Effect of a heart failure program on hospitalization frequency and exercise tolerance

Hospitalization outcome of heart diseases between patients who received medical care by cardiologists and non-cardiologist physicians: A propensity-score matched study

Background and aims

The effects of physician specialty on the outcome of heart disease remains incompletely understood because of inconsistent findings from some previous studies. Our purpose is to compare the admission outcomes of heart disease in patients receiving care by cardiologists and noncardiologist (NC) physicians.

Methods

Using reimbursement claims data of Taiwan’s National Health Insurance from 2008–2013, we conducted a matched study of 6264 patients aged ≥20 years who received a cardiologist’s care during admission for heart disease. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, and type of heart disease, 6264 controls who received an NC physician’s care were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for complications and mortality during admission for heart disease associated with a cardiologist’s care.

Results

Patients who received a cardiologist’s care had a lower risk of pneumonia (OR = 0.61; 95% CI, 0.53–0.70), septicemia (OR = 0.49; 95% CI, 0.39–0.61), urinary tract infection (OR = 0.76; 95% CI, 0.66–0.88), and in-hospital mortality (OR = 0.37; 95% CI, 0.29–0.47) than did patients who received an NC physician’s care. The association between a cardiologist’s care and reduced adverse events following admission was significant in both sexes and in patients aged ≥40 years.

Conclusion

We raised the possibility that cardiologist care was associated with reduced infectious complications and mortality among patients who were admitted due to heart disease.

Implementation of a Multidisciplinary Inpatient Cardiology Service to Improve Heart Failure Outcomes in Guyana

BACKGROUND

Guyana is a small developing country with a high burden of cardiovascular disease and extensive barriers to optimal care delivery. We investigated the effectiveness of a newly established multidisciplinary inpatient cardiology service in this setting.

METHODS

We performed an interrupted time-series cohort study of heart failure (HF) patients admitted to the Georgetown Public Hospital Corporation from January to December 2015 and July 2016 to December 2017. The primary outcome was discharge on guideline-directed medical therapy (GDMT). Secondary outcomes included length of hospitalization and all-cause mortality.

RESULTS

We identified 740 patients, 347 (46.9%) of whom were admitted after service implementation. The postimplementation cohort was more likely to be discharged on a beta-blocker (66.6% vs 41.7%; P < .01) and mineralocorticoid receptor antagonist (31.7% vs 15.3%; P = .01). They were also more likely to undergo echocardiography (60.8% vs 40.5%; P < .01) and chest x-rays (70.6% vs 46.6%; P < .01). Hospitalization length (10.0 ± 13.1 vs 9.8 ± 10.1 days) and readmissions within 90 days (19.0% vs 19.1%) were not significantly different. There were fewer deaths in the postimplementation cohort compared with the preimplementation cohort (12/347 vs 28/393).

CONCLUSIONS

Establishment of a multidisciplinary inpatient cardiology service demonstrated increased adherence to GDMT without extending length of hospitalization.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions

Background

Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies.

Method

Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy.

Results

Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital’s side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients.

Conclusion

Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

Rationales and choices for the treatment of patients with NYHA class II heart failure

Heart failure (HF) in the United States represents a significant burden for patients and a tremendous strain on the healthcare system. Patients receiving a diagnosis of HF can be placed into 1 of 4 New York Heart Association (NYHA) functional classifications; the greatest proportion of patients are in the NYHA class II category, which is defined as patients having a slight limitation of physical activity but who are comfortable at rest, and for whom ordinary physical activity results in symptoms of HF. Because the severity of NYHA class II HF may be perceived as mild or unalarming by this definition, the urgency to treat this type of HF may be overlooked. However, these patients are optimal candidates for active intervention because their HF is at a critical point on the disease progression continuum when untoward changes can be halted or reversed. This review discusses the physiological consequences of NYHA class II HF with reduced ejection fraction and describes recent clinical trials that have demonstrated a therapeutic benefit for patients in this population. In doing so, we hope to establish that patients with NYHA class II disease merit careful attention and to provide reassurance to the treating community that options are available for these patients.

Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries

INTRODUCTION AND OBJECTIVES

The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists.

METHODS

We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome.

RESULTS

Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695).

CONCLUSIONS

Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.

Telecardiology: One-lead electrocardiogram monitoring and nurse triage in chronic heart failure

We investigated a home-based intervention based on telecardiology in patients with chronic heart failure (CHF). Two hundred and thirty CHF patients, aged 59 years (SD 9), in stable condition and with optimized therapy were enrolled. The programme consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring followed by visits from a paramedical and medical team. The patient could call the centre when required (tele-assistance), while the team could call the patient at pre-scheduled times (telemonitoring). During the first 12 months, there were 3767 calls (873 ad hoc and 2894 scheduled calls). There were 648 events, including 126 episodes of asymptomatic hypotension and 168 episodes which were not due to cardiological symptoms. No actions were taken by the nurse after 2417 calls (64%). A change in therapy was suggested after 418 calls, hospital admission in 62 patients, further investigations for 243 patients and a consultation with the general practitioner in 41 patients. A total of 2303 one-lead ECG recordings were received (10 per patient); 126 recordings (6%) were diagnosed as pathological in comparison with the baseline one. The one-lead ECG recording was used for titration of beta-blockers in 79 patients (mean dosage 38 mg vs 42 mg, P<0.01). Home telenursing could be an important application of telemedicine and single-lead ECG recording seems to offer additional benefit in comparison with telephone follow-up alone.

Effect of home-based telecardiology on chronic heart failure: Costs and outcomes

Chronic heart failure (CHF) remains a common cause of disability. We have investigated the use of home-based telecardiology (HBT) in CHF patients. Four hundred and twenty-six patients were enrolled in the study: 230 in the HBT group and 196 in the usual-care group. HBT consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring, followed by visits from the paramedical and medical team. A one-lead ECG recording was transmitted to a receiving station, where a nurse was available for reporting and interactive teleconsultation. The patient could call the centre when assistance was required (tele-assistance), while the team could call the patient for scheduled appointments (telemonitoring). The one-year clinical outcomes showed that there was a significant reduction in rehospitalizations in the HBT group compared with the usual-care group (24% versus 34%, respectively). There was an increase in quality of life in the HBT group (mean Minnesota Living Questionnaire scores 29 and 23.5, respectively). The total costs were lower in the HBT group (107,494 and 140,874, respectively). The results suggest that a telecardiology service can detect and prevent clinical instability, reduce rehospitalization and lower the cost of managing CHF patients.

Chronic heart failure home-based management with a telecardiology system: A comparison between patients followed by general practitioners and by a cardiology department

A group of patients with chronic heart failure (CHF) were followed by general practitioners (GPs) with a telecardiology system, and a second group of patients were followed by a home-based telemonitoring (HBT) protocol with medical and nursing supervision. The 212 GP patients were older than the 226 HBT patients, mostly women, with CHF secondary to chronic hypertension, less self-sufficient and with a non-optimized therapy. The mean number of telephone calls was 2.6 per patient in the GP group and 16.6 per patient in the HBT group (P<0.001). These preliminary data suggest the applicability and the efficacy of both management models for CHF 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.

Classification and Quality Standards of Heart Failure Units: Scientific Consensus of the Spanish Society of Cardiology

The prevalence of heart failure remains high and represents the highest disease burden in Spain. Heart failure units have been developed to systematize the diagnosis, treatment, and clinical follow-up of heart failure patients, provide a structure to coordinate the actions of various entities and personnel involved in patient care, and improve prognosis and quality of life. There is ample evidence on the benefits of heart failure units or programs, which have become widespread in Spain. One of the challenges to the analysis of heart failure units is standardization of their classification, by determining which "programs" can be identified as heart failure "units" and by characterizing their complexity level. The aim of this article was to present the standards developed by the Spanish Society of Cardiology to classify and establish the requirements for heart failure units within the SEC-Excellence project.

Home-Based Disease Management in Congestive Heart Failure

Disease management programs have emerged as a comprehensive strategy to decrease costs and increase quality of care for patients with chronic diseases. It is a long-term strategy that emphasizes patient involvement in his or her own care and early recognition of potential worsening of the condition. Disease management programs address more than just the educational needs of patients by intervening before the problems get out of control. Because of their role in patients’ homes and lives, home care nurses are ideal agents of disease management. This discussion presents a comparison of disease management in home care and proposes a way for the best of both entities to be combined in the setting of congestive heart failure (CHF). The program developed at the Visiting Nurse Association of Maryland is presented as an example of how the two can be blended to address the complex problems of patients with CHF.

Effect of Home-Based Intervention on Hospital Readmission and Quality of Life in Middle-Aged Patients with Severe Congestive Heart Failure: A 12-Month Follow Up Study

Objective: Home care surveillance has been shown to reduce hospital readmission and improve functional status and quality of life of elderly patients with mild to moderate or severe congestive heart failure and in younger patients candidates for transplantation. The present study aimed to investigate the effect of home-based intervention on hospital readmission and quality of life of middle-aged patients with severe congestive heart failure. Methods: Thirty-three patients aged 50–75 (mean age 65.4±6.7) with class III and IV congestive heart failure were included in this observational, community-based study. Intervention consisted of intensive home surveillance of patients, including frequent home visits associated with laboratory tests and telephone contacts to implement standard therapy, treat early symptoms and provide psychological support. Results: Admissions for cardiovascular reasons decreased from 2.143±1.11 for the year before the initiation of the study to 1.25±1 after its completion ( P=0.0005). Quality of life improved, as showed by a decrease of the mean score of the Minnesota Living with Heart Failure Questionnaire from 2.68±0.034 to 2.33±0.032 ( P=0.0001). Conclusion: Intensive home care of middle-aged patients with severe heart failure results in improved quality of life and a decrease in hospital readmission rates.

Patient's Education by Nurse: What We Really do Achieve?

Aim: To evaluate what is really achieved with nurse education in an outpatient heart failure population.

Method: The answers obtained in a nurse questionnaire performed at the first visit to the Unit and at 1 year of follow-up were compared. The questionnaire was addressed to know how compliant patients were and how much they knew about their disease and their treatment.

Results: Two hundred and ninety eight patients (219 men and 79 women) were evaluated. Baseline mean age was 65 years (35–86). At first visit only 30% knew and understood the performance of the heart; 56% at 1 year ( p < 0.001). Only 28% initially understood the disease; 55% at follow-up ( p < 0.001). Awareness of more than 3 worsening signs increased from 66.5% to 86.5% ( p < 0.001). Knowledge of the names of all the pills they were receiving increased from 33% to 44% ( p < 0.001), of the action of these pills from 24% to 44% ( p < 0.001), and of how to use nitroglycerine among patients with ischemic heart disease from 87% to 96% ( p < 0.001). Initially 63% monitored their weight only at the medical visit and 21% monitored it at least once a week; at 1 year these percentages were 16% and 39% respectively ( p < 0.001). At baseline 45% checked blood pressure only at the medical visit and 28.5% checked it at least once a week; at 1 year these percentages were 12% and 43% ( p < 0.001). Whereas no significant differences were found in sodium restricted diet compliance, exercise performance increased slightly although statistically significantly ( p = 0.01). The great majority of patients never or only very rarely smoked or drunk alcoholic beverages, both at first visit and at 1 year, although both habits increased slightly during follow-up. No significant differences in treatment compliance (92% vs. 88% were taking all the medications prescribed) were found.

Conclusion: Nurse-guided education has changed self-care behaviour of patients with heart failure in several important aspects, as weight and blood monitoring, and has increased their knowledge and understanding of the disease and treatment. However, these improvements have not been reflected in a better compliance of treatment and sodium restricted diet. Such aspects need more and more work to obtain better results.

Patient's View of Heart Failure: From the Understanding to the Quality of Life

BACKGROUND

Non-pharmacological management is one of heart failure treatment cornerstones. Despite its importance several studies showed lack of clinical advising by medical staff as well as poor patient compliance to education and pharmacological treatment. Hospitalizations and symptoms of heart failure negatively influence patients' quality of life. In Slovenia there is a scarcity of non-pharmacological management and quality of life data in heart failure patients.

AIMS

We wanted to obtain data on heart failure patient's quality of life and their satisfaction with management of the condition in Slovenia.

METHODS

During 6 weeks, patients from one university and two community Slovenian hospitals were prospectively enrolled to the EuroHeart survey. We invited 415 patients (mean age 70.6+/-11.4 years, 53% men) to attend an interview 12 weeks after the discharge. Out of 415 eligible patients 25 (6%) died during follow up period and 187 (45%) attended the interview. Twenty-three percent of them were re-hospitalized. Vast majority (89%) of interviewed patients were aware of their heart condition but only 61% were satisfied with the explanation of their clinical condition given by medical staff. On average they were taking 6.3+/-2.3 drugs. General clinical advice (salt intake 65%, cholesterol or fat intake 63%) was more common than specific (daily weighing 35%, avoidance of non-steroidal anti-inflammatory drugs 17%). Patients reported high adherence as only 3% of given advice were neglected. Symptoms of heart failure were much less common at rest than during daily activity (breathlessness in 20% and 78%, fatigue in 18% and 81%, respectively). Psychological symptoms as anxiety (70%), depression (50%) and stress (48%) were common, as well as cognitive and sleep disturbances, both present in more than half of the patients.

CONCLUSIONS

Patients with heart failure experienced restrictions in quality of life and psychological status. Non-pharmacological and pharmacological management and patient's satisfaction with medical care were below optimal. Educational strategies for medical staff and patients as well as organization of an out-patient setting in community hospitals are needed.

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.

Heart failure in South Asia

South Asia (SA) is both the most populous and the most densely populated geographical region in the world. The countries in this region are undergoing epidemiological transition and are facing the double burden of infectious and non-communicable diseases.

Heart failure (HF) is a major and increasing burden all over the world. In this review, we discuss the epidemiology of HF in SA today and its impact in the health system of the countries in the region. There are no reliable estimates of incidence and prevalence of HF (heart failure) from this region.

The prevalence of HF which is predominantly a disease of the elderly is likely to rise in this region due to the growing age of the population. Patients admitted with HF in the SA region are relatively younger than their western counterparts. The etiology of HF in this region is also different from the western world. Untreated congenital heart disease and rheumatic heart disease still contribute significantly to the burden of HF in this region. Due to epidemiological transition, the prevalence of hypertension, diabetes mellitus, obesity and smoking is on the rise in this region. This is likely to escalate the prevalence of HF in South Asia.

We also discuss potential developments in the field of HF management likely to occur in the nations in South Asia. Finally, we discuss the interventions for prevention of HF in this region

Delayed hospital presentation in acute decompensated heart failure: clinical and patient reported factors

BACKGROUND

Patients with acute decompensated heart failure (ADHF) often wait a considerable amount of time before going to the hospital. Prior studies have examined the reasons why such delays may occur, but additional studies are needed to identify modifiable factors contributing to these delays.

PURPOSE

To describe care-seeking delay times, factors associated with prolonged delay, and patient's thoughts and actions in adult men and women hospitalized with ADHF.

METHODS

We surveyed 1271 patients hospitalized with ADHF at 8 urban medical centers between 2007 and 2010.

RESULTS

The average age of our study population was 73 years, 47% were female, and 72% had prior heart failure. The median duration of pre-hospital delay prior to hospital presentation was 5.3 h. Patients who delayed longer than the median were older, more likely to have diabetes, peripheral edema, to have symptoms that began in the afternoon, and to have contacted their medical provider(s) about their symptoms. Prolonged care seekers were less likely to have attributed their symptoms to ADHF, less likely to want to have bothered their doctor or family, and were more likely to be concerned about missing work due to their illness (all p values < 0.05).

CONCLUSIONS

Care-seeking delays are common among patients with ADHF. A variety of factors contribute to these delays, which in some cases may represent efforts to manage ADHF symptoms at home. More research is needed to better understand the detrimental effects of these delays and how best to encourage timely care-seeking behavior in the setting of ADHF.

Telephone counseling for patients with chronic heart failure: results of an evaluation study

BACKGROUND

The effectiveness of a secondary prevention program for patients suffering from chronic heart failure (CHF) was evaluated.

PURPOSE

The program aimed at improving participants' perceived health and actual physical symptoms. Insurants of a German health insurance company participated in a telephone counseling program with four modules focusing on dietary habits, physical activity, fluid intake, and medication compliance.

METHOD

Multilevel analyses were conducted to analyze changes in health related outcome variables over time in N = 259 participants who completed the program in about 6 months.

RESULTS

The results showed an improvement of perceived health status, physical symptoms, and somatic impairment. Furthermore, differential change was found when comparing "finishers" compared to "non-finishers" of specific modules indicating specific module effects.

CONCLUSION

The results are auspicious and, if sustained, are expected to bring about long-term health benefits for our study's participants. The program proved to be applicable and well accepted in the sample of older, severely impaired CHF patients and effective in changing perceived health.

Costs and benefits of personalized healthcare for patients with chronic heart failure in the care and education program "Telemedicine for the Heart"

OBJECTIVE

A health economic analysis was conducted to evaluate the program "Telemedicine for the Heart," which the German Foundation for the Chronically Ill organizes for the Techniker Krankenkasse, one of the biggest German statutory health insurance funds. The program consists of nurse-calls to motivate patients to perform regular self-measurements (blood pressure, pulse, weight) with either their own or telemedical measuring devices provided by the program. In the case of measured values outside of set limits, calls to treating physicians were placed to allow for the initiation of therapy adjustments where applicable.

MATERIALS AND METHODS

To evaluate the program, a retrospective matched-pairs analysis was performed. Program participants (n=281) and regularly insured patients (n=843) were matched for demographics and morbidity status and compared according to their use of resources.

RESULTS

Significant cost differences in favor of the study group of up to 25% in relation to total costs could be detected, particularly in the group of New York Heart Association (NYHA) classification II patients (persons with mild symptoms and slight limitation according to the NYHA classification for the extent of heart failure). In the more severe NYHA stages III and IV the cost relation differed and showed a slight cost disadvantage for the program group. Mortality was 35.1% lower in the program group than in the control group. Quality of life measures were almost constant over the observation time, compatible with a positive impact of the program on the highly impaired patient group.

CONCLUSIONS

The findings suggest that, besides a reduction of costs, by participating in "Telemedicine for the Heart" patients with chronic heart failure experienced a reduced number of hospital stays, optimized medical therapy, better quality of life, and reduced mortality.

Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial

OBJECTIVE

To examine the changes in performance on heart failure knowledge assessments administered before and after discharge education.

METHODS

We conducted a randomized controlled trial comparing the effects of a 1-h, one-on-one teaching session with a nurse educator to the standard discharge process in patients with systolic heart failure. Patients completed a 30 point heart failure knowledge questionnaire (HFKQ) prior to and 3 months after the education intervention.

RESULTS

Patients randomized to the nurse education intervention (n=113) demonstrated significantly higher total HFKQ score increases compared to patients receiving the standard discharge process (n=114) (median, IQR 1, 0 to 4 vs 0, -2 to 2, p=0.007). Patients experiencing death or rehospitalization in the subsequent 6 months were found to have significantly lower HFKQ scores (10, 7 to 12 vs 11, 8 to 13, p=0.002) compared to patients without a clinical event.

CONCLUSION

Heart failure nurse education at the time of hospital discharge results in improved patient knowledge and reduced risk of readmission.

PRACTICE IMPLICATIONS

Health care personnel should encourage education sessions for heart failure patients. Resources possibly need to be allocated for nurse led education sessions in heart failure patients as it improves outcomes and knowledge.

Towards a Personal Health Management Assistant

We describe design and prototyping efforts for a Personal Health Management Assistant for heart failure patients as part of Project HealthDesign. An assistant is more than simply an application. An assistant understands what its users need to do, interacts naturally with them, reacts to what they say and do, and is proactive in helping them manage their health. In this project, we focused on heart failure, which is not only a prevalent and economically significant disease, but also one that is very amenable to self-care. Working with patients, and building on our prior experience with conversational assistants, we designed and developed a prototype system that helps heart failure patients record objective and subjective observations using spoken natural language conversation. Our experience suggests that it is feasible to build such systems and that patients would use them. The system is designed to support rapid application to other self-care settings.

Six-minute walk distance predicts 30-day readmission in hospitalized heart failure patients

BACKGROUND AND AIMS

Identification of patients with heart failure (HF) at high risk of hospital readmission is critical to refine processes for reducing readmission rates. We hypothesized that patients with higher 6-min walk (6MW) distance at the time of hospital discharge are at low risk for early readmission.

METHODS

We prospectively enrolled 265 patients admitted with HF and left ventricular systolic dysfunction. 6MW testing was administered prior to discharge. Multivariate logistic regression analysis was performed to determine the relationship between 6MW distance and 30-day readmission, stratifying by ≤400 m and >400 m.

RESULTS

Two hundred ten patients underwent 6MW testing prior to discharge. Patients with 6MW >400 m had a 30-day readmission rate of 15.9%, whereas patients with 6MW ≤400 m had a 30-day readmission rate of 30.3% (p = 0.016). Patients requiring readmission within 30 days had a median 6MW of 30 m, whereas patients not requiring readmission at 30 days walked 338 m (p = 0.012). 6MW distance predicted freedom from readmission at 30 days (OR: 0.435, 95% CI 0.21-0.9, p = 0.025). Other independent predictors of 30-day readmission included history of gout (0.117, 0.021-0.637, p = 0.013), use of angiotensin-converting enzyme inhibitor or accepted alternative (0.372, 0.169-0.820, p = 0.014) and blood urea nitrogen level (1.019, 1.003-1.035, p = 0.020).

CONCLUSIONS

Low 6MW distance predicts early hospital readmission in patients with HF. Programs seeking to produce systems that are effective in reducing early hospital readmission may desire to incorporate 6MW testing during HF hospital care.

Evaluating outpatient pharmacy services: a literature review of specialist heart failure services

Objective

To identify appropriate methods to evaluate a specialist pharmacy service for heart failure patients in an ambulatory care setting.

Method

An extensive literature review was undertaken to identify the published data on evaluative studies of specialist pharmacy services, including those directed at heart failure patients in an ambulatory care model of service provision.

Key findings

Six studies were identified evaluating outpatient pharmacy services for heart failure. The pharmacy services provided in these settings were not well defined. The impact of the pharmacist was compared to ‘usual care’, that is care delivered without a pharmacist, by either a prospective randomised controlled trial (RCT), or before and after studies. In most cases the service was delivered by one pharmacist at one site. Services were primarily targeted at patients and focused on medication and lifestyle education, adverse drug reaction monitoring, and compliance/adherence. In all studies, there was a trend for improvement in the outcomes measured. Different study endpoints were examined, including process indicators such as compliance and outcome measures such as morbidity (clinical), quality of life (humanistic), and hospital admissions (economic). The ideal evaluative study would be an adequately powered, prospective, randomised controlled trial, comparing the effect of the pharmacist service to usual care (without the specified pharmacy service). Appropriate study endpoints including process indicators and outcome measures are needed. Identification of specific components and the extent of the service that would provide the most benefit to selected patient groups would be of interest.

Conclusions

Specialist ambulatory care pharmacy services have not been well defined or evaluated in the literature. Limited randomised controlled data exist.

Factors related to time to admission to specialized multidisciplinary clinics in patients with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF.

OBJECTIVES

To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics.

METHODS

Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients.

RESULTS

A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF.

CONCLUSION

There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.

Prognostic markers in heart failure--congestion, neurohormones, and the cardiorenal syndrome

There are several markers of poor prognosis in heart failure (HF). The most established markers of poor prognosis in HF include neurohormonal (NH) imbalance, low ejection fraction (EF), ventricular arrhythmias, intraventricular conduction delays, low functional capacity, low SBP, and renal failure. The relative importance of these factors is unknown, as they have never been studied together. We present a 74-year-old female with nonischemic cardiomyopathy and an EF<20% who over 24 years since diagnosis, never developed clinical or hemodynamic congestion, was never hospitalized for HF, and never required a loop diuretic. She had all of the clinical indicators of poor prognosis in HF except for severe NH imbalance and renal failure, illustrating their importance in HF prognosis. While NH activation in HF is initially an adaptive mechanism, an imbalance of NH effectors causes congestion leading to a vicious cycle of congestion, renal dysfunction, and worsening of HF. The combination of NH activation and renal failure in HF is a vasomotor nephropathy known as the cardiorenal syndrome (CRS) and portends a poor prognosis. Pharmacological disruption of NH pathways early in HF may prevent CRS and, therefore, improve outcomes.

Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) remains a common cause of disability, death and hospital admission. Several investigations support the usefulness of programs of disease management for improving clinical outcomes. However, the effect of home-based telemanagement programs on the rate of hospital readmission is still unclear and the cost-effectiveness ratio of such programs is unknown. The aim of the study was to determine whether a home-based telemanagement (HBT) programme in CHF patients decreased hospital readmissions and hospital costs in comparison with the usual care (UC) follow-up programme over a one-year period.

METHODS AND RESULTS

Four hundred-sixty CHF patients (pts), aged 57+/-10 years were randomised to two management strategies: 230 pts to HBT programme and 230 pts to UC programme. The HBT pts received a portable device, transferring, by telephone, a one-lead trace to a receiving station where a nurse was available for interactive teleconsultation. The UC pts were referred to their primary care physicians and cardiologists. The primary objective of the study was one-year hospital readmission for cardiovascular reasons. During one-year follow-up 55 pts (24%) in HBT group and 83 pts (36%) in UC group had at least one readmission (RR=0.56; 95% CI: 0.38-0.82; p=0.01). After adjusting for clinical and demographic characteristics, the HBT group had a significantly lower risk of readmission compared with the UC group (HR=0.50, 95% CI: 0.34-0.73; p=0.01). The intervention was associated with a 36% decrease in the total number of hospital readmissions (HBT group: 91 readmissions; UC group: 142 readmissions) and a 31% decrease in the total number of episodes of hemodynamic instability (101 in HBT group vs 147 in UC group). The rate of hearth failure-related readmission was 19% (43 pts) in HBT group and 32% (73 pts) in UC group (RR=0.49, 95% [CI]: 0.31-0.76; p=0.0001). No significant difference was found on cardiovascular mortality between groups. Mean cost for hospital readmission was significantly lower in HBT group (euro 843+/-1733) than in UC group (euro 1298+/-2322), (-35%, p<0.01).

CONCLUSIONS

This study suggests that one-year HBT programme reduce hospital readmissions and costs in CHF patients.

[Heart failure patient management: evolution, organization, application on a local scale]

Heart failure is a severe disease which prevalence and incidence are steadily growing, with high morbidity and mortality rates, and responsible for significant financial cost. This evolution requires our therapeutic approach to be modified, by favouring multidisciplinary management and including patient education. The proof of the effectiveness of these measures is brought by many studies, and therapeutic education is now recommended by the European Society of Cardiology. This new approach of management is set out according to various procedures. In Le Creusot, the therapeutic unit of heart failure management was created in September 2004 and operate on a day hospital pattern. The results are satisfactory knowing that the average duration of spells fell by 33% after one year. Further local initiatives are spreading and need shall arise to pooling equipment and personnel as well as reinforcing collaboration between public and private professionals in order to improve heart failure patients' management. In the meantime a more sustained involvement of the authorities is to be hoped.

Beta-blocker therapy for heart failure: should the therapeutic target be dose or heart rate reduction?

Therapeutic target with beta blockers in heart failure, i.e., target heart rate reduction or beta-blocker dose, is controversial. To resolve this controversy, the authors studied 152 heart failure patients on beta blockers who were divided into four groups based on median peak exercise heart rate reduction as compared with predicted and prescription of at least 50% recommended beta-blocker dose. Event-free survival (vs. death or assist device placement or urgent transplantation) was compared. Baseline and peak exercise heart rates were 74 +/- 14 and 116 +/- 21 bpm, respectively. Median heart rate reduction at peak exercise was 35%. When median or higher peak heart rate reduction was achieved, there were no significant survival differences noted between patients on different beta-blocker doses. With below-median peak heart rate reduction, there was a strong trend toward better event-free survival with higher beta-blocker doses. In conclusion, the results suggest that higher heart rate reduction is associated with better outcomes for heart failure patients overall and, for patients with persistently elevated heart rates, higher beta-blocker doses provided additional benefit.

Executive summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline

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

Telecardiology for patients with acute or chronic cardiac complaints: The ‘SHL’ experience in Israel and Germany

OBJECTIVE

To assess the impact of a telemedicine program in which electrocardiogram (EKG), body weight and/or blood pressure are measured at home and medically trained personnel judge the transmitted data and council the patients by telephone.

METHOD

We systematically studied the outcome and cost-effectiveness of the cardiac programs carried out by Shahal (SHL) during the past 19 years.

RESULT

Most patients (85%) with acute complaints resembling coronary artery disease, could be reassured, representing a savings of about 677.000 euro per 10,000 members/yr in Israël in 1989, and a marked reduction in patient delay to 44 min (median). In chronic heart failure a 66% reduction in hospitalisation days was observed, together with an improvement in quality of life. A large Healthcare Insurance Company in Germany (Taunus BKK) has calculated that it can save at least 5 million euro per year with the use of such services.

CONCLUSION

Disease management with concomitant telemedicine for coronary artery disease and chronic heart failure is safe and effective and has a huge potential for cost savings, improvements in quality of life and in prognosis of heart disease.

Multidisciplinary and multisetting team management programme in heart failure patients affects hospitalisation and costing

BACKGROUND

We evaluated whether multidisciplinary disease management programme developed with collaboration of physicians and nurses inside and outside general district hospital settings can affect clinical outcomes in heart failure population over a 12-month period.

METHODS

571 patients hospitalised with CHF were referred to our unit and 509 patients agreed to participation. The intervention team included physicians and nurses from Internal Medicine and Cardiac Dept., and the patient's general practitioners. Contacts were on a pre-specified schedule, included a computerised programme of hospital visits and phone calls; in case of NYHA functional class III and IV patients, home visits were also planned.

RESULTS

The median age of patients was 77.7+/-9 years (43.3% women). At baseline the percentage of patients with NYHA class III and IV was 56.0% vs. 26.0% after 12 months (P<0.05). Programme enrolment reduced total hospital admissions (82 vs. 190, -56%, P<0.05), number of patients hospitalised (62 vs. 146, 57%, P<0.05). All NYHA functional class benefited (class I=75%, class IV=67%), with reduction in the costing (-48%, P<0.05). Improvement in symptoms (-9.0+/-3.2) and signs (-5.2+/-3.1) scores was measured (P<0.01). Therapy optimisation was obtained by 20.5% increase in patients taking betablockade and 21.0% increase in those on anti-aldosterone drugs.

CONCLUSIONS

Multidisciplinary approach to CHF management can improve clinical management, reducing hospitalisation rate and costing.

Heart failure disease management: implementation and outcomes

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

A comprehensive e-education engine for a virtual diabetes centre

It seems likely that the development of effective diabetes education for patients, carers and staff would prove highly cost-effective. Diabetes-e is an electronic diabetes encyclopaedia designed to provide comprehensive education to patients, carers (e.g. family, schools, care homes) and health professionals (specialist and non-specialist). In addition, educational media such as information leaflets (that can be printed during a consultation), streaming educational video and slide resource packs are available. Self-assessment questionnaires with feedback guide further education and facilitate targeted continuing professional development (CPD) for health professionals. The prototype has been developed with a particular emphasis on patient input. It is anticipated that Diabetes-e will be implemented across Central Nottinghamshire, including training of key personnel, by the end of 2005. The project has already gone live for insulin commencement.