Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis

A nurse-led coaching intervention with home telemonitoring for patients with heart failure: Protocol for a feasibility randomized clinical trial

Poor treatment adherence and lack of self-care behaviors are significant contributors to hospital readmissions of people with heart failure (HF). A transitional program with non-invasive telemonitoring may help sustain patients and their caregivers to timely recognize signs and symptoms of exacerbation. We will conduct a Randomized Clinical Trial (RCT) to evaluate the feasibility and acceptability of a 6-month supportive intervention for patients discharged home after cardiac decompensation. Forty-five people aged 65 years and over will be randomized to either receive a supportive intervention in addition to standard care, which combines nurse-led telephone coaching and a home-based self-monitoring vital signs program, or standard care alone. Four aspects of the feasibility will be assessed using a mixed-methods approach: process outcomes (e.g., recruitment rate), resources required (e.g., adherence to the intervention), management data (e.g., completeness of data collection), and scientific value (e.g. 90- and 180-day all-cause and HF-related readmissions, self-care capacity, quality of life, psychological well-being, mortality, etc.). Participants will be interviewed to explore preferences and satisfaction with the intervention. The study is expected to provide valuable insight into the design of a definitive RCT.

Demographic trends and disparities in mortality related to coexisting heart failure and diabetes mellitus among older adults in the United States between 1999 and 2020: A retrospective population-based cohort study from the CDC WONDER database

Background

Heart Failure (HF) and Diabetes Mellitus (DM) often coexist, and each condition independently increases the likelihood of developing the other. While there has been concern regarding the increasing burden of disease for both conditions individually over the last decade, a comprehensive examination of mortality trends and demographic and regional disparities needs to be thoroughly explored in the United States (US).

Methods

This study analyzed death certificates from the CDC WONDER database, focusing on mortality caused by the co-occurrence of HF and DM in adults aged 75 and older from 1999 to 2020. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were computed and categorized by year, gender, race, census region, state, and metropolitan status.

Results

A total of 663,016 deaths were reported in patients with coexisting HF and DM. Overall, AAMR increased from 154.1 to 186.1 per 100,000 population between 1999 and 2020, with a notable significant increase from 2018 to 2020 (APC: 11.30). Older men had consistently higher AAMRs than older women (185 vs. 135.4). Furthermore, we found that AAMRs were highest among non-Hispanic (NH) American Indian or Alaskan natives and lowest in NH Asian or Pacific Islanders (214.4 vs. 104.1). Similarly, AAMRs were highest in the Midwestern region and among those dwelling in non-metropolitan areas.

Conclusions

Mortality from HF and DM has risen significantly in recent years, especially among older men, NH American Indian or Alaska Natives, and those in non-metropolitan areas. Urgent policies need to be developed to address these disparities and promote equitable healthcare access.

[Effects of a return-to -home assistance programm (PRADO-IC) on the patient journey in a cohort of cardiac heart failure patients]

INTRODUCTION

Congestive heart failure (HF) is associated with prolonged and recurrent hospitalizations; the prognosis remains poor a better follow up might be beneficial. PRADO-IC program is provided in order to improve the transition of care.

AIM OF THE STUDY

To evaluate PRADO-IC program in term of healthcare consumption and prognosis in a cohort of patients hospitalized for decompensated HF, using the insight of the national data base SNDS (Système National de Données de Santé).

METHODS

From September 2016 to September 2018, all patients hospitalized for heart failure at Saint-Joseph Hospital were included in an observational study. The inclusion in the PRADO-IC program was at physician's discretion. Two groups were compared according to the inclusion in PRADO-IC (P group) or not (control group (C)). The primary endpoints were the comparison of one-year mortality and heart failure readmission rate between the two groups. The secondary end points were time to the first contact with a general practitioner (GP), a cardiologist, CHF drugs prescription, and others follow up data.

RESULTS

Six hundred and fifteen patients were included, 254 in the P group and 361 in the C group. Patients in the P cohort presented more frequently severity criteria (age, weight, BNP level, arrhythmia, anemia, renal failure). Mortality at one year (n = 47; 18.5% P group vs. n = 65; 16.2% C group, p = 0.87) did not differ in both groups. There was no significant difference in one-year re-hospitalization rate for HF (n = 93, 36.6% in P group vs. n = 133, 26.8% in C group, p = 0.95). Time to the first contact with the GP was shorter in P group (8.00 vs. 18.50 days, p < 0.0001). Time to first hospitalization (69.0 vs. 37.0 days, p = 0.028) and the length of hospitalization (6.0 vs. 4.0 days, p = 0.045) were longer in P group. There was no difference for HF drugs prescription rate between the two groups.

CONCLUSION

Our study shows that the PRADO-IC program concerned more severe patients. Despite this, the one-year mortality and the HF readmission rates are similar between the two groups. The follow up is improved in P group.

Assessment of non-inferiority in terms of six-month morbidity and mortality of a hospital-at-home care pathway for patients with acute heart failure: FIL-EAS-ic study protocol

BACKGROUND

Heart failure (HF) is a common cause of hospitalization and is associated with high mortality rates, long hospital stays and high economic costs worldwide. Novel care pathways are increasingly considered to address these burdens. In France, a mixed conventional hospitalization and hospital-at-home (HaH) care pathway (named FIL-EAS-ic) has been designed to reduce hospital length of stay without impairing HF outcomes. This protocol describes the study design evaluating the non-inferiority of the FIL-EAS-ic pathway compared to conventional hospitalization in terms of six-month all-cause mortality and/or unscheduled HF-related hospitalization.

METHODS AND RESULTS

A randomized, prospective, multicenter trial (NCT04878263) will be conducted involving two groups of patients in a 1:2 ratio: i) a control group following the conventional hospitalization pathway, and ii) the experimental group following the FIL-EAS-ic pathway. We aim to include 454 patients from the Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer and the Hôpital d'Instruction des Armées Sainte-Anne in France from June 2021 to June 2023. The non-inferiority of the FIL-EAS-ic pathway compared to conventional hospitalization, in terms of six-month all-cause mortality and/or unscheduled HF-related hospitalization will be tested by the Farrington-Manning method. Impact on treatment adherence, HF rehospitalizations and cumulative time spent in the hospital will also be compared between the two groups.

CONCLUSIONS

This clinical trial will provide evidence on a novel HF care pathway in France as well as its potential to improve follow-up care, quality of life and patient satisfaction as well as its potential to reduce costs.

Improving TRansitions ANd outcomeS for heart FailurE patients in home health CaRe (I-TRANSFER-HF): a type 1 hybrid effectiveness-implementation trial: study protocol

BACKGROUND

Some of the most promising strategies to reduce hospital readmissions in heart failure (HF) is through the timely receipt of home health care (HHC), delivered by Medicare-certified home health agencies (HHAs), and outpatient medical follow-up after hospital discharge. Yet national data show that only 12% of Medicare beneficiaries receive these evidence-based practices, representing an implementation gap. To advance the science and improve outcomes in HF, we will test the effectiveness and implementation of an intervention called Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF), comprised of early and intensive HHC nurse visits combined with an early outpatient medical visit post-discharge, among HF patients receiving HHC.

METHODS

This study will use a Hybrid Type 1, stepped wedge randomized trial design, to test the effectiveness and implementation of I-TRANSFER-HF in partnership with four geographically diverse dyads of hospitals and HHAs ("hospital-HHA" dyads) across the US. Aim 1 will test the effectiveness of I-TRANSFER-HF to reduce 30-day readmissions (primary outcome) and ED visits (secondary outcome), and increase days at home (secondary outcome) among HF patients who receive timely follow-up compared to usual care. Hospital-HHA dyads will be randomized to cross over from a baseline period of no intervention to the intervention in a randomized sequential order. Medicare claims data from each dyad and from comparison dyads selected within the national dataset will be used to ascertain outcomes. Hypotheses will be tested with generalized mixed models. Aim 2 will assess the determinants of I-TRANSFER-HF's implementation using a mixed-methods approach and is guided by the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0). Qualitative interviews will be conducted with key stakeholders across the hospital-HHA dyads to assess acceptability, barriers, and facilitators of implementation; feasibility and process measures will be assessed with Medicare claims data.

DISCUSSION

As the first pragmatic trial of promoting timely HHC and outpatient follow-up in HF, this study has the potential to dramatically improve care and outcomes for HF patients and produce novel insights for the implementation of HHC nationally.

TRIAL REGISTRATION

This trial has been registered on ClinicalTrials.Gov (#NCT06118983). Registered on 10/31/2023, https://clinicaltrials.gov/study/NCT06118983?id=NCT06118983&rank=1 .

Group-based trajectories of potentially preventable hospitalisations among older adults after a hip fracture

Key predictors of three trajectory group membership of potentially preventable hospitalisations were age, the number of comorbidities, the presence of chronic obstructive pulmonary disease and congestive heart failure, and frailty risk at the occurrence of hip fracture. These predictors of their trajectory group could be used in targeting prevention strategies.

PURPOSE

Although older adults with hip fracture have a higher risk of multiple readmissions after index hospitalisation, little is known about potentially preventable hospitalisations (PPH) after discharge. This study examined group-based trajectories of PPH during a five-year period after a hip fracture among older adults and identified factors predictive of their trajectory group membership.

METHODS

This retrospective cohort study was conducted using linked hospitalisation and mortality data in New South Wales, Australia, between 2013 and 2021. Patients aged ≥ 65 years who were admitted after a hip fracture and discharged between 2014 and 2016 were identified. Group-based trajectory models were derived based on the number of subsequent PPH following the index hospitalisation. Multinominal logistic regression examined factors predictive of trajectory group membership.

RESULTS

Three PPH trajectory groups were revealed among 17,591 patients: no PPH (89.5%), low PPH (10.0%), and high PPH (0.4%). Key predictors of PPH trajectory group membership were age, number of comorbidities, dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), frailty risk, place of incident, surgery, rehabilitation, and length of hospital stay. The high PPH had a higher proportion of patients with ≥ 2 comorbidities (OR: 1.86, 95% confidence interval (CI): 1.04-3.32) and COPD (OR: 2.97, 95%CIs: 1.76-5.04) than the low PPH, and the low and high PPHs were more likely to have CHF and high frailty risk as well as ≥ 2 comorbidities and COPD than the no PPH.

CONCLUSIONS

Identifying trajectories of PPH after a hip fracture and factors predictive of trajectory group membership could be used to target strategies to reduce multiple readmissions.

Intensive therapeutic education strategy for patients with acute heart failure (EduStra-HF): Design of a randomized controlled trial

BACKGROUND

Heart failure is associated with reduced quality of life, hospitalizations, death and high healthcare costs. Despite care improvements, the rehospitalization rate after an acute heart failure episode, especially for acute heart failure, remains high.

METHODS

The Education Strategy for patients with acute Heart Failure (EduStra-HF; ClinicalTrials.gov Identifier NCT03035123) study will randomize patients admitted for acute heart failure in six French hospitals to usual care (control) or therapeutic education (intervention). All patients will be evaluated at baseline and will meet with a therapeutic education nurse before discharge. Those in the usual care arm will have standard appointments with their cardiologist and general practitioner. Those in the intervention arm will have an intensive follow-up schedule of phone calls, home visits and text messages from the therapeutic education nurses, plus cardiologist visits. Patients will be stratified by discharge location (home or cardiac rehabilitation centre) before randomization, and will be followed up for 1 year. The primary outcome will be the readmission rates for acute heart failure during 1 year in the two groups. Secondary outcomes will include: quality of life; time from inclusion to first readmission for acute heart failure; non-heart failure cardiovascular rehospitalization rates; length of stay for heart failure; cardiovascular and all-cause death; rates of patients receiving optimal medical therapies; evolution of knowledge about heart failure; and cost-effectiveness.

CONCLUSIONS

This study will assess the efficacy and feasibility of a standardized management strategy for the care and follow-up of patients discharged after hospitalization for acute heart failure. The EduStra-HF strategy will combine various nurse care methods to help prevent rehospitalization.

Outpatient Follow-Up Visits to Reduce 30-Day All-Cause Readmissions for Heart Failure, COPD, Myocardial Infarction, and Stroke: A Systematic Review and Meta-Analysis

Introduction

Hospital readmissions is an important public health problem that US hospitals are responsible for reducing. One strategy for preventing readmissions is to schedule an outpatient follow-up visit before discharge. The objective of this study was to determine whether outpatient follow-up visits are an effective method to reduce 30-day all-cause readmissions for patients discharged from US hospitals with heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), or stroke.

Methods

We conducted a systematic review and meta-analysis to identify relevant articles published from 2013 through 2023. We searched PubMed, CINAHL, and Cochrane. Eligible studies were those that assessed the effect of postdischarge outpatient follow-up visits on 30-day all-cause readmission. We used random effect meta-analyses to generate pooled adjusted effect estimates and 95% CIs.

Results

We initially identified 2,256 articles. Of these, 32 articles underwent full-text review and 15 met inclusion criteria. Seven studies addressed heart failure, 3 COPD, 2 AMI, and 3 stroke. Ten articles provided sufficient information for meta-analysis. The pooled adjusted effect measure was 0.79 (95% CI, 0.69-0.91), indicating that outpatient follow-up visits were associated with a 21% lower risk of readmission. However, we found a high degree of between-study heterogeneity (Q = 122.78; P < .001; I2 = 92.7%). Subgroup analyses indicated that study quality, disease condition, and particularly whether a time-dependent analysis method was used, explained much of the heterogeneity.

Conclusion

Outpatient follow-up visits are a potentially effective way to reduce 30-day all-cause readmissions for patients discharged with heart failure or stroke, but evidence of benefit was lacking for COPD and we found no studies for assessing AMI. Our results emphasize the importance of study quality.

The effect of telemedicine employing telemonitoring instruments on readmissions of patients with heart failure and/or COPD: a systematic review

Background

Hospital readmissions pose a challenge for modern healthcare systems. Our aim was to assess the efficacy of telemedicine incorporating telemonitoring of patients' vital signs in decreasing readmissions with a focus on a specific patient population particularly prone to rehospitalization: patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) through a comparative effectiveness systematic review.

Methods

Three major electronic databases, including PubMed, Scopus, and ProQuest's ABI/INFORM, were searched for English-language articles published between 2012 and 2023. The studies included in the review employed telemedicine incorporating telemonitoring technologies and quantified the effect on hospital readmissions in the HF and/or COPD populations.

Results

Thirty scientific articles referencing twenty-nine clinical studies were identified (total of 4,326 patients) and were assessed for risk of bias using the RoB2 (nine moderate risk, six serious risk) and ROBINS-I tools (two moderate risk, two serious risk), and the Newcastle-Ottawa Scale (three good-quality, four fair-quality, two poor-quality). Regarding the primary outcome of our study which was readmissions: the readmission-related outcome most studied was all-cause readmissions followed by HF and acute exacerbation of COPD readmissions. Fourteen studies suggested that telemedicine using telemonitoring decreases the readmission-related burden, while most of the remaining studies suggested that it had a neutral effect on hospital readmissions. Examination of prospective studies focusing on all-cause readmission resulted in the observation of a clearer association in the reduction of all-cause readmissions in patients with COPD compared to patients with HF (100% vs. 8%).

Conclusions

This systematic review suggests that current telemedicine interventions employing telemonitoring instruments can decrease the readmission rates of patients with COPD, but most likely do not impact the readmission-related burden of the HF population. Implementation of novel telemonitoring technologies and conduct of more high-quality studies as well as studies of populations with ≥2 chronic disease are necessary to draw definitive conclusions.

Systematic Review Registration

This study is registered at the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY), identifier (INPLASY202460097).

Implementation of guideline-directed medical therapy for heart failure patients with reduced ejection fraction in Belgium: a Delphi panel approach

BACKGROUND

The 2021 European Society of Cardiology (ESC) guidelines recommended a shift from a traditional hierarchical treatment for heart failure with reduced ejection fraction (HFrEF) to a four-pillar medical therapy strategy intended for near-simultaneous initiation. However, practical guidance for implementation in clinical practice is lacking. To address this, a Delphi Panel of 12 Belgian heart failure experts aimed to obtain consensus on integrating guideline-directed medical therapy (GDMT) in HFrEF patients in Belgian clinical practice, considering local specificities, including reimbursement criteria.

METHODS

A geographically representative sample of 12 Belgian cardiologists engaged in a three-round Delphi process, evolving from 20 open-ended questions to 39 statements. A qualitative analysis after the first round resulted in expert statements for the subsequent questionnaire, categorised into treatment for newly diagnosed and chronic HFrEF patients.

RESULTS

The Delphi consensus revealed four key findings: (i) Agreement on initiating the four medical cornerstones within 7-14 days of HFrEF diagnosis, prioritising initiation over individual class up-titration; (ii) Lack of consensus on a fixed sequence for initiation due to patient variability and national reimbursement criteria; (iii) Emphasis on treatment adjustment based on the patient's clinical presentation and comorbidities; (iv) Recognition of the crucial role of regular follow-up visits, allowing optimisation of medical therapy where appropriate.

CONCLUSION

This national Delphi consensus addresses clinical implementation of GDMT in HFrEF patients for Belgian cardiologists. The consensus highlights the importance of swift implementation of the four cornerstone medical therapies in newly diagnosed HFrEF patients, individualising treatment sequencing, and ensuring regular follow-up to optimise therapy.

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence

Background

Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care.

Methods

We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps.

Results

The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified.

Conclusions

Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting.

Limitations

Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified.

Future work

Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study

BACKGROUND

Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care.

OBJECTIVE

To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations.

DESIGN

Retrospective cohort study.

SETTING

Medicare.

PARTICIPANTS

Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019.

MEASUREMENTS

Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes.

RESULTS

The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF.

LIMITATION

Generalizability to other payers.

CONCLUSION

Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF.

PRIMARY FUNDING SOURCE

National Institute on Aging.

From Hospital to Home: Evidence-Based Care for Worsening Heart Failure

Heart failure (HF) is a leading cause of hospitalization in older adults. Patients are at high risk of readmission and death following hospitalization for HF. There is no standard approach of health care delivery during the hospital-to-home transition period, leaving missed opportunities in care optimization. In this review, we discuss contemporary randomized clinical trials that tested decongestion strategies, disease-modifying therapies, and health care services that inform the care of patients with worsening HF. We provide evidence-informed recommendations for optimizing therapies and improving outcomes during and following hospitalization for HF. These include adequate decongestion with loop diuretics and select sequential nephron blockade strategies based on early evaluation of diuretic response; initiation of disease-modifying pharmacotherapies prior to hospital discharge with close follow-up and optimization after discharge; cardiac rehabilitation; and transitional or palliative care referral post-hospitalization. Evidence-based implementation strategies to facilitate broad uptake include digital health tools and algorithm-driven optimization of pharmacotherapies.

Regional Collaboration for Heart Failure Patients Certified as Needing Support or Care in Long-Term Care Insurance System

BACKGROUND

Heart failure (HF) patients with complex care needs often experience exacerbations during the transitional phase as care providers and settings change. Regional collaboration aims to ensure continuity of care; however, its impact on vulnerable patients certified as needing support or care under the Japanese long-term care insurance (LTCI) system remains unclear.

METHODS AND RESULTS

We implemented a regional collaborative program for HF patients involving 3 pillars of transitional care with general practitioners and nursing care facilities: (1) standardized health monitoring using a patient diary and identification of exacerbation warning signs; (2) standardized information sharing among care providers; and (3) standardized HF management manuals. We evaluated outcomes within 1 year of discharge for patients hospitalized with HF and referred to other facilities for outpatient follow-up in 2017-2018 before program implementation (n=110) and in 2019-2020 after implementation (n=126). Patients with LTCI frequently received non-cardiologist follow up and care services and had a higher risk of all-cause mortality and HF readmission compared with those without LTCI (P<0.05). Program implementation was significantly associated with a greater reduction in HF readmissions among patients with LTCI compared with those without (P<0.05 for interaction), although mortality rates remained unchanged.

CONCLUSIONS

A regional collaborative program significantly reduces HF readmissions in HF patients with LTCI who are at high risk of worsening HF.

Clinical Utility of Machine Learning-Derived Vocal Biomarkers in the Management of Heart Failure

Background

This study aimed to systematically evaluate voice symptoms during heart failure (HF) treatments and to exploratorily extract HF-related vocal biomarkers.

Methods and Results

This single-center, prospective study longitudinally acquired 839 audio files from 59 patients with acute decompensated HF. Patients' voices were analyzed along with conventional HF indicators (New York Heart Association [NYHA] class, presence of pulmonary congestion and pleural effusion on chest X-ray, and B-type natriuretic peptide [BNP]) and GOKAN scores based on the assessment of a cardiologist. Machine-learning (ML) models to estimate HF conditions were created using a Light Gradient Boosting Machine. Voice analysis identified 27 acoustic features that correlated with conventional HF indicators and GOKAN scores. When creating ML models based on the acoustic features, there was a significant correlation between actual and ML-derived BNP levels (r=0.49; P<0.001). ML models also identified good diagnostic accuracies in determining HF conditions characterized by NYHA class ≥2, BNP ≥300 pg/mL, presence of pulmonary congestion or pleural effusion on chest X-ray, and decompensated HF (defined as NYHA class ≥2 and BNP levels ≥300 pg/mL; accuracy: 75.1%, 69.1%, 68.7%, 66.4%, and 80.4%, respectively).

Conclusions

The present study successfully extracted HF-related acoustic features that correlated with conventional HF indicators. Although the data are preliminary, ML models based on acoustic features (vocal biomarkers) have the potential to infer various HF conditions, which warrant future studies.

PRADOC: A Multicenter Randomized Controlled Trial to Assess the Efficiency of PRADO-IC, a Nationwide Pragmatic Transition Care Management Plan for Hospitalized Patients With Heart Failure in France

BACKGROUND

The PRADO-IC (Programme de Retour à Domicile après une Insuffisance Cardiaque) is a transition care program designed to improve the coordination of care between hospital and home that was generalized in France in 2014. The PRADO-IC consists of an administrative assistant who visits patients during hospitalization to schedule follow-up visits. The aim of the present study was to evaluate the PRADO-IC program based on the hypotheses provided by health authorities.

METHODS AND RESULTS

The PRADOC study is a multicenter, controlled, randomized, open-label, mixed-method trial of the transition program PRADO-IC versus usual management in patients hospitalized with heart failure (standard of care group; NCT03396081). A total of 404 patients were recruited between April 2018 and May 2021. The mean patient age was 75 years (±12 years) in both groups. The 2 groups were well balanced regarding severity indices. At discharge, patients homogeneously received the recommended drugs. There was no difference between groups regarding hospitalizations for acute heart failure at 1 year, with 24.60% in the standard of care group and 25.40% in the PRADO-IC group during the year following the index hospitalization (hazard ratio, 1.04 [95% CI, 0.69-1.56]; P=0.85) or cardiovascular mortality (hazard ratio, 0.67 [95% CI, 0.34-1.31]; P=0.24).

CONCLUSIONS

The PRADO-IC has not significantly improved clinical outcomes, though a trend toward reduced cardiovascular mortality is evident. These results will help in understanding how transitional care programs remain to be integrated in pathways of current patients, including telemonitoring, and to better tailor individualized approaches.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03396081.

Cost-effectiveness of a multidimensional post-discharge disease management program for heart failure patients-economic evaluation along a one-year observation period

OBJECTIVE

This study aimed to assess the cost-effectiveness of the telemedically assisted post-discharge management program (DMP) HerzMobil Tirol (HMT) for heart failure (HF) patients in clinical practice in Austria.

METHODS

We conducted a cost-effectiveness analysis along a retrospective cohort study (2016-2019) of HMT with a propensity score matched cohort of 251 individuals in the HMT and 257 in the usual care (UC) group and a 1-year follow-up. We calculated the effectiveness (hospital-free survival, hospital-free life-years gained, and number of avoided rehospitalizations), costs (HMT, rehospitalizations), and the incremental cost-effectiveness ratio (ICER). We performed a nonparametric sensitivity analysis with bootstrap sampling and sensitivity analyses on costs of HF rehospitalizations and on costs per disease-related diagnosis (DRG) score for rehospitalizations.

RESULTS

Base-case analysis showed that HMT resulted in an average of 42 additional hospital-free days, 40 additional days alive, and 0.12 avoided hospitalizations per patient-year compared with UC during follow-up. The average HMT costs were EUR 1916 per person. Mean rehospitalization costs were EUR 5551 in HMT and EUR 6943 in UC. The ICER of HMT compared to UC was EUR 4773 per life-year gained outside the hospital. In a sensitivity analysis, HMT was cost-saving when "non-HF related costs" related to the DMP were replaced with average costs.

CONCLUSIONS

The economic evaluation along the cohort study showed that the HerzMobil Tirol is very cost-effective compared to UC and cost-saving in a sensitivity analysis correcting for "non-HF related costs." These findings promote a widespread adoption of telemedicine-assisted DMP for HF.

An Innovative Patient-Centred Approach to Heart Failure Management: The Best Care Heart Failure Integrated Disease-Management Program

Background

The management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline-directed care, but the impact of IDM in the community setting requires further evaluation.

Methods

A retrospective evaluation of community-based IDM. Patient characteristics were described, and outcomes using a pre- and post-intervention design were HF-related health-service use, quality of life, and concordance with guideline-directed medical therapy (GDMT).

Results

715 patients were treated in the program (2016 to 2023), 219 in a community specialist-care clinic, and 496 in 25 primary-care clinics. The overall cohort was predominantly male (60%), with a mean age of 73.5 years (± 10.7), and 60% with HF with reduced ejection fraction. In patients with ≥ 6 months of follow-up (n = 267), pre vs post annualized rates of HF-related acute health-service use decreased from 36.3 to 8.5 hospitalizations per 100 patients per year, P < 0.0001, from 31.8 to 13.1 emergency department visits per 100 patients per year, P < 0.0001, and from 152.8 to 110.0 urgent physician visits per 100 patients per year, P = 0.0001. The level of concordance with GDMT improved; the number of patients receiving triple therapy and quadruple therapy increased by 10.1% (95% confidence interval [CI], 2.4%,17.8%) and 19.6% (95% CI, 12.0%, 27.3%), respectively. Within these groups, optimal dosing was achieved in 42.5% (95% CI, 32.0%, 53.6%) and 35.0% (95% CI, 23.1%, 48.4%), respectively. In patients with at least one follow-up visit (n = 286), > 50% experienced a clinically relevant improvement in their quality of life.

Conclusions

A community-based IDM program for HF, may reduce HF-related acute health-service use, improve quality of life and level of concordance with GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.

Patient outcomes after implementation of transitional care protocols in elective neurosurgery: a systematic review and meta-analysis

OBJECTIVE

30-day readmissions are a significant burden on the healthcare system. Postoperative transitional care protocols (TCPs) for safe and efficient discharge planning are being more widely adopted to reduce readmission rates. Currently, little evidence exists to justify the utility of TCPs for improving patient outcomes in elective neurosurgery. The objective of this systematic review was to determine the extent to which TCPs reduce adverse outcomes in patients undergoing elective neurosurgical procedures.

MATERIALS AND METHODS

A systematic review and meta-analysis was conducted after PROSPERO registration. Pubmed, Embase, and Cochrane review databases were searched through February 1, 2024. Keywords included: "transitional care AND neurosurgery", "Discharge planning AND neurosurgery". Articles were included if they assessed postoperative TCPs in an adult population undergoing elective neurosurgeries. Exclusion criteria were pediatric patients, implementation of Enhanced Recovery After Surgery (ERAS) protocols, or non-elective neurosurgical procedures. The primary outcome was readmission rates after implementation of TCPs.

RESULTS

16 articles were included in this review. 2 articles found that patients treated with TCPs had significantly higher chances of home discharge. 7 articles found a significant association between implementation of TCP and reduced length of stay and intensive care unit stay. 3 articles reported an increase in patient satisfaction after implementation of TCPs. 3 found that TCP led to a significant decrease in readmissions. After meta-analysis, TCPs were associated with significantly decreased readmission rates (OR: 0.68, p < 0.0001), length of stay (mean difference: -0.57, p < 0.00001), and emergency department visits (OR: 0.33, p < 0.0001).

CONCLUSIONS

This systematic review and meta-analysis found that an overwhelming majority of the available literature supports the effectiveness of discharge planning on at least one measure of patient outcomes. However, the extent to which each facet of the TCP affects outcomes in elective neurosurgery remains unclear. Future efforts should be made to compare the effectiveness of different TCPs.

Effectiveness of nurse-led heart failure clinic: A systematic review

Objectives

Heart failure is a stage of various cardiovascular diseases and constitutes a growing major public health problem worldwide. Nurse-led heart failure clinics play an important role in managing heart failure. All nurse-led heart failure clinic services are clinic-based. We conducted a systematic review to describe the contents and impact of nurse-led heart failure clinics.

Methods

A review of nurse-led heart failure clinic research was undertaken in PubMed, Embase, Web of Science, and Cochrane Library. The search was initially conducted on October 23, 2022 and updated on November 21, 2023. Articles were appraised using the Joanna Briggs Institute Appraisal criteria by two independent reviewers. This review was registered on PROSPERO (CRD42022352209).

Results

Twelve articles were included in this systematic review. The nurse-led heart failure clinic contents were: medication uptitration, educational counselling, evidence-based transitional care, psychosocial support, physical examination and mental well-being assessment, therapy monitoring and adjustment, follow-up, and phone consultations. Most studies reported largely positive clinical outcomes in nurse-led heart failure clinics. Four studies examined the quality of life and reported conflicting results; four studies examined medication titration efficacy, and the results were generally positive. Only two studies examined cost-effectiveness.

Conclusions

Nurse-led heart failure clinics have shown a largely positive impact on patient outcomes, quality of life, and medication titration efficacy. More randomised controlled trials and other studies are needed to obtain more robust conclusions.

Narrative synthesis of the effectiveness and characteristics of heart failure disease self-management support programmes

A deeper understanding of the key elements that should be included in heart failure (HF) disease self-management support (DSMS) programmes is crucial to enhance programme effectiveness and applicability to diverse settings. We investigated the characteristics and effectiveness of DSMS programmes designed to improve survival and decrease acute care readmissions for people with HF and determine the generalizability and applicability of the evidence to low- and middle-income countries (LMICs). A narrative meta-synthesis approach was used, and systematic reviews of randomized controlled trials (RCTs) of DSMS programmes were included. The Cochrane Database of Systematic Reviews, MEDLINE, and Embase were searched without language restriction and guided by the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight high-quality systematic reviews were identified representing 250 studies, of which 138 were unique RCTs measuring the outcomes of interest. The findings revealed statistically significant reductions in HF readmissions [relative risk (RR) range 0.64-0.85, P < 0.5, five out of six reviews], all-cause readmissions (RR range 0.85-0.95, P < 0.5, five out of six reviews), and all-cause mortality (RR range 0.67-0.87, P < 0.5, five out of five reviews). Overall, 44.2% (n = 61) of RCTs reduced acute care readmission and improved survival. Studies were categorized according to intensity (low, moderate, moderate+, and high) based on the opportunity for immediate treatment of HF instability; 29.2% (14/48) of low-intensity, 63.6% (21/33) of moderate-intensity, 40% (6/15) of moderate+-intensity, and 47.6% (20/42) of high-intensity interventions were effective. Most effective programmes used moderate-intensity (39.4%, 48%, or 50%, respectively) or high-intensity (33.3%, 36%, and 43.7%, respectively) interventions. The majority of studies (90.6%) were conducted in high-income countries. Programmes that provided opportunities for early recognition and response to HF instability were more likely to reduce acute care readmission and enhance survival. Generalizability and applicability to LMICs are clearly limited. Tailoring HF DSMS programmes to accommodate cultural, resource, and environmental challenges requires careful consideration of intervention intensity, duration of follow-up, and feasibility in low-resource settings.

The management of heart failure in Sweden-the physician's perspective: a survey

Aims

To assess the barriers to guideline-directed medical therapy (GDMT) use in heart failure (HF), diagnostic workup and general knowledge about HF among physicians in Sweden.

Methods

A survey about the management of HF was sent to 828 Swedish physicians including general practitioners (GPs) and specialists during 2021-2022. Answers were reported as percentages and comparisons were made by specialty (GPs vs. specialists).

Results

One hundred sixty-eight physicians participated in the survey (40% females, median age 43 years; 41% GPs and 59% specialists). Electrocardiography and New York Heart Association class evaluations are mostly performed once a year by GPs (46%) and at every outpatient visit by specialists (40%). Echocardiography is mostly requested if there is clinical deterioration (60%). One-third of participants screen for iron deficiency only if there is anemia. Major obstacles to implementation of different drug classes in HF with reduced ejection fraction are related to side effects, with no significant differences between specialties. Device implantation is deemed appropriate regardless of aetiology (69%) and patient age (86%). Specialists answered correctly to knowledge questions more often than GPs. Eighty-six percent of participants think that GDMT should be implemented as much as possible. Most participants (57%) believe that regular patient assessment in nurse-led HF clinics improve adherence to GDMT.

Conclusion

Obstacles to GDMT implementation according to physicians in Sweden mainly relate to potential side effects, lack of specialist knowledge and organizational aspects. Further efforts should be placed in educational activities and structuring of nurse-led clinics.

Association of a Transitional Heart Failure Management Program With Readmission and End-of-Life Care in Rural Japan

Background: Evidence on transitional care for heart failure (HF) in Japan is limited. Methods and Results: We implemented a transitional HF management program in rural Japan in 2019. This involved collaboration with general practitioners or nursing care facilities and included symptom monitoring by medical/nursing staff using a handbook; standardized discharge care planning and information sharing on self-care and advance care planning using a collaborative sheet; and sharing expertise on HF management via manuals. We compared the outcomes within 1 year of discharge among patients hospitalized with HF in the 2 years before program implementation (2017-2018; historical control, n=198), in the first 2 years after program implementation (2019-2020; Intervention Phase 1, n=205), and in the second 2 years, following program revision and regional dissemination (2021-2022; Intervention Phase 2, n=195). HF readmission rates gradually decreased over Phases 1 and 2 (P<0.05). This association was consistent regardless of physician expertise, follow-up institution, or the use of nursing care services (P>0.1 for interaction). Mortality rates remained unchanged, but significantly more patients received end-of-life care at home in Phase 2 than before (P<0.05). Conclusions: The implementation of a transitional care program was associated with decreased HF readmissions and increased end-of-life care at home for HF patients in rural Japan.

Contemporary American and European Guidelines for Heart Failure Management: JACC: Heart Failure Guideline Comparison

This review serves to compare contemporary clinical practice recommendations for the management of heart failure (HF), as codified in the 2021 European Society of Cardiology (ESC) guideline, the 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline, and the 2023 focused update of the 2021 ESC document. Overall, these guidelines aim to solidify significant advances throughout the HF continuum since the publication of previous full guideline iterations (2013 and 2016 for the ACC/AHA and ESC, respectively). All guidelines provide new recommendations for an increasingly complex landscape of HF care, with focus on primary HF prevention, HF stages, rapid initiation and optimization of evidence-based pharmacotherapies, overlapping cardiac and noncardiac comorbidities, device-based therapies, and management pathways for special groups of patients, including those with cardiac amyloidosis. Importantly, the ACC/AHA/HFSA document features special emphasis on HF risk prediction and screening, cost/value, social determinants of health, and health care disparities. The review discusses major similarities and differences between these recent guidelines and guideline updates, as well as their potential downstream implications for clinical care.

Clinical impact of remote heart failure management using the multiparameter ICD HeartLogic alert

INTRODUCTION AND OBJECTIVES

The multiparametric implantable cardioverter-defibrillator HeartLogic index has proven to be a sensitive and timely predictor of impending heart failure (HF) decompensation. We evaluated the impact of a standardized follow-up protocol implemented by nursing staff and based on remote management of alerts.

METHODS

The algorithm was activated in HF patients at 19 Spanish centers. Transmitted data were analyzed remotely, and patients were contacted by telephone if alerts were issued. Clinical actions were implemented remotely or through outpatient visits. The primary endpoint consisted of HF hospitalizations or death. Secondary endpoints were HF outpatient visits. We compared the 12-month periods before and after the adoption of the protocol.

RESULTS

We analyzed 392 patients (aged 69±10 years, 76% male, 50% ischemic cardiomyopathy) with implantable cardioverter-defibrillators (20%) or cardiac resynchronization therapy defibrillators (80%). The primary endpoint occurred 151 times in 86 (22%) patients during the 12 months before the adoption of the protocol, and 69 times in 45 (11%) patients (P<.001) during the 12 months after its adoption. The mean number of hospitalizations per patient was 0.39±0.89 pre- and 0.18±0.57 postadoption (P<.001). There were 185 outpatient visits for HF in 96 (24%) patients before adoption and 64 in 48 (12%) patients after adoption (P<.001). The mean number of visits per patient was 0.47±1.11 pre- and 0.16±0.51 postadoption (P<.001).

CONCLUSIONS

A standardized follow-up protocol based on remote management of HeartLogic alerts enabled effective remote management of HF patients. After its adoption, we observed a significant reduction in HF hospitalizations and outpatient visits.

conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT)

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future.

METHODS

A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses.

RESULTS

Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses.

CONCLUSION

This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Review of the National Institute for Health and Care Excellence guidelines on chronic heart failure

Guidelines are more accessible than ever and represent an important tool in clinical practice. The National Institute for Health and Care Excellence (NICE) has developed recommendations for heart failure diagnosis and management based not only on morbidity and mortality trial outcome data but also in-depth economic analysis, with a focus on generalisability to UK National Health Service clinical practice. There is broad consistency in structure and content between NICE guidelines and those produced by major cardiovascular organisations such as the American College of Cardiology/American Heart Association and the European Society of Cardiology. However, important differences do exist-largely attributable to publication timing-a factor that is enhanced by the rapid pace of heart failure research. This article reviews the most recent iteration of NICE chronic heart failure guidelines and compares them with major guidelines on an international scale. Variations in recommendations will be explored including implications for NICE guideline updates in the future.

Effect of a transitional care model following hospitalization for heart failure: 3-year outcomes of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) randomized controlled trial

AIMS

Patients are at high risk of death or readmission following hospitalization for heart failure (HF). We tested the effect of a transitional care model that included month-long nurse-led home visits and long-term heart function clinic visits - with services titrated to estimated risk of clinical events - on 3-year outcomes following hospitalization.

METHODS AND RESULTS

In a pragmatic, stepped-wedge cluster randomized trial, 10 hospitals were randomized to the intervention versus usual care. The primary outcome was a composite of all-cause death, readmission, or emergency department (ED) visit. Secondary outcomes included components of the primary composite outcomes, HF readmissions and healthcare resource utilization. There were 2494 patients (50.4% female) with mean age of 77.7 years. The primary outcome was reached in 1040 (94.2%) patients in the intervention and 1314 (94.5%) in the usual care group at 3 years. The intervention did not reduce the risk of the primary composite outcome (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.81-1.05) nor the component outcomes overall, although numerically reduced the risk of ED visits in women but not men (HR 0.79, 95% CI 0.63-1.00 vs. HR 0.98, 95% CI 0.80-1.19; sex-treatment interaction p = 0.23). The uptake of guideline-directed medical therapy was no different with the intervention than with usual care, with the exception of sacubitril/valsartan, which increased with the intervention (3.3% vs 1.5%; relative risk 6.2, 95% CI 1.92-20.06).

CONCLUSIONS

More than 9 of 10 patients hospitalized for HF experienced all-cause death, readmission, or ED visit at 3 years. A transitional care model with services titrated to risk did not improve the composite of these endpoints, likely because there were no major differences in uptake of medical therapies between the groups.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02112227.

Cost of Cardiovascular Disease Event and Cardiovascular Disease Treatment-Related Complication Hospitalizations in the United States

BACKGROUND

Cardiovascular disease (CVD) is among the costliest conditions in the United States, and cost-effectiveness analyses can be used to assess economic impact and prioritize CVD treatments. We aimed to develop standardized, nationally representative CVD events and selected possible CVD treatment-related complication hospitalization costs for use in cost-effectiveness analyses.

METHODS

Nationally representative costs were derived using publicly available inpatient hospital discharge data from the 2012-2018 National Inpatient Sample. Events were identified using the principal International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Facility charges were converted to costs using charge-to-cost ratios, and total costs were estimated by applying a published professional fee ratio. All costs are reported in 2021 US dollars. Mean costs were estimated for events overall and stratified by age, sex, and survival status at discharge. Annual costs to the US health care system were estimated by multiplying the mean annual number of events by the mean total cost per discharge.

RESULTS

The annual mean number of hospital discharges among CVD events was the highest for heart failure (1 087 000 per year) and cerebrovascular disease (800 600 per year). The mean cost per hospital discharge was the highest for peripheral vascular disease ($33 700 [95% CI, $33 300-$34 000]) and ventricular tachycardia/ventricular fibrillation ($32 500 [95% CI, $32 100-$32 900]). Hospitalizations contributing the most to annual US health care costs were heart failure ($19 500 [95% CI, $19 300-$19 800] million) and acute myocardial infarction ($18 300, [95% CI, $18 200-$18 500] million). Acute kidney injury was the most frequent possible treatment complication (515 000 per year), and bradycardia had the highest mean hospitalization costs ($17 400 [95% CI, $17 200-$17 500]).

CONCLUSIONS

The hospitalization cost estimates and statistical code reported in the current study have the potential to increase transparency and comparability of cost-effectiveness analyses for CVD in the United States.

Impact of nurse-led education on the prognosis of heart failure patients: A systematic review and meta-analysis

AIM

To perform a meta-analysis of randomized controlled trials to investigate the effect of nurse-led education on death, readmission, and quality of life in patients with heart failure.

BACKGROUND

The evidence of the effectiveness of nurse-led education in heart failure patients from randomized controlled trials is limited, and the results are inconsistent. Therefore, the impact of nurse-led education remains poorly understood, and more rigorous studies are needed.

INTRODUCTION

Heart failure is a syndrome associated with high morbidity, mortality, and hospital readmission. Authorities advocate nurse-led education to raise awareness of disease progression and treatment planning, as this could improve patients' prognosis.

METHODS

PubMed, Embase, and the Cochrane Library were searched up to May 2022 to retrieve relevant studies. The primary outcomes were readmission rate (all-cause or HF-related) and all-cause mortality. The secondary outcome was quality of life, evaluated by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), EuroQol-5D (EQ-5D), and visual analog scale for quality of life.

RESULTS

Although there was no significant association between the nursing intervention and all-cause readmissions [RR (95% CI) = 0.91 (0.79, 1.06), P = 0.231], the nursing intervention decreased HF-related readmission by 25% [RR (95% CI) = 0.75 (0.58, 0.99), P = 0.039]. The e nursing intervention reduced all-cause readmission or mortality as a composite endpoint by 13% [RR (95% CI) = 0.87 (0.76, 0.99), P = 0.029]. In the subgroup analysis, we found that home nursing visits reduced HF-related readmissions [RR (95% CI) = 0.56 (0.37, 0.84), P = 0.005]. In addition, the nursing intervention improved the quality of life in MLHFQ and EQ-5D [standardized mean differences (SMD) (95% CI) = 3.38 (1.10, 5.66), 7.12 (2.54, 11.71), respectively].

DISCUSSION

The outcome variation between studies may be due to reporting methods, comorbidities, and medication management education. Patient outcomes and quality of life may also vary between different educational approaches. Limitations of this meta-analysis stem from the incomplete reporting of information from the original studies, the small sample size, and the inclusion of English language literature only.

CONCLUSION

Nurse-led education programs significantly impact HF-related readmission rates, all-cause readmission, and mortality rates in patients with HF.

IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICIES

The results suggest stakeholders should allocate resources to develop nurse-led education programs for HF patients.

Referral Versus Embedded Palliative Care Consultation Among People Hospitalized With Heart Failure: A Report From a Single Center Pilot Program

CONTEXT

Despite calls for integration into routine heart failure (HF) care, optimal palliative care delivery for people living with HF remains unclear.

OBJECTIVES

Describe an innovative model of an embedded palliative care nurse practitioner (NP) within a HF team. Compare demographics and utilization among people hospitalized with HF receiving referral or embedded consultation.

METHODS

Using an electronic health record-based palliative care registry, we conducted descriptive analyses and t-tests and χ2 tests, as appropriate, to examine bivariate associations between sociodemographic, clinical and utilization data of hospitalized people with HF receiving a traditional, referral-based palliative care consultation generated exclusively by the primary team vs. a novel, embedded-based consultation generated by collaboration between a palliative care NP and the advanced HF team at an urban, quaternary care academic medical center in New York City.

RESULTS

During the study period from January 1, 2019-December 31, 2021, consultation volume nearly doubled with 363 consults from traditional referrals and an additional 317 consults from the newly embedded NP. People in the embedded group, as compared to referral, were younger (mean age: 60.1 vs. 71.9 years (2019); 59.2 vs. 70.4 (2020); 61.3 vs. 69.6 (2021), p-value < 0.001), more functional (median Karnofsky Performance Status: 40% vs. 30%, p-value = 0.01 (2019); 40% vs 20%, p-value < 0.0001 (2020); 40% vs. 20%, p-value = 0.02 (2021)), more likely had capacity to designate a medical decision maker (56.4% vs. 20.6%, p-value < 0.001 (2020); 76.3% vs. 49.5%, p-value < 0.001 (2021)), received earlier consultation (median days before discharge: 9.5 vs. 4 (2019); 11 vs. 5 (2020); 7 vs. 3 (2021), p-value ≤ 0.001), and more likely to discharge home (60% vs. 26%, p-value ≤ 0.001 (2019); 62.7% vs 20.6%, p-value ≤ 0.001 (2020); 42.3% vs. 28%, p-value = 0.03 (2021)).

CONCLUSION

Hospitalized people living with advanced HF who received an embedded palliative care consult were younger, had higher functional status and less illness severity compared to those served by a traditional, referral-based consult.

Consumer and provider perceptions of the specialist unit model of care: A qualitative study

BACKGROUND

Specialist care units cater to targeted cohorts of patients, applying evidence-based practice to people with a specific condition (e.g., dementia) or meeting other specific criteria (e.g., children). This paper aimed to collate perceptions of local consumers and health providers around specialist care units, as a model of care that may be considered for a new local healthcare facility.

METHODS

This was a qualitative study using two-hour workshops and interviews to collect data. Participants were consumers and health providers in the planned facility's catchment: 49 suburbs in metropolitan Australia. Consumers and health providers were recruited through advertisements and emails. An initial survey collected demographic details. Consumers and health providers participated in separate two-hour workshops in which a scenario around the specialist unit model was presented and discussion on benefits, barriers and enablers of the model was led by researchers. Detailed notes were taken for analysis.

RESULTS

Five consumer workshops (n = 22 participants) and five health provider workshops (n = 42) were conducted. Participants were representative of this culturally diverse region. Factors identified by participants as relevant to the specialist unit model of care included: accessibility; a perceived narrow scope of practice; coordination with other services; resources and infrastructure; and awareness and expectations of the units. Some factors identified as risks or barriers when absent were identified as strengths and enablers when present by both groups of participants.

CONCLUSIONS

Positive views of the model centred on the higher perceived quality of care received in the units. Negative views centred on a perceived narrow scope of care and lack of flexibility. Consumers hinted, and providers stated explicitly, that the model needed to be complemented by an integrated model of care model to enable continuity of care and easy transfer of patients into and out of the specialist unit.

Heart Failure Nurses within the Primary Care Setting

Cardiology services within primary care often focus on disease prevention, early identification of illness and prompt referral for diagnosis and specialist treatment. Due to advances in pharmaceuticals, implantable cardiac devices and surgical interventions, individuals with heart failure are living longer, which can place a significant strain on global healthcare resources. Heart failure nurses in a primary care setting offer a wealth of clinical knowledge and expertise across all phases of the heart failure trajectory and are able to support patients, family members and other community services, including general practitioners. This review examines the recently published evidence on the current and potential future practice of heart failure nurses within primary care.

The Impact of Specialised Heart Failure Outpatient Care on the Long-Term Application of Guideline-Directed Medical Therapy and on Prognosis in Heart Failure with Reduced Ejection Fraction

(1) Background: Besides the use of guideline-directed medical therapy (GDMT), multidisciplinary heart failure (HF) outpatient care (HFOC) is of strategic importance in HFrEF. (2) Methods: Data from 257 hospitalised HFrEF patients between 2019 and 2021 were retrospectively analysed. Application and target doses of GDMT were compared between HFOC and non-HFOC patients at discharge and at 1 year. 1-year all-cause mortality (ACM) and rehospitalisation (ACH) rates were compared using the Cox proportional hazard model. The effect of HFOC on GDMT and on prognosis after propensity score matching (PSM) of 168 patients and the independent predictors of 1-year ACM and ACH were also evaluated. (3) Results: At 1 year, the application of RASi, MRA and triple therapy (TT: RASi + βB + MRA) was higher (p < 0.05) in the HFOC group, as was the proportion of target doses of ARNI, βB, MRA and TT. After PSM, the composite of 1-year ACM or ACH was more favourable with HFOC (propensity-adjusted HR = 0.625, 95% CI = 0.401-0.974, p = 0.038). Independent predictors of 1-year ACM were age, systolic blood pressure, application of TT and HFOC, while 1-year ACH was influenced by the application of TT. (4) Conclusions: HFOC may positively impact GDMT use and prognosis in HFrEF even within the first year of its initiation.

Reducing the hospitalization epidemic of chronic heart failure by disease management programs

Chronic heart failure is the most common cause of hospitalization in Europe and rates are steadily increasing due to aging of the population. Hospitalization identifies a fundamental change in the natural history of heart failure (HF) increasing the risk of re-hospitalization and mortality. Heart failure management programs improve the quality of care for HF patients and reduce hospitalization burden. The goals of the heart failure management programs include optimization of drug therapy, patient education, early recognition of signs of decompensation, and management of comorbidities. Randomized clinical trials evidenced that system of care for heart failure patients improved adherence to treatment and reduced unplanned re-admissions to hospital. Multidisciplinary programs and home-visiting have shown improved efficacy with reductions in HF and all-cause hospitalizations and mortality. Community HF clinics should take care of the management of stable patients in strict contact with primary care, while hospital out-patients clinics should care of patients with severe disease or persistent clinical instability, candidates to advanced treatment options. In any case a holistic, patient-centered approach is suggested, to optimize care considering the needs of the individual patient. Telemonitoring is a new opportunity for HF patients, because it allows the continuity of care at home. All heart failure patients should require follow-up in a specific management program, but most of date come from clinical trials that included high-risk patients. While clinical trials have a specified duration (from months to some years), lifelong follow-up is recommended with differentiated approaches according to the patient's need.

The economics of heart failure care

Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.

Developing Multidisciplinary Management of Heart Failure in the Super-Aging Society of Japan

The Japanese population is rapidly aging because of its long life expectancy and low birth rate; additionally, the number of patients with heart failure (HF) is increasing to the extent that HF is now considered a pandemic. According to a recent HF registry study, Japanese patients with HF have both medical and care-related problems. Although hospitalization is used to provide medical services, and institutionalization is used to provide care for frail older adults, it can be difficult to distinguish between them. In this context, multidisciplinary management of HF has become increasingly important in preventing hospital readmissions and maintaining a patient's quality of life. Academia has promoted an increase in the number of certified HF nurses and educators. Researchers have issued numerous guidelines or statements on topics such as cardiac rehabilitation, nutrition, and palliative care, in addition to the diagnosis and treatment of acute and chronic HF. Moreover, the Japanese government has created incentives through various medical and long-term care systems adjustments to increase collaboration between these two fields. This review summarizes current epidemiological registries that focus not only on medical but also care-related problems and the 10 years of multidisciplinary management experience in Japanese medical and long-term care systems.

Acute Heart Failure Is a Malignant Process: But We Can Induce Remission

Acute heart failure is a common and increasingly prevalent condition, affecting >10 million people annually. For those patients who survive to discharge, early readmissions and death rates are >30% everywhere on the planet, making it a malignant condition. Beyond these adverse outcomes, it represents one of the largest drivers of health care costs globally. Studies in the past 2 years have demonstrated that we can induce remissions in this malignant process if therapy is instituted rapidly, at the first acute heart failure episode, using full doses of all available effective medications. Multiple studies have demonstrated that this goal can be achieved safely and effectively. Now the urgent call is for all stakeholders, patients, physicians, payers, politicians, and the public at large to come together to address the gaps in implementation and enable health care providers to induce durable remissions in patients with acute heart failure.

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project

PURPOSE OF STUDY

Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission.

PRIMARY PRACTICE SETTING

The setting was a vertically integrated health care system located in Northern California.

METHODOLOGY AND SAMPLE

This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings.

RESULTS

Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).

[Home return Assistance Program for Chronic heart failure in-hospitalized patients (PRADO-IC) : Description, evaluations, perspectives]

INTRODUCTION

Return to home after discharge for congestive heart failure (CHF) is associated with prolonged and recurrent hospitalizations, the prognosis remains poor. Since 2013, the Caisse Nationale d'Assurance Maladie (CNAM) with the Société Française de Cardiologie (SFC) has set up a support program PRADO-IC (support program for returning home after hospitalization for heart failure).

THE AIM OF THIS STUDY

was to describe the program, to present epidemiologic data, and the evaluations by the CNAM, and by clinical studies, then to expose strengths limits and perspectives.

RESULTS

After the inclusion a CPAM advisor organize the outcome, the care of the outpatient is based on his general practitioner (GP) and a private nurse trained in CHF care during a three-months program. Between 2017 and 2019, 20 264 patients per year were hospitalized in Ile de France, 8.8% were included in PRADO-IC. The retrospective CNAM evaluations were positive: follow up criteria were improved and mortality rate at 6 months was lower (10.3% vs. 14.1%). However, clinical retrospective study of Troyes hospital (n = 89), and Paris Saint Joseph Hospital (n = 633), did not confirm these results: rate mortality and/or re-hospitalization were not different between patients and control. Several prospective studies are underway; results will be soon available. Limits of PRADO-IC are discussed like the lack of inclusion criteria, lack of geriatric evaluation, or the pivotal role based on GP, and the short term of duration. Strengths are its existence, national reach, multi-disciplinary approach, educational contents. Clinical studies showed that the PRADO-IC program concerned to the most severe patients. Despite this, the one-year mortality and the HF readmission rate are the same than out-program patients.

CONCLUSION

PRADO-IC is the one and the only national transition of care program for IC patients. First evaluations are positive but prospective evaluation studies are needed in order to limit methodologic bias.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers' Evolutionary Approach

Objective

The purpose of this study was to clarify the concept of transitional care in patients with heart failure.

Background

Transitional care is increasingly being applied in patients with heart failure, but the concept of transitional care in heart failure patients is not uniform and confused with other definitions, which limits further research and practice on transitional care for these patients.

Design

Rodgers' evolutionary concept analysis.

Methods

A comprehensive literature search was conducted using the PUBMED, EMBASE, EBSCO, Chinese Biological Medicine (CBM), CNKI, and WANFANG databases (up to January 26, 2023). We used Rodgers' evolutionary concept analysis method to identify related concepts, attributes, antecedents, and consequences of transitional care in patients with heart failure.

Results

A total of 33 articles were included. The following attributes belonging to transitional care in patients with heart failure were extracted from the literature: self-care, multidisciplinary collaboration, and information transmission. The antecedents were patients' health status, the health literacy of patients and caregivers, the role functions of the main implementer and social and medical resources. Consequences were separated into two categories: patient-centered health outcomes (all-cause mortality, health-related quality of life, discharge preparedness, self-care behaviors, satisfaction of patients) and healthcare utilization outcomes (hospital readmission, length of hospital stay, emergency department visits).

Conclusion

This study found that transitional care in heart failure patients is a systemic care process during a vulnerable period that improves patient self-management and coordination between hospital resources and social support systems for continuous management to promote smooth patient transitions between different locations. This concept analysis will inform healthcare providers in designing evidence-based interventions and quality improvement strategies to ensure that transition processes lead to desired outcomes. In addition, this study will also be helpful for developing specific assessment tools to identify patients with HF who need transitional care.

Feasibility, acceptability, and outcome responsiveness of the SYMPERHEART intervention to support symptom perception in persons with heart failure and their informal caregivers: a feasibility quasi-experimental study

BACKGROUND

Symptom perception is an important process of heart failure (HF) self-care that persons with HF need in order to master self-care management. It also leads to better patient outcomes. Symptom perception consists of body observation and analysis, which are both challenging. We aimed to test the feasibility, acceptability, and outcome responsiveness of a novel intervention (SYMPERHEART) delivered to persons with HF with their informal caregiver.

METHODS

We designed SYMPERHEART as a complex evidence-informed education and support intervention targeting body observation and analysis. We conducted a feasibility quasi-experimental study with a single group pre-post-test design. We included three subsamples: persons with HF receiving home-based care, their informal caregivers exposed to SYMPERHEART, and home-care nurses who delivered SYMPERHEART during 1 month. We assessed feasibility by recruitment time, time to deliver SYMPERHEART, eligibility rate, and intervention fidelity. We assessed acceptability by consent rate, retention rate, persons with HF engagement in body observation, and treatment acceptability. Outcome responsiveness was informed by patient-reported (PRO) and clinical outcomes: HF self-care and the informal caregivers' contribution to HF self-care, perception of HF symptom burden, health status, caregivers' burden, and HF events. We performed descriptive analyses for quantitative data and calculated Cohen's d for PROs. A power analysis estimated the sample size for a future full-scale effectiveness study.

RESULTS

We included 18 persons with HF, 7 informal caregivers, and 9 nurses. Recruitment time was 112.6 h. The median time to deliver SYMPERHEART for each participant was 177.5 min. Eligibility rate was 55% in persons with HF. Intervention fidelity revealed that 16 persons with HF were exposed to body observation and analysis. Consent and retention rates in persons with HF were 37.5% and 100%, respectively. Participants engaged actively in symptom and weight monitoring. Treatment acceptability scores were high. Symptom perception and informal caregivers' contribution to symptom perception were found to be responsive to SYMPERHEART. We estimate that a sample size of 50 persons with HF would be needed for a full-scale effectiveness study.

CONCLUSIONS

SYMPERHEART was found to be feasible and acceptable. This feasibility study provides information for a subsequent effectiveness study.

TRIAL REGISTRATION

ISRCTN. ISRCTN18151041 , retrospectively registered on 4 February 2021, ICTRP Search Portal.

A scoping review of heart failure transitional care quality indicators and outcomes for use in clinical care and research

AIMS

There are no accepted quality indicators for transitional care following hospitalization for heart failure (HF). Current quality measures focus on 30-day readmissions without accounting for competing risks such as death. In this scoping review of clinical trials, we aimed to develop a set of HF transitional care quality indicators for clinical or research applications following hospitalization for HF.

METHODS AND RESULTS

We performed a scoping review using MEDLINE, Embase, CINAHL, HealthSTAR, reference lists and grey literature from January 1990 to November 2022. We included randomized controlled trials (RCTs) of adults hospitalized for HF who received a healthcare service or strategy intervention that aimed to improve patient-reported or clinical outcomes. We independently extracted data and performed a qualitative synthesis of the results. We generated a list of process, structure, patient-reported, and clinical measures that could be used as quality indicators. We highlighted process indicators that were associated with improved clinical outcomes and patient-reported outcomes that had high adherence to COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and United States Food and Drug Administration standards. From 42 RCTs included in the study, we identified a set of process, structure, patient-reported, and clinical indicators that could be used as transitional care measures in clinical or research settings.

CONCLUSION

In this scoping review, we developed a list of quality indicators that could guide clinical efforts or serve as research endpoints in transitional care in HF. Clinicians, researchers, institutions, and policymakers can use the indicators to guide management, design research, allocate resources, and fund services that improve clinical outcomes.

Bridging Treatment Implementation Gaps in Patients With Heart Failure: JACC Focus Seminar 2/3

Heart failure (HF) is a leading cause of death and disability in older adults. Despite decades of high-quality evidence to support their use, guideline-directed medical therapies (GDMTs) that reduce death and disease burden in HF have been suboptimally implemented. Approaches to closing care gaps have focused largely on strategies proven to be ineffective, whilst effective interventions shown to improve GDMT uptake have not been instituted. This review synthesizes implementation interventions that increase the uptake of GDMT, discusses barriers and facilitators of implementation, summarizes conceptual frameworks in implementation science that could improve knowledge uptake, and offers suggestions for trial design that could better facilitate end-of-trial implementation. We propose an evidence-to-care conceptual model that could foster the simultaneous generation of evidence and long-term implementation. By adopting principles of implementation science, policymakers, researchers, and clinicians can help reduce the burden of HF on patients and health care systems worldwide.

Broadening Heart Failure Care Beyond Cardiology: Challenges and Successes Within the Landscape of Multidisciplinary Heart Failure Care

PURPOSE OF REVIEW

Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals.

RECENT FINDINGS

The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.

Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown.

OBJECTIVES

This study characterized opportunities for and achievement of heart failure (HF) medication initiation.

METHODS

Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation.

RESULTS

Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10).

CONCLUSIONS

Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.

The value of multiparametric prediction scores in heart failure varies with the type of follow-up after discharge: a comparative analysis

AIMS

Multiple prediction score models have been validated to predict major adverse events in patients with heart failure. However, these scores do not include variables related to the type of follow-up. This study aimed to evaluate the impact of a protocol-based follow-up programme of patients with heart failure regarding scores accuracy for predicting hospitalizations and mortality occurring during the first year after hospital discharge.

METHODS AND RESULTS

Data from two heart failure populations were collected: one composed of patients included in a protocol-based follow-up programme after an index hospitalization for acute heart failure and a second one-the control group-composed of patients not included in a multidisciplinary HF management programme after discharge. For each patient, the risk of hospitalization and/or mortality within a period of 12 months after discharge was calculated using four different scores: BCN Bio-HF Calculator, COACH Risk Engine, MAGGIC Risk Calculator, and Seattle Heart Failure Model. The accuracy of each score was established using the area under the receiver operating characteristic curve (AUC), calibration graphs, and discordance calculation. AUC comparison was established by the DeLong method. The protocol-based follow-up programme group included 56 patients, and the control group, 106 patients, with no significant differences between groups (median age: 67 years vs. 68.4 years; male sex: 58% vs. 55%; median ejection fraction: 28.2% vs. 30.5%; functional class II: 60.7% vs. 56.2%, I: 30.4% vs. 31.9%; P = not significant). Hospitalization and mortality rates were significantly lower in the protocol-based follow-up programme group (21.4% vs. 54.7%; P < 0.001 and 5.4% vs. 17.9%; P < 0.001, respectively). When applied to the control group, COACH Risk Engine and BCN Bio-HF Calculator had, respectively, good (AUC: 0.835) and reasonable (AUC: 0.712) accuracy to predict hospitalization. There was a significant reduction of COACH Risk Engine accuracy (AUC: 0.572; P = 0.011) and a non-significant accuracy reduction of BCN Bio-HF Calculator (AUC: 0.536; P = 0.1) when applied to the protocol-based follow-up programme group. All scores showed good accuracy to predict 1 year mortality (AUC: 0.863, 0.87, 0.818, and 0.82, respectively) when applied to the control group. However, when applied to the protocol-based follow-up programme group, a significant predictive accuracy reduction of COACH Risk Engine, BCN Bio-HF Calculator, and MAGGIC Risk Calculator (AUC: 0.366, 0.642, and 0.277, P < 0.001, 0.002, and <0.001, respectively) was observed. Seattle Heart Failure Model had non-significant reduction in its acuity (AUC: 0.597; P = 0.24).

CONCLUSIONS

The accuracy of the aforementioned scores to predict major events in patients with heart failure is significantly reduced when they are applied to patients included in a multidisciplinary heart failure management programme.

A Public Health Critical Race Praxis Informed Congestive Heart Failure Quality Improvement Initiative on Inpatient General Medicine

BACKGROUND

Prior evaluation at our hospital demonstrated that, compared to White patients, Black and Latinx patients with congestive heart failure (CHF) were less likely to be admitted to the cardiology service rather than the general medicine service (GMS). Patients admitted to GMS (compared to cardiology) had inferior rates of cardiology follow-up and 30-day readmission.

OBJECTIVE

To develop and test the feasibility and impacts of using quality improvement (QI) methods, in combination with the Public Health Critical Race Praxis (PHCRP) framework, to engage stakeholders in developing an intervention for ensuring guideline-concordant inpatient CHF care across all patient groups.

METHODS

We compared measures for all patients admitted with CHF to GMS between September 2019 and March 2020 (intervention group) to CHF patients admitted to GMS in the previous year (pre-intervention group) and those admitted to cardiology during the pre-intervention and intervention periods (cardiology group). Our primary measures were 30-day readmissions and 14- and 30-day post-discharge cardiology follow-up.

RESULTS

There were 79 patients admitted with CHF to GMS during the intervention period, all of whom received the intervention. There were similar rates of Black and Latinx patients across the three groups. Compared to pre-intervention, intervention patients had a significantly lower 30-day readmission rate (18.9% vs. 24.8%; p=0.024), though the cardiology group also had a decrease in 30-day readmissions from the pre-intervention to intervention period. Compared to pre-intervention, intervention patients had significantly higher 14-day and 30-day post-discharge follow-up visits scheduled with cardiology (36.7% vs. 24.8%, p=0.005; 55.7% vs. 42.3%, p=0.0029), but no improvement in appointment attendance.

CONCLUSION

This study provides a first test of applying the PHCRP framework within a stakeholder-engaged QI initiative for improving CHF care across races and ethnicities. Our study design cannot evaluate causation. However, the improvements in 30-day readmission, as well as in processes of care that may affect it, provide optimism that inclusion of a racism-conscious framework in QI initiatives is feasible and may enhance QI measures.

The diversity of providers' and consumers' views of virtual versus inpatient care provision: a qualitative study

BACKGROUND

A broad-based international shift to virtual care models over recent years has accelerated following COVID-19. Although there are increasing numbers of studies and reviews, less is known about clinicians' and consumers' perspectives concerning virtual modes in contrast to inpatient modes of delivery.

METHODS

We conducted a mixed-methods study in late 2021 examining consumers' and providers' expectations of and perspectives on virtual care in the context of a new facility planned for the north-western suburbs of Sydney, Australia. Data were collected via a series of workshops, and a demographic survey. Recorded qualitative text data were analysed thematically, and surveys were analysed using SPSS v22.

RESULTS

Across 12 workshops, 33 consumers and 49 providers from varied backgrounds, ethnicities, language groups, age ranges and professions participated. Four advantages, strengths or benefits of virtual care reported were: patient factors and wellbeing, accessibility, better care and health outcomes, and additional health system benefits, while four disadvantages, weaknesses or risks of virtual care were: patient factors and wellbeing, accessibility, resources and infrastructure, and quality and safety of care.

CONCLUSIONS

Virtual care was widely supported but the model is not suitable for all patients. Health and digital literacy and appropriate patient selection were key success criteria, as was patient choice. Key concerns included technology failures or limitations and that virtual models may be no more efficient than inpatient care models. Considering consumer and provider views and expectations prior to introducing virtual models of care may facilitate greater acceptance and uptake.