. As of July 30, 2023, the training and onboarding of all 9 centers had been completed. Preliminary analyses will be conducted by the end of the second quarter of 2024, and results are expected to be publicly available by the middle of 2024.

CONCLUSIONS

This study will provide the necessary data on HF, which will inform decisions on the prevention and management of HF and form the basis for future research.

TRIAL REGISTRATION

ISRCTN Registry (United Kingdom) ISRCTN18216214; https:www.isrctn.com/ISRCTN18216214.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52616.

Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification

Point of care ultrasound (POCUS) is a first-line tool to assess hemodynamically unstable patients, however, there is confusion surrounding intertwined concepts such as: "flow," "congestion," "fluid responsiveness (FR)," and "fluid tolerance." We argue that the Frank-Starling relationship is clarifying because it describes the interplay between "congestion" and "flow" on the x-axis and y-axis, respectively. Nevertheless, a single, simultaneous assessment of congestion and flow via POCUS remains a static approach. To expand this, we propose a two-step process. The first step is to place the patient on an ultrasonographic Diamond-Forrester plot. The second step is a dynamic assessment for FR (e.g., passive leg raise), which individualizes therapy across the arc of critical illness.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Impact of Radar Chart-Based Information Sharing in a Multidisciplinary Team on In-Hospital Outcomes and Prognosis in Older Patients With Heart Failure

Background: A multidisciplinary team (MDT) approach is crucial for managing older patients with heart failure (HF). We investigated the impact on clinical outcomes of implementation of a conference sheet (CS) with an 8-component radar chart for visualizing and sharing patient information. Methods and Results: We enrolled 395 older inpatients with HF (median age 79 years [interquartile range 72-85 years]; 47% women) and divided them into 2 groups according to CS implementation: a non-CS group (before CS implementation; n=145) and a CS group (after CS implementation; n=250). The clinical characteristics of patients in the CS group were assessed using 8 scales (physical function, functional status, comorbidities, nutritional status, medication adherence, cognitive function, HF knowledge level, and home care level). In-hospital outcomes (Short Physical Performance Battery, Barthel Index score, length of hospital stay, and hospital transfer rate) were significantly better in the CS than non-CS group. During the follow-up period, 112 patients experienced composite events (all-cause death or admission for HF). Inverse probabilities of treatment-weighted Cox proportional hazard analyses demonstrated a 39% reduction in risk of composite events in the CS group (adjusted hazard ratio 0.65; 95% confidence interval 0.43-0.97). Conclusions: Radar chart-based information sharing among MDT members is associated with superior in-hospital clinical outcomes and a favorable prognosis.

Interaction between body mass index and blood pressure on the risk of vascular stiffness : A community-based cross-sectional study and implications for nursing

Objective

This study aimed to analyze associations between body mass index (BMI) and vascular measurements (brachial ankle pulse wave velocity [baPWV] and ankle-brachial index [ABI]), whether blood pressure (BP) was involved in the relationship, and implications for nursing.

Methods

A cross-sectional study was conducted, including 1,894 middle-aged and older adults who underwent routine health screening at a community medical center in the Zhangjiang community in Shanghai, China. Participants were divided into three groups based on BMI: normal weight (n = 1,202), overweight (n = 480), and obese (n = 212). Multivariate linear regression models and smooth curve fittings were used to evaluate the associations between BMI and indices of vascular stiffness. Mediation analysis examined whether blood pressure mediate the association between BMI and vascular stiffness.

Results

Multiple linear regression analysis showed that BMI to be significantly and negatively associated with baPWV (β = -0.06 [-0.10, -0.03]) and ABI (β = -0.004 [-0.005, -0.003]), respectively. The interaction test results of systolic blood pressure (SBP) in the relationship between BMI and baPWV were significant (P for interaction = 0.01). After adjusting for age and sex, mediation analyses showed that BMI and baPWV were correlated (β = 0.090, P < 0.001) and mediated by SBP (β = 0.533, P < 0.001) and diastolic blood pressure (DBP) (β = 0.338, P < 0.001). A negative association was found between BMI and ABI (β = -0.135, P < 0.001), which appeared to be partially mediated by SBP (β = 0.124, P < 0.001) and DBP (β = 0.053, P < 0.001). Additional subgroup analysis based on blood pressure levels did not revealed statistically significant mediating effects.

Conclusions

Our findings showed conflicting associations between BMI and non-invasive vascular measurements of arterial stiffness. BP may have a biological interaction in the relationship between BMI and baPWV. Managing blood pressure and weight through comprehensive clinical care is crucial for preventing stiffness or blockage of vessels in middle-aged and older adults.

Positive Psychology Interventions in Medical Populations: Critical Issues in Intervention Development, Testing, and Implementation

Positive psychological well-being is prospectively associated with superior health outcomes. Positive psychology interventions have promise as a potentially feasible and effective means of increasing well-being and health in those with medical illness, and several initial studies have shown the potential of such programs in medical populations. At the same time, numerous key issues in the existing positive psychology literature must be addressed to ensure that these interventions are optimally effective. These include (1) assessing the nature and scope of PPWB as part of intervention development and application; (2) identifying and utilizing theoretical models that can clearly outline potential mechanisms by which positive psychology interventions may affect health outcomes; (3) determining consistent, realistic targets for positive psychology interventions; (4) developing consistent approaches to the promotion of positive psychological well-being; (5) emphasizing the inclusion of diverse samples in treatment development and testing; and (6) considering implementation and scalability from the start of intervention development to ensure effective real-world application. Attention to these six domains could greatly facilitate the generation of effective, replicable, and easily adopted positive psychology programs for medical populations with the potential to have an important impact on public health.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Drug Treatment of Heart Failure in Children: Gaps and Opportunities

Medical therapy for pediatric heart failure is based on a detailed mechanistic understanding of the underlying causes, which are diverse and unlike those encountered in most adult patients. Diuresis and improved perfusion are the immediate goals of care in the child with acute decompensated heart failure. Conversion to maintenance oral therapy for heart failure is based on the results of landmark studies in adults, as well as recent pediatric clinical trials and heart failure guidelines. There will continue to be an important role for newer drugs, some of which are in active trials in adults, and some of which are already approved for use in children. The need to plan for clinical trials in children during drug development for heart failure is emphasized.

Impact of a Social Support Program Supervised by a Multidisciplinary Team on Psychosocial Distress and Knowledge About Heart Failure Among Heart Failure Patients

Background

Heart failure drains significant financial resources with morbidity and mortality higher than cancer. Social support is defined as the care provided by the family members, friends and health care workers to the patients. Absence of social support and poor perceived social support will create stress, anxiety, depression and anger which further deteriorate the underlying disease and worsen quality of life. Discussion in group creates better understanding of the disease which helps the patients improving their skills in managing their condition.

Objective

To evaluate the impact of multidisciplinary team supervised social support program on components of psychosocial distress and knowledge about heart failure among heart failure patients.

Methods

Adult patients with heart failure attending King Fahad Medical City as inpatient or outpatient were enrolled in this prospective cohort study. Patients were given questionnaire to assess their perception of social support they have at their disposal, quality of life, knowledge regarding heart failure and self-care behavior. They then had interactive education in groups supervised by multidisciplinary team members about the pathogenesis of their disease with management strategies, dietary restriction, importance of exercise and healthy life style pattern. Patients shared their experiences in the group and had opportunity to learn from each other. Patients were assessed regarding their perceived social support, quality of life, knowledge regarding heart failure and self-care behavior immediately after the session and at 1 month interval.

Results

There were total 500 patients participated in the study. Among the study participants 62% were male and majority was living with the family. Components of psychosocial distress were present in up to 40% of study participants and only 36% considered knowledgeable regarding heart failure. After the interactive social support group meeting components of psychosocial distress were significantly reduced with significant improvement in knowledge about heart failure. At 1 month follow up participants reported persistent improvement in quality of life, improvement in self-care behavior, perceived social support and wanted to continue in social group program.

Conclusion

Social support program supervised by multidisciplinary team providing education and social support improved knowledge, self-care behavior, perceived social support and quality of life among heart failure patients.

[The risks of re-hospitalization of patients with heart failure with prolonged follow-up in a specialized center for the treatment of heart failure and in real clinical practice.]

Relevance The number of patients with functional class III-IV chronic heart failure (CHF) characterized by frequent rehospitalization for acute decompensated HF (ADHF) has increased. Rehospitalizations significantly increase the cost of patient management and the burden on health care system.Objective To determine the effect of long-term follow-up at a specialized center for treatment of HF (Center for Treatment of Chronic Heart Failure, CTCHF) on the risk of rehospitalization for patients after ADHF.Materials and Methods The study successively included 942 patients with CHF after ADHF. Group 1 consisted of 510 patients who continued the outpatient follows-up at the CTCHF, and group 2 included 432 patients who refused of the follow-up at the CTCHF and were managed at outpatient clinics at their place of residence. CHF patient compliance with recommendations and frequency of rehospitalization for ADHF were determined by outpatient medical records and structured telephone calls. A rehospitalization for ADHF was recorded if the patient stayed for more than one day in the hospital and required intravenous loop diuretics. The follow-up period was two years. Statistical analyses were performed using a Statistica 7.0 software for Windows, SPSS, and a R statistical package.Results Patients of group 2 were significantly older, more frequently had FC III CHF and less frequently had FC I CHF than patients of group 1. Both groups contained more women and HF patients with preserved ejection fraction. Using the method of binary multifactorial logit-regression a mathematical model was created, which showed that risk of rehospitalization during the entire follow-up period did not depend on age and sex but was significantly increased 2.4 times for patients with FC III-IV CHF and 3.4 times for patients of group 2. Multinomial multifactorial logit-regression showed that the risk of one, two, three or more rehospitalizations within two years was significantly higher in group 2 than in group 1 (2.9-4.5 times depending on the number of rehospitalizations) and for patients with FC III-IV CHF compared to patients with FC I-II CHF (2-3.2 times depending on the number of rehospitalizations). Proportion of readmitted patients during the first year of follow-up was significantly greater in group 2 than in group 1 (55.3 % vs. 39.8 % of patients [odd ratio (OR) =1.9; 95% confidence interval (CI), 1.4-2.4; р&lt;0.001]; during the second year, the proportion was 67.4 % vs. 28.2 % (OR=5.3; 95 % CI, 3.9-7.1; р&lt;0.001). Patients of group 1 were readmitted more frequently during the first year than during the second year (р&lt;0,001) whereas patients of group 2 were readmitted more frequently during the second than the first year of follow-up (р&lt;0.001). Total proportion of readmitted patients for two years of follow-up was significantly greater in group 2 (78.0 % vs. 50.6 %) (OR=3.5; 95 % CI, 2.6-4.6; р&lt;0.001). Reasons for rehospitalizations were identified in 88.7 % and 45.9 % of the total number of readmitted patients in groups 1 and 2, respectively. The main cause for ADHF was non-compliance with recommendations in 47.4 % and 66.7 % of patients of groups 1 and 2, respectively (р&lt;0.001).Conclusion Follow-up in the system of specialized health care significantly decreases the risk of rehospitalization during the first and second years of follow-up and during two years in total for both patients with FC I-II CHF and FC III-IV CHF. Despite education of patients, personal contacts with medical personnel, and telephone support, main reasons for rehospitalization were avoidable.

The Association Between Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide With Functional Status in Patients With Heart Failure

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and depressive symptoms are each associated with functional status in patients with heart failure (HF), but their association together with functional status has not been examined.

OBJECTIVE

The aim of this study was to determine whether functional status scores differ as a function of depressive symptoms and NT-proBNP levels considered together.

METHODS

We studied 284 patients with HF who were divided into 4 groups based on the median split of NT-proBNP levels and cut point for depressive symptoms (Beck Depression Inventory ≥ 14): (1) low NT-proBNP of 562.5 pg/mL or less without depressive symptoms, (2) low NT-proBNP of 562.5 pg/mL or less with depressive symptoms, (3) high NT-proBNP of greater than 562.5 pg/mL without depressive symptoms, and (4) high NT-proBNP of greater than 562.5 pg/mL with depressive symptoms. The Duke Activity Status Index was used to assess functional status.

RESULTS

Nonlinear regression demonstrated that patients without depressive symptoms were more than twice as likely to have higher (better) functional status scores than patients with depressive symptoms regardless of NT-proBNP levels after controlling for age, gender, prescribed antidepressants, and body mass index. Functional status levels of patients with low NT-proBNP did not differ from those with high NT-proBNP in the presence of depressive symptoms.

CONCLUSION

When examined together, depressive symptoms rather than NT-proBNP levels predicted functional status.

CLINICAL IMPLICATIONS

Adequate treatment of depressive symptoms may lead to better functional status regardless of HF severity.

Defining the role of peritoneal dialysis in management of congestive heart failure

Introduction: Congestion is an integral component of heart failure (HF) pathophysiology and portends an adverse impact on outcome. Peritoneal dialysis (PD) is a home-based therapeutic modality that has been used in the setting of refractory congestive HF to help optimize volume status. Not only does PD allow for customized sodium and water removal, but it also provides the opportunity for the patients to fully benefit from guideline-directed medical therapy for HF that could have otherwise been challenging to use. Areas covered: Authors provide an overview of the pathophysiologic basis for the use of PD in HF, followed by a review of the findings of the main clinical trials such as the salutary impact on HF re-admissions and quality of life. Since the goals of therapy in this setting differ from those for patients with end-stage renal disease, pertinent practical considerations in the use of this modality are then discussed as well as potential barriers. Expert opinion: For patients with chronic refractory HF, PD represents an alternative to medical therapy alone. Identification of patients that would benefit most from this modality and detection of major enablers and obstacles for the implementation of this therapy should be the focus of future studies.

Contemporary Treatment of Heart Failure

Heart failure (HF) affects 2.4% of the adult population in the United States and is associated with high health care costs. Medical and device therapy delay disease progression and improve survival in HF with reduced ejection fraction. Stage D HF is characterized by significant functional limitation, frequent HF hospitalization for decompensation, intolerance of medical therapy, use of inotropes, and high diuretic requirement. Advanced therapies with left ventricular assist devices and cardiac transplantation reduce mortality and improve quality of life, and early referral to specialized centers is imperative for patient selection and success with these therapies.

Population-based Study of First Hospitalizations for Heart Failure and the Interaction Between Readmissions and Survival

INTRODUCTION AND OBJECTIVES

Disease progression in patients after a first hospitalization for heart failure (HF), in particular the interaction between survival and rehospitalizations, is not well established.

METHODS

We studied all patients with a first hospitalization and main diagnosis of HF from 2009 to 2013 by analyzing the Minimum Data Set of the Region of Murcia. Both incident and recurrent patients were studied, and the trend in hospitalization rates was calculated by joinpoint regression. Patients were followed-up through their health cards until the end of 2015. Mortality and readmissions, including causes and chronology in relation to the time of death, were assessed.

RESULTS

A total of 8258 incident patients were identified, with annual rates increasing (+2.3%, P <.05) up to 1.24 patients per 1000 inhabitants, representing 71% of hospitalized individuals and 57% of total discharges due to HF. In the first year, 22% were readmitted due to HF, 31% due to cardiovascular causes, and 54% due to any cause. Five-year survival was 40%, which was significantly lower than age- and sex-adjusted expected survival for the general population (76%) (P <.001). Among patients who died during follow-up, readmissions (1.5 per patient/y, 0.4 due to HF) showed a "J" pattern, with 48% of rehospitalizations being concentrated in the last 3 deciles of survival prior to death.

CONCLUSIONS

Rates of first hospitalization due to HF continue to increase, with high mortality and rehospitalizations during follow-up, which are concentrated mainly in the period prior to death.

Frequency of Care and Mortality Following an Incident Diagnosis of Peripheral Artery Disease in the Inpatient or Outpatient Setting: The ARIC (Atherosclerosis Risk in Communities) Study

Background

Available health services data for individuals with peripheral artery disease (PAD) are often from studies of those eligible for or undergoing intervention. Knowledge of the frequency of care and mortality following an initial PAD diagnosis by setting (outpatient versus inpatient) is limited and represents an opportunity to provide new benchmark information.

Methods and Results

The purpose of this study was to characterize the frequency of care and mortality following an incident PAD diagnosis in the outpatient or inpatient setting using data from the ARIC (Atherosclerosis Risk in Communities) study cohort linked with Centers for Medicare and Medicaid Services fee‐for‐service claims data (2002–2012). Direct standardization was used to estimate age‐standardized rates of encounters and mortality. PAD was defined by billing code in any claim position. We observed 1086 incident PAD cases (873 outpatient, 213 inpatient). At 1 year after diagnosis, participants diagnosed in the outpatient setting had 2.15 (95% confidence interval [CI], 2.10–2.21) PAD‐related outpatient encounters per person‐year, and 6.4% (95% CI, 4.8–8.1) had a PAD‐related hospitalization. Conversely, participants diagnosed in the inpatient setting had 1.02 (95% CI, 0.94–1.10) PAD‐related outpatient encounters per person‐year, and 14.2% (95% CI, 9.3–18.7) had a PAD‐related rehospitalization. One‐year mortality was 7.1% (95% CI, 5.4–8.7) and 16.0% (95% CI, 11.0–21.1) among those diagnosed in outpatient and inpatient settings, respectively.

Conclusions

This study provides important data estimating frequency of care and mortality by the setting of initial PAD diagnosis. Individuals with PAD are frequent users of health care, and those diagnosed in the inpatient setting have high rates of rehospitalization and mortality.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project

BACKGROUND

Heart failure is a major public health concern which contributes significantly to rising healthcare costs. Comprehensive discharge planning can improve health outcomes and reduce readmission rates which, in turn, can lead to cost savings.

OBJECTIVES

The aim of this project was to promote best practice in the discharge planning of heart failure patients admitted in the coronary care unit of Zhongshan Hospital.

METHODS

A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Five audit criteria that represent best practice recommendations for heart failure discharge planning were used. A baseline audit was conducted followed by the implementation of multiple strategies, and the project was finalized with a follow-up audit to determine change in practice.

RESULTS

Improvements in practice were observed for all five criteria. The most significant improvements were in the following: completion of a discharge checklist (from 0% to 100% compliance), comprehensive (i.e. inclusion of six topics for self-care) discharge education for patients (from 7% to 100% compliance), and conducting a telephone follow-up (from 0% to 76% compliance). The compliance rates for the two remaining criteria, completion of a structured education for patients and scheduling an outpatient clinic visit, both increased from 93% to 100%.Strategies that were implemented to achieve change in practice included development of a local discharge planning checklist, provision of training for nurses, and development of resources.

CONCLUSIONS

The project demonstrated positive changes in the discharge planning practices of nurses in the coronary care unit of Zhongshan Hospital. A formalized discharge planning is currently in place and plans for sustaining practice change are underway. A continuous cycle of audit and re-audit will need to be carried out in the future to determine the impact of this evidence implementation activity on heart failure patient outcomes.

TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care

OBJECTIVE

End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.

METHODS

We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.

RESULTS

Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.

CONCLUSIONS

For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

Role of Clinical Pharmacist in a Heart Failure Clinic

Purpose

To determine if the inclusion of a clinical pharmacist (CP) in a heart failure (HF) multidisciplinary team could lead to a reduction in the number of hospital admissions and additionally decrease the clinical signs and symptoms of HF patients with either Medicaid or no medical insurance.

Methods

Longitudinal study to determine the impact of a pharmaceutical-care service program to HF patients by comparing the 9-month period before (pre-intervention) and the 9-month period after (post-intervention) implementation of the program. The intervention of the CP was directed in two complementary functions. The first was direct patient contact and the second was to provide drug information to the medical clinicians.

Results

Twenty-nine outpatients completed the study. Over 9 months, the CP made a total of 216 interventions and had three in-person, follow-up contacts and three telephone contacts per patient. At post-intervention, there was a statistically significant reduction in the total number of hospitalizations (50 vs 23; P < 0.018) and length of stay (LOS) (263 days vs 108 days; P < 0.03). However, there was an insignificant reduction in HF hospitalizations, LOS, and total number of HF signs and symptoms.

Conclusions

Addition of a CP to an outpatient HF clinic can lead to fewer hospital admissions and a reduction in the LOS in patients with either Medicaid or no medical insurance.

A Personalized and Interactive Web-Based Health Care Innovation to Advance the Quality of Life and Care of Patients With Heart Failure (ACQUIRE-HF): A Mixed Methods Feasibility Study

Background

Heart failure (HF) is a progressive, debilitating, and complex disease, and due to an increasing incidence and prevalence, it represents a global health and economic problem. Hence, there is an urgent need to evaluate alternative care modalities to current practice to safeguard a high level of care for this growing population.

Objective

Our goal was to examine the feasibility of engaging patients to use patient-centered and personalized tools coupled with a Web-based, shared care and interactive platform in order to empower and enable them to live a better life with their disease.

Methods

We used a mixed methods, single-center, pre-post design. Patients with HF and reduced left ventricular ejection fraction (n=26) were recruited from the outpatient HF clinic at Odense University Hospital (Svendborg Hospital), Denmark, between October 2015 and March 2016. Patients were asked to monitor their health status via the platform using the standardized, disease-specific measure, the Kansas City Cardiomyopathy Questionnaire (KCCQ), and to register their weight. A subset of patients and nursing staff were interviewed after 3-month follow-up about their experiences with the platform.

Results

Overall, patients experienced improvement in patient-reported health status but deterioration in self-care behavior between baseline and 3-month follow-up. The mean score reflecting patient expectations toward use prior to start of the study was lower (16 [SD 5]) than their actual experiences with use of the platform (21 [SD 5]) after 3-month follow-up. Of all patients, 19 completed both a baseline and follow-up KCCQ. A total of 9 experienced deterioration in their health status (range from 3-34 points), while 10 experienced an improvement (range from 1-23 points). The qualitative data indicated that the majority of patients found the registration and monitoring on the platform useful. Both nursing staff and patients indicated that such monitoring could be a useful tool to engage and empower patients, in particular when patients are just diagnosed with HF.

Conclusions

The use of patient tracking and monitoring of health status in HF using a standardized and validated measure seems feasible and may lead to insights that will help educate, empower, and engage patients more in their own disease management, although it is not suitable for all patients. Nursing staff found the patient-centered tool beneficial as a communication tool with patients but were more reticent with respect to using it as a replacement for the personal contact in the outpatient clinic.

Polish Nurses' Knowledge of Heart Failure Self-Care Education Principles

: On the basis of management guidelines, multidisciplinary treatments are essential in the care of patients with heart failure (HF) to improve quality of life and clinical outcomes.

PURPOSE

The aim of the study was to assess nurses' knowledge of HF self-care principles as a way to be prepared for educating patients about HF self-care maintenance and management.

METHODS

Nurses providing cardiology intensive care (n = 48), nonintensive hospital care (n = 129), and family practices care (n = 50) completed the Nurses' Knowledge of HF Education Principles survey. Data were analyzed using descriptive statistics, Student t test, analysis of variance for qualitative variables, the Kruskal-Wallis correlation test, simple linear regression, and Pearson rank correlation for continuous variables.

RESULTS

Mean (SD) HF self-care maintenance knowledge score was 12.1 (2.7) that equated to 60.4% (13.4%). Scores were highest among nurses working in cardiology intensive care (12.39 [2.7]) and noninvasive care (12.3 [2.7]) and lowest in family medicine (10.74 [2.3]), P < .001. Nurses' knowledge was associated with level of education (r = 0.1399, P = .05), number of graduate courses (r = 0.1483, P = .05), and specialization in cardiac nursing (r = 0.1457, P = .05).

CONCLUSIONS

Polish nurses' knowledge deficits in HF self-care principles may lead to problems in providing patients with adequate education.

'Who is on your health-care team?' Asking individuals with heart failure about care team membership and roles

BACKGROUND

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care.

OBJECTIVES

To explore how individuals with HF conceptualize their care team, and perceive team members' roles.

SETTING AND PARTICIPANTS

Individuals with advanced HF were recruited from five cities in three Canadian provinces.

DESIGN

Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis.

RESULTS

A total of 62 individuals with HF identified 2-19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management.

DISCUSSION

Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses.

CONCLUSION

Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens - and collaborating meaningfully among identified team members - may improve health-care delivery.

Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial

BACKGROUND

A Dutch online patient decision aid to support prosthetic heart valve selection was recently developed. A multicenter randomized controlled trial was conducted to assess whether use of the patient decision aid results in optimization of shared decision making in prosthetic heart valve selection.

METHODS AND RESULTS

In a 5-center randomized controlled trial, patients were allocated to receive either standard preoperative care (control group) or additional access to the patient decision aid (intervention group). Legally capable adult patients accepted for elective isolated or combined aortic and mitral valve replacement were included. Primary outcome was preoperative decisional conflict (Decisional Conflict Scale); secondary outcomes included patient knowledge, involvement in valve selection, anxiety and depression, (valve-specific) quality of life, and regret. Out of 306 eligible patients, 155 were randomized (78 control and 77 intervention). Preoperative decisional conflict did not differ between the groups (34% versus 33%; P=0.834). Intervention patients felt better informed (median Decisional Conflict Scale informed subscore: 8 versus 17; P=0.046) and had a better knowledge of prosthetic valves (85% versus 68%; P=0.004). Intervention patients experienced less anxiety and depression (median Hospital Anxiety and Depression Scale score: 6 versus 9; P=0.015) and better mental well-being (mean Short Form Health Survey score: 54 versus 50; P=0.032). Three months postoperatively, valve-specific quality of life and regret did not differ between the groups.

CONCLUSIONS

A patient decision aid to support shared decision making in prosthetic heart valve selection does not lower decisional conflict. It does result in more knowledgeable, better informed, and less anxious and depressed patients, with a better mental well-being.

CLINICAL TRIAL REGISTRATION

http://www.trialregister.nl. Unique identifier: NTR4350.

Patient satisfaction with nurse-led chronic kidney disease clinics: A multicentre evaluation

BACKGROUND

There is growing international evidence that nurse-led chronic kidney disease (CKD) clinics provide a comprehensive approach to achieving clinical targets effective in slowing the progression of CKD. Across Queensland, Australia, these clinics have been established in many renal outpatient departments although patient satisfaction with these clinics is unknown.

OBJECTIVES

To measure patient satisfaction levels with CKD nurse-led clinics.

METHOD

This was a cross-sectional study undertaken at five clinics located in metropolitan, regional and remote hospitals in Queensland. Participants were >18 years of age (no upper age limit) with CKD (non-dialysis) who attended CKD nurse-led clinics over a six month period (N = 873). They completed the Nurse Practitioner Patient Satisfaction questionnaire which was modified for CKD.

RESULTS

The response rate was 64.3 % (n = 561); half of the respondents were male (55.5 %), there was a median age range of 71-80 years (43.5 %) and most respondents were pensioners or retired (84.2 %). While the majority reported that they were highly satisfied with the quality of care provided by the nurse (83.8 %), we detected differences in some aspects of satisfaction between genders, age groups and familiarity with the nurse. Overall, patients' comments were highly positive with a few improvements to the service being suggested; these related to car-parking, providing more practical support, and having accessible locations.

CONCLUSION

In an era of person-centred care, it is important to measure patient satisfaction using appropriate and standardised questionnaires. Our results highlight that, to improve services, communication strategies should be optimised in nurse-led clinics.

Improving quality of life and decreasing readmissions in heart failure patients in a multidisciplinary transition-to-care clinic

OBJECTIVES

The purpose was to pilot the feasibility and impact of a 4-week transition-to-care program on quality of life for heart failure patients.

BACKGROUND

The transition from the acute care to the outpatient setting has been shown to be a critical time with heart failure patients.

METHODS

A pre- and post-test design was used. Quality of Life, measured by the Minnesota Living with Heart Failure Questionnaire, and hospital readmissions were the outcomes. A convenience sample of 50 persons was recruited into a multidisciplinary transition-to-care program for heart failure patients following hospitalization. Thirty-six (72%) completed the study.

RESULTS

There was a significant improvement in quality of life. Men reported greater improvement in physical symptoms and less emotional distress when compared to women. Only 2 participants were readmitted within 30 days.

CONCLUSIONS

Study findings support improved quality of life and decreased readmission rates following a multidisciplinary transition-to care program for heart failure patients.

Gender Differences in Patients with Heart Failure

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

Adult congenital heart disease nurse coordination: Essential skills and role in optimizing team-based care a position statement from the International Society for Adult Congenital Heart Disease (ISACHD)

BACKGROUND

Founded in 1992, the International Society for Adult Congenital Heart Disease (ISACHD) is the leading global organization of professionals dedicated to pursuing excellence in the care of adults with congenital heart disease (CHD) worldwide. Among ISACHD's objectives is to "promote a holistic team-based approach to the care of the adult with CHD that is comprehensive, patient-centered, and interdisciplinary" (http://www.isachd.org). This emphasis on team-based care reflects the fact that adults with CHD constitute a heterogeneous population with a wide spectrum of disease complexity, frequent association with other organ involvement, and varied co-morbidities and psychosocial issues.

METHODS

Recognizing the vital role of the adult CHD (ACHD) nurse coordinator (ACHD-NC) in optimizing team-based care, ISACHD established a task force to elucidate and provide guidance on the roles and responsibilities of the ACHD-NC. Acknowledging that nursing roles can vary widely from region to region based on factors such as credentials, scopes of practice, regulations, and local culture and tradition, an international panel was assembled with experts from North America, Europe, East Asia, and Oceania. The writing committee was tasked with reviewing key aspects of the ACHD-NC's role in team-based ACHD care.

RESULTS/CONCLUSION

The resulting ISACHD position statement addresses the ACHD-NC's role and skills required in organizing, coordinating, and facilitating the care of adults with CHD, holistic assessment of the ACHD patient, patient education and counseling, and support for self-care management and self-advocacy.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Nurse-Managed Heart Failure Programmes in the Netherlands

Heart failure (HF) care in Europe is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients in the Netherlands. The first steps to organise HF nurses have been taken and an overview of HF management programmes in Netherlands has been recently made available. A descriptive study was performed consisting of: (1) a screening phase in which all hospitals ( n=109) and 105 home care organisations were approached by telephone to assess availability of HF management programmes and (2) a questionnaires in which content and organisation of the programmes were described. At the moment, the majority of all the hospitals (75%) have, or are currently developing a HF management programme. In 19 home care organisations (18%) a programme was available and 3 organisations had concrete plans to start on short notice. Components of HF programmes differ considerably, with follow-up after discharge from the hospital as the most often reported component. Other components of programmes include patient education, increased access to health care professionals and adjusting medication. Exercise programmes are not often available. Organisational aspects in regard to setting, financing and staffing also differ between various programmes. It was concluded that there is a considerable increase in the number of HF management programmes in the Netherlands, both hospital based and home based. A lot of questions in regard to the most optimal content and the organisation of HF management programmes remain unanswered.

Development of the Mexican Heart Team: The Long and Winding Road

Heart failure (HF) is the leading cause of death worldwide. Efforts to decrease HF mortality rates include a multidisciplinary approach management. Although evidence suggests that this has been an optimal strategy for treating HF, the model remains not widely implanted. The current article explores the rationale behind the formation of a Heart Team in a developing country and its development despite the lack of an allocated budget.

Team-based Palliative and End-of-life Care for Heart Failure

Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.

Team-Based Care for Outpatients with Heart Failure

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

Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial

BACKGROUND

The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure (HF) patients.

OBJECTIVE

The purpose of this article is to (1) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies, (2) describe resources and materials used in the group clinic appointment, and (3) present results supporting this patient-centered group intervention.

METHODS

This clinical trial included 198 HF patients (randomized to either group clinical appointments or to standard care). Data were collected from 72 group clinic appointments via patients' (1) group clinic session evaluations, (2) HF self-care behaviors skills, (3) HF-related discouragement and quality of life scores, and (4) HF-related reshopitalizations during the 12-month follow-up. Also, the costs of delivery of the group clinical appointments were tabulated.

RESULTS

Overall, patients rated group appointments as 4.8 of 5 on the "helpfulness" in managing HF score. The statistical model showed a 33% decrease in the rate of rehospitalizations (incidence rate ratio, 0.67) associated with the intervention over the 12-month follow-up period when compared with control patients (χ(2)1=3.9, P=.04). The total cost for implementing 5 group appointments was $243.58 per patient.

CONCLUSION

The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care. In turn, better self-care was associated with reductions in HF-related hospitalizations.

The changes and factors associated with post-discharge self-care behaviors among Chinese patients with heart failure

BACKGROUND

Self-care behavior is essential for achieving good outcomes among patients with heart failure. Understanding the factors associated with self-care over time is important for the provision of appropriate and targeted interventions. However, little is known regarding the changes and factors associated with post-discharge self-care behaviors among Chinese patients with heart failure.

OBJECTIVE

To investigate the changes and factors of self-care behaviors during the first 3 months following discharge among patients with heart failure in the People's Republic of China.

METHODS

A descriptive design with a convenience sample was utilized in this study. Patients (N=128) from two hospitals, West China Hospital and Angjin Hospital, in Chengdu, People's Republic of China, were recruited from June 2013 to June 2014. The instruments used in the study included the following: the Social Support Rating Scale, the Hospital Anxiety and Depression Scale, the Self-Efficacy for Managing Chronic Disease 6-Item Scale, and the European Heart Failure Self-Care Behaviour Scale. Multivariate linear regression analyses were used to identify the factors related to self-care behaviors at baseline, 1 month, and 3 months following discharge.

RESULTS

Patients' self-care behaviors were poor and decreased significantly over time (F=4.09, P<0.05). The factors associated with self-care behaviors at baseline included the following: education level, comorbidities, and social support. The factors related to self-care behaviors at 1 and 3 months following discharge included the following: education level, comorbidities, social support, and self-efficacy. The variances in self-care behaviors attributed to these factors were 43%, 46%, and 42% at baseline, 1 month, and 3 months following discharge, respectively.

CONCLUSION

Additional support should be provided to patients with heart failure with low educational levels and patients with multiple comorbidities. Follow-up, continuity of care, and family caregiver integration following discharge are necessary for the said patients to improve their self-care behaviors and obtain better outcomes.