Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program

Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials

BACKGROUND

Poor adherence to medications is a common problem among heart failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function, and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown.

METHODS AND RESULTS

We conducted a comprehensive search and systematic review of intervention studies testing interventions to improve adherence to HF medications. Mortality and readmission outcome effect sizes (ESs) were calculated from the reported data. ESs were combined using random-effects model meta-analysis methods, because differences in true between-study effects were expected from variation in study populations and interventions. ES differences attributed to study design, sample, and intervention characteristics were assessed using moderator analyses when sufficient data were available. We assessed publication bias using funnel plots. Comprehensive searches yielded 6665 individual citations, which ultimately yielded 57 eligible studies. Overall, medication adherence interventions were found to significantly reduce mortality risk among HF patients (relative risk, 0.89; 95% CI, 0.81, 0.99), and decrease the odds for hospital readmission (odds ratio, 0.79; 95% CI, 0.71, 0.89). Heterogeneity was low. Moderator analyses did not detect differences in ES from common sources of potential study bias.

CONCLUSIONS

Interventions to improve medication adherence among HF patients have significant effects on reducing readmissions and decreasing mortality. Medication adherence should be addressed in regular follow-up visits with HF patients, and interventions to improve adherence should be a key part of HF self-care programs.

Assessing Risk and Preventing 30-Day Readmissions in Decompensated Heart Failure: Opportunity to Intervene?

Heart failure (HF) patients are at high risk of hospital readmission, which contributes to substantial health care costs. There is great interest in strategies to reduce rehospitalization for HF. However, many readmissions occur within 30 days of initial hospital discharge, presenting a challenge for interventions to be instituted in a short time frame. Potential strategies to reduce readmissions for HF can be classified into three different forms. First, patients who are at high risk of readmission can be identified even before their initial index hospital discharge. Second, ambulatory remote monitoring strategies may be instituted to identify early warning signs before acute decompensation of HF occurs. Finally, strategies may be employed in the emergency department to identify low-risk patients who may not need hospital readmission. If symptoms improve with initial therapy, low-risk patients could be referred to specialized, rapid outpatient follow-up care where investigations and therapy can occur in an outpatient setting.

Transitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.

Team-Based Care for Outpatients with Heart Failure

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

Implementing a pharmacy resident run transition of care service for heart failure patients: Effect on readmission rates

OBJECTIVE

Heart failure (HF) is a leading cause of hospital readmissions adversely affecting resources and hospital reimbursements. The purpose of this study was to optimize medication therapy, provide patient education and facilitate discharge and follow-up through the creation of a pharmacy resident managed HF transition service with the intention of decreasing readmission rates.

METHODS

A 6-month prospective, single center pilot study was conducted by a pharmacy resident to decrease readmission rates in patients with HF. Patients were identified through emergency department admission reports and direct requests from discharge nurses. The pharmacy resident provided patients with tailored medication and disease state counseling, ensured obtainment of discharge medications and performed follow up telephone calls for appointment reminders and further counseling. The primary outcome measured was readmission rate at 30 days. Secondary outcomes were number of patients requesting safety net medications, reason for readmission(s), and appointment compliance.

RESULTS

Thirty patients were enrolled in the program. The 30-day heart failure readmission rate decreased from 28.1% to 16.6%. Eighty-eight percent of patients attended their follow up appointments.

CONCLUSION

A reduction in readmission rate was achieved through this pharmacy resident-run HF transition service. The majority of patients attended follow-up visits and financial appointments after discharge.

Do Self-Management Interventions Work in Patients With Heart Failure? An Individual Patient Data Meta-Analysis

BACKGROUND

Self-management interventions are widely implemented in the care for patients with heart failure (HF). However, trials show inconsistent results, and whether specific patient groups respond differently is unknown. This individual patient data meta-analysis assessed the effectiveness of self-management interventions in patients with HF and whether subgroups of patients respond differently.

METHODS AND RESULTS

A systematic literature search identified randomized trials of self-management interventions. Data from 20 studies, representing 5624 patients, were included and analyzed with the use of mixed-effects models and Cox proportional-hazard models, including interaction terms. Self-management interventions reduced the risk of time to the combined end point of HF-related hospitalization or all-cause death (hazard ratio, 0.80; 95% confidence interval [CI], 0.71-0.89), time to HF-related hospitalization (hazard ratio, 0.80; 95% CI, 0.69-0.92), and improved 12-month HF-related quality of life (standardized mean difference, 0.15; 95% CI, 0.00-0.30). Subgroup analysis revealed a protective effect of self-management on the number of HF-related hospital days in patients <65 years of age (mean, 0.70 versus 5.35 days; interaction P=0.03). Patients without depression did not show an effect of self-management on survival (hazard ratio for all-cause mortality, 0.86; 95% CI, 0.69-1.06), whereas in patients with moderate/severe depression, self-management reduced survival (hazard ratio, 1.39; 95% CI, 1.06-1.83, interaction P=0.01).

CONCLUSIONS

This study shows that self-management interventions had a beneficial effect on time to HF-related hospitalization or all-cause death and HF-related hospitalization alone and elicited a small increase in HF-related quality of life. The findings do not endorse limiting self-management interventions to subgroups of patients with HF, but increased mortality in depressed patients warrants caution in applying self-management strategies in these patients.

Tailoring of self-management interventions in patients with heart failure

The effectiveness of heart failure (HF) self-management interventions varies within patients suggesting that one size does not fit all. It is expected that effectiveness can be optimized when interventions are tailored to individual patients. The aim of this review was to synthesize the literature on current use of tailoring in self-management interventions and patient characteristics associated with self-management capacity and success of interventions, as building blocks for tailoring. Within available trials, the degree to which interventions are explicitly tailored is marginal and often limited to content. We found that certain patient characteristics that are associated with poor self-management capacity do not influence effectiveness of a given intervention (i.e., age, gender, ethnicity, disease severity, number of comorbidities) and that other characteristics (low: income, literacy, education, baseline self-management capacity) in fact are indicators of patients with a high likelihood for success. Increased scientific efforts are needed to continue unraveling success of self-management interventions and to validate the modifying impact of currently known patient characteristics.

[Medico-economic impact of an innovative management of CHF by HF unit]

Chronic heart failure remains a frequent, severe and costly disease. Despite encouraging data from different countries, heart failure clinics are scarce in France. We have analyzed the impact of a heart failure clinic (UTIC of Pontoise) in terms of reduction of rehospitalizations and in hospitalization costs in 4855 consecutive patients. In our study, heart failure clinic management dramatically reduces HF related hospitalizations (RRR: -28 %, P=0.001) and HF related costs (55% reduction, P<0.001) regardless of comorbidities or disease severity. HF clinics have to be developed in France in order to optimize management of CHF and reduce the HF related costs.

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

PURPOSE

We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration.

RESULTS

We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious.

CONCLUSIONS

Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

Impact of a Multidisciplinary Heart Failure Post-hospitalization Program on Heart Failure Readmission Rates

BACKGROUND

Specialized chronic heart failure (HF) clinics have demonstrated significant reductions in readmissions. Limited evidence is available regarding HF clinics in the immediate post-discharge period.

OBJECTIVE

To evaluate the effect of a multidisciplinary HF clinic on 90-day readmission rates and all-cause mortality in those recently discharged from a HF hospitalization.

METHODS

In this retrospective cohort study, patients discharged with a primary HF diagnosis who attended the HF postdischarge clinic in 2010-2012 were compared with controls from 2009. During 6 clinic visits, patients were seen by a physician assistant, clinical pharmacist specialist, and case manager, with care overseen by a cardiologist. The program focused on optimizing therapy, identifying HF etiology/precipitating factors, medication titration, education, and medication adherence. The primary outcome was 90-day HF readmission. A multivariate Cox proportional hazards model was used to compare outcomes.

RESULTS

Among the 277 patients (144 clinic, 133 control) in the study, 7.6% of patients in the clinic and 23.3% of patients in the control group were readmitted for HF within 90 days (aHR (adjusted hazard ratio) = 0.17; 95% CI = 0.07-0.41; P < 0.001; ARR (absolute risk reduction) = 15.7%; NNT (number needed to treat) = 7). Clinic patients had lower 90-day time-to-first HF readmission or all-cause mortality (9.0% vs 28.6%; aHR = 0.28; 95% CI = 0.06-0.31; P < 0.001; ARR = 19.6%; NNT = 6).

CONCLUSIONS

The multidisciplinary HF posthospitalization outpatient program was associated with a significant reduction in 90-day HF readmissions in patients who were recently discharged from a HF hospitalization.

Effectiveness of nurse-led early discharge planning programmes for hospital inpatients with chronic disease or rehabilitation needs: a systematic review and meta-analysis

AIMS AND OBJECTIVES

To compare the effectiveness of nurse-led early discharge planning programmes to standard care for inpatients with chronic disease or rehabilitation needs.

BACKGROUND

Nurse-directed early discharge planning could shorten inpatient stays and reduce medical costs; however, it is not known whether the development of discharge planning programmes is effective for inpatients with chronic disease nor how such programmes might be optimally organised.

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, MEDLINE, EMBASE, CINAHL and Cochrane Library were searched for randomized controlled trials assessing nurse-directed discharge planning for inpatients with chronic disease or rehabilitation needs. Two reviewers independently extracted data and assessed risk of bias. Meta-analyses were conducted for the eligible studies by RevMan 5.2.6. Data were pooled using a fixed-effect or random effects model. Where meta-analysis was not possible, narrative analysis was reported.

RESULTS

Ten randomized controlled trials and 3438 participants were included. Meta-analysis demonstrated that, compared to standard care, early discharge planning programmes are effective in reducing hospital readmission rates, duration of inpatient readmissions and all-cause mortality. However, no reduction in the length of stay of the index admission was demonstrated. Narrative analysis suggested that discharge planning may reduce total and readmission costs, as well as improving patients' satisfaction and overall quality of life.

CONCLUSIONS

Compared to standard care, nurse-led early discharge planning programmes have a positive impact on several aspects of care for inpatients with chronic disease and rehabilitation requirements, including reducing readmission, readmission length of stay and mortality and improving quality of life. These findings should be taken into account in future health service policy development.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant to clinical and managerial staff in formulating and implementing discharge planning programmes for inpatients with chronic disease or rehabilitation needs.

The Efficacy of Written Information Intervention in Reduction of Hospital Re-admission Cost in Patients With Heart Failure; A Systematic Review and Meta-Analysis

Objective: To assess the efficacy of written information versus non written information intervention in reducing hospital readmission cost, if prescribed or presented to the patients with HF.

Methods: The study was a systematic review and meta-analysis. We searched Medline (Ovid) and Cochrane library during the past 20 years from 1993 to 2013. We also conducted a manual search through Google Scholar and a direct search in the group of related journals in Black Well and Science Direct trough their websites. Two reviewers appraised the identified studies, and meta-analysis was done to estimate the mean saving cost of patient readmission. All the included studies must have been done by randomization to be eligible for study.

Result: We assessed the full-texts 3 out of 65 studies with 754 patients and average age of 74.33. The mean of estimated saving readmission cost in intervention group versus control group was US $2751 (95% CI: 2708 – 2794) and the mean of total saving cost in intervention group versus control group was US $2047 (base year 2010) with (95% CI: 2004 – 2089). No publication bias was found by testing the heterogeneity of studies.

Conclusion: One of the effective factors in minimizing the healthcare cost and preventing from hospital re-admission is providing the patients with information prescription in a written format. It is suggested that hospital management, Medicare organizations, policy makers and individual physicians consider the prescription of appropriate medical information as the indispensable part of patient’s care process.

Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial

Background

Chronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care.

Methods

A randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient’s cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient’s education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients’ education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs.

Discussion

This trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients’ education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training.

Trial registration

ETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [NCT01065142, 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0208-3) contains supplementary material, which is available to authorized users.

Systematic review of trial-based analyses reporting the economic impact of heart failure management programs compared with usual care

BACKGROUND

The cost-effectiveness of heart failure management programs (HF-MPs) is highly variable. We explored intervention and clinical characteristics likely to influence cost outcomes.

METHODS

A systematic review of economic analyses alongside randomized clinical trials comparing HF-MPs and usual care. Electronic databases were searched for English peer-reviewed articles published between 1990 and 2013.

RESULTS

Of 511 articles identified, 34 comprising 35 analyses met the inclusion criteria. Eighteen analyses (51%) reported a HF-MP as more effective and less costly; four analyses (11%), and five analyses (14%) also reported they were more effective but with no significant or an increased cost difference, respectively. Alternatively, five analyses (14%) reported no statistically significant difference in effects or costs, and one analysis (3%) reported no statistically significant effect difference but was less costly. Finally, two analyses (6%) reported no statistically significant effect difference but were more costly. Interventions that reduced hospital admissions tended to result in favorable cost outcomes, moderated by increased resource use, intervention cost and/or the durability of the intervention effect. The reporting quality of economic evaluation assessed by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist varied substantially between 5% and 91% (median 45%; 34 articles) of the checklist criteria adequately addressed. Overall, none of the study, patient or intervention characteristics appeared to independently influence the cost-effectiveness of a HF-MP.

CONCLUSION

The extent that HF-MPs reduce hospital readmissions appears to be associated with favorable cost outcomes. The current evidence does not provide a sufficient evidence base to explain what intervention or clinical attributes may influence the cost implications.

Identifying keys to success in reducing readmissions using the ideal transitions in care framework

BACKGROUND

Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions.

METHODS

Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework.

RESULTS

66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0).

CONCLUSIONS

Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.

Frequent Utilization of the Emergency Department for Acute Heart Failure Syndrome

Background—

Although most research on patients with acute heart failure syndrome (AHFS) has focused on readmissions, this may provide an incomplete picture of health-care utilization. We examined the proportion and characteristics of patients with frequent emergency department (ED) visits for AHFS and associated health-care utilization.

Methods and Results—

A retrospective cohort study of adults with at least 1 ED visit for AHFS between 2010 and 2011 was performed, derived from population-based multipayer data of state ED and inpatient databases for 2 large and diverse states, California and Florida. The analytic sample comprised 113 033 patients with 175 491 ED visits for AHFS. During the 1-year follow-up period, 30.8% of patients had ≥2 (frequent) visits, accounting for 55.4% (95% confidence interval, 55.2–55.5%) of all ED visits for AHFS. In the multivariable model, significant predictors of frequent ED visits were non-Hispanic black race, Hispanic ethnicity, Medicaid insurance, and lower median household income (all P <0.001). At the visit level, patients with frequent ED visits accounted for 55.0% (95% confidence interval, 54.8–5.3%) of all AHFS hospitalizations via ED. Total charges for AHFS were $3.08 billion (95% confidence interval, $3.03–3.14 billion) in Florida alone; patients with frequent ED visits accounted for 53.3% of total charges (95% confidence interval, 53.2–53.3%).

Conclusions—

In this large cohort study, we found that one third (31%) of ED patients with AHFS had frequent ED visits for this condition and that minority race/ethnicity and lower socioeconomic status were associated with frequent ED visits. Individuals with frequent ED visits accounted for the majority of ED visits, hospitalizations, and hospital charges.

Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials

IMPORTANCE

Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions.

OBJECTIVE

To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects.

DATA SOURCES

We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.

STUDY SELECTION

Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home.

DATA EXTRACTION AND SYNTHESIS

Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model.

MAIN OUTCOMES AND MEASURES

Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge.

RESULTS

In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers.

CONCLUSIONS AND RELEVANCE

Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.

Predictors of excess heart failure readmissions: implications for nursing practice

In this study of California, Massachusetts, and New York hospitals, 6 factors predicted 27.6% of readmissions for patients with heart failure (HF). We found that higher admissions per bed, teaching hospitals, and poor nurse-patient communication increased HF readmissions. Conversely, the HF readmissions were lower when nurse staffing was greater, more patients reported receiving discharge information, and among hospitals in California. The implications for nursing practice in the delivery of care to patients with HF are discussed.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives

INTRODUCTION

Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers.

METHODS

Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software.

RESULTS

Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers.

CONCLUSIONS

Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

OBJECTIVE

To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.

DATA SOURCES

Reviews and primary studies that evaluated chronic care management interventions.

STUDY DESIGN

A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.

PRINCIPAL FINDINGS

Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72-0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76-0.93) and improves quality of life by 7.14 points (95 percent CI: -9.55 to -4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.

CONCLUSION

Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To update the previously published review which assessed the effectiveness of disease management interventions for patients with CHF.

SEARCH METHODS

A number of databases were searched for the updated review: CENTRAL, (the Cochrane Central Register of Controlled Trials) and DARE, on The Cochrane Library, ( Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-January 2009); AMED (1985-January 2009). For the original review (but not the update) we had also searched: Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research Register (2003) and NHS Economic Evaluations Database (2001). We also searched reference lists of included studies for both the original and updated reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least six months follow up, comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data and assessed study quality. Study authors were contacted for further information where necessary. Data were analysed and presented as odds ratios (OR) with 95% confidence intervals (CI).

MAIN RESULTS

Twenty five trials (5,942 people) were included. Interventions were classified by: (1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the 'usual care' comparator provided in different trials.Case management interventions were associated with reduction in all cause mortality at 12 months follow up, OR 0.66 (95% CI 0.47 to 0.91, but not at six months. No reductions were seen for deaths from CHF or cardiovascular causes. However, case management type interventions reduced CHF related readmissions at six month (OR 0.64, 95% CI 0.46 to 0.88, P = 0.007) and 12 month follow up (OR 0.47, 95% CI 0.30 to 0.76). Impact of these interventions on all cause hospital admissions was not apparent at six months but was at 12 months (OR 0.75, 95% CI 0.57 to 0.99, I(2) = 58%).   CHF clinic interventions (for six and 12 month follow up) revealed non-significant reductions in all cause mortality, CHF related admissions and all cause readmissions. Mortality was not reduced in the two studies that looked at multidisciplinary interventions. However, both all cause and CHF related readmissions were reduced (OR 0.46, 95% CI 0.46-0.69, and 0.45, 95% CI 0.28-0.72, respectively). 

AUTHORS' CONCLUSIONS

Amongst CHF patients who have previously been admitted to hospital for this condition there is now good evidence that case management type interventions led by a heart failure specialist nurse reduces CHF related readmissions after 12 months follow up, all cause readmissions and all cause mortality.  It is not possible to say what the optimal components of these case management type interventions are, however telephone follow up by the nurse specialist was a common component.Multidisciplinary interventions may be effective in reducing both CHF and all cause readmissions. There is currently limited evidence to support interventions whose major component is follow up in a CHF clinic.

Transitional care programs: who is left behind? A systematic review

OBJECTIVE

Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support.

DESIGN

Systematic review.

SETTING

Hospital to home.

PARTICIPANTS

Older hospitalized adults.

MEASUREMENTS

For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based.

RESULTS

Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization.

CONCLUSIONS

These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.

Effectiveness of heart failure management programmes with nurse-led discharge planning in reducing re-admissions: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) is a clinical condition with major socioeconomic burden. Scientists are trying to find effective solutions to eliminate the effects of the disease and the current innovations in research address the introduction of HF management programmes (HF-MPs).

OBJECTIVES

A meta-analysis was undertaken to estimate the effect of HF-MP with a nurse-driven pre-discharge phase on the outcomes of HF and all-cause re-admission.

DATA SOURCES

A systematic search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Library (reviews and clinical trials) was performed to locate randomised controlled trials (RCTs), published in English language, which implemented any HF-MP with discharge planning carried out by a nurse. Identified articles were further screened for additional studies.

STUDY SELECTION

Two reviewers independently screened relevant abstracts or titles using a standardised predefined check list. Pilot studies, studies additionally assessing other conditions and studies that evolved technology utilities or included medication management beyond optimisation of therapy, were excluded.

DATA EXTRACTION

Selected articles were thoroughly screened and data of interest (characteristics and outcomes) were obtained. Quality assessment was done by two reviewers separately.

DATA SYNTHESIS

Nineteen RCTs were selected for the meta-analysis. The overall pooled effect (relative risk, RR) of the intervention group compared with the control group was estimated by using a random effects analysis (95% confidence interval (CI)) for the outcomes of HF-related re-admission and all-cause re-admission. The overall RR of HF re-admissions was 0.68, 95% CI (0.53, 0.86), p<0.05 and of all-cause re-admission was 0.85, 95% CI (0.76, 0.94), p<0.05 favouring the intervention. Metaregression analysis was performed while trying to explain the observed heterogeneity but none of the factors (environment, duration of follow-up, origin and complexity) were significantly related with the RR. No significant publication bias was observed regarding both HF and all-cause re-admission.

CONCLUSIONS

The results of the current meta-analysis highlight the potential of HF-MPs with nurse-driven pre-discharge interventions to reduce hospital re-admissions. Essential characteristics or components of a successful HF-MP are still to be determined; thus more studies are required to solve this issue.

Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics)

BACKGROUND

Disease management programmes (DMPs) have been shown to reduce hospital readmissions and mortality in adults with heart failure (HF), but their effectiveness in elderly patients or in those with major comorbidity is unknown. The Multicenter Randomised Trial of a Heart Failure Management Programme among Geriatric Patients (HF-Geriatrics) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity.

METHODS/DESIGN

Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain. Each patient should meet at least one of the following comorbidty criteria: Charlson index ≥ 3, dependence in ≥ 2 activities of daily living, treatment with ≥ 5 drugs, active treatment for ≥ 3 diseases, recent emergency hospitalization, severe visual or hearing loss, cognitive impairment, Parkinson's disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), anaemia, or constitutional syndrome. Half of the patients will be randomly assigned to a 1-year DMP led by a case manager and the other half to usual care. The DMP consists of an educational programme for patients and caregivers on the management of HF, COPD (knowledge of the disease, smoking cessation, immunizations, use of inhaled medication, recognition of exacerbations), diabetes (knowledge of the disease, symptoms of hyperglycaemia and hypoglycaemia, self-adjustment of insulin, foot care) and depression (knowledge of the disease, diagnosis and treatment). It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance. The main outcome variables are quality of life, hospital readmissions, and overall mortality during a 12-month follow-up.

DISCUSSION

The physiological changes, lower life expectancy, comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF. The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty, and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients.

TRIAL REGISTRATION

(ClinicalTrials.gov number, NCT01076465).

Outcome of heart failure with preserved ejection fraction: a multicentre spanish registry

Background:

Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting.

Aims:

To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF.

Methods and Results:

We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively).

Conclusions:

In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups.

Influence of gender on long-term prognosis of patients with chronic heart failure seen in heart failure clinics

BACKGROUND

Controversy exists concerning the influence of gender in the prognosis of patients with heart failure and no evidence is available from specific heart failure clinics.

HYPOTHESIS

Women with ambulatory heart failure are managed differently than men, although their prognosis might be better than men.

METHODS AND RESULTS

We analyzed the clinical characteristics, complementary test results, treatment, and prognosis in 4720 patients with chronic heart failure seen in 62 specialized clinics forming part of a multicenter registry during a mean follow-up of 40 months. The mean age was 65 +/- 12 years and 71% were men. The men were younger than the women and more often had a history of hyperlipidemia and ischemic heart disease. The men had a more advanced heart failure New York Heart Association (NYHA) functional class (III-IV) than the women and a greater frequency of systolic ventricular dysfunction. The men more often received treatment with beta-blockers, vasodilators, and antiplatelet aggregators as well as higher mean doses as compared with the women. The overall survival after the follow-up was similar for both genders, although the women had lower rates of survival free of admission for heart failure.

CONCLUSIONS

Despite the mortality of women and men with heart failure being similar, the rate of readmission for heart failure is greater in women in specialized heart failure clinics. These results may be associated with the pharmacological treatment differences observed.

[Noninvasive remote telemonitoring for ambulatory patients with heart failure: effect on number of hospitalizations, days in hospital, and quality of life. CARME (CAtalan Remote Management Evaluation) study]

INTRODUCTION AND OBJECTIVES

Multidisciplinary strategies for the management of heart failure (HF) improve outcomes. We aimed to evaluate the effectiveness of noninvasive home telemonitoring in ambulatory patients with HF already included in a structured multidisciplinary HF program.

METHODS

Prospective intervention study with before/after comparison design of an interactive telemedicine platform in HF patients, randomized 1:1 into two groups: A) Motiva System with educational videos, motivational messages, and questionnaires, and B) Motiva System + self monitoring of blood pressure, heart rate, and weight. Hospitalizations were compared over 12 months prior to and post study inclusion. Quality of life was evaluated using the generic EuroQoL visual analogue scale and the specific questionnaire Minnesota Living With Heart Failure Questionnaire.

RESULTS

There were 92 patients included (71% male; 66.3 ± 11.5 years; 71% ischemic aetiology). During real-time telemonitoring over 11.8 months (interquartile range 8.6-12), 14,730 questionnaires were administered with 89% median response rate. Hospitalizations for HF decreased by 67.8% (P = .010) and for other cardiac causes by 57.6% (P = .028). The number of days in hospital for HF decreased by 73.3% (P =.036), without statistically significant differences between groups, and for other cardiac causes by 82.9% (P =.008). The perception of quality of life improved significantly both for the generic scale (P < .001) and for the HF specific questionnaire (P=.005).

CONCLUSIONS

HF patients who used an interactive telehealth system with motivational support tools at home spent less time in hospital and felt their quality of life had significantly improved. No significant differences were observed between groups.

Cost analysis and cost-effectiveness of NT-proBNP-guided heart failure specialist care in addition to home-based nurse care

BACKGROUND

Heart failure management programmes have been shown to reduce re-hospitalizations. We recently investigated a new disease management programme comparing usual care (UC) to home-based nurse care (HNC) and a HNC group in which decision-making was based on NT-proBNP levels (BNC). As re-hospitalization is the main contributing economic factor in heart failure expenditures, we hypothesized that this programme might be able to reduce costs and could be conducted cost effectively compared to UC.

METHODS

One hundred and ninety congestive heart failure patients, who were included in a randomized trial to receive UC, HNC or BNC at discharge, were analysed in a cost-effectiveness model. Different models were applied to perform analysis of all medical costs, and the costs per year survived were chosen as an effectiveness parameter.

RESULTS

Per patient costs because of heart failure treatment in the UC and the BNC group were € 7109 ± 11,687 and € 2991 ± 4885 (P=0·027), respectively. Corrected for death as a competing risk, the costs in the UC group were € 7893 ± 11,734 and were reduced by BNC to €3148 ± 4949 (P=0·012). Considering costs because of all-cause re-hospitalizations, calculated costs per year survived after discharge were € 19,694 ± 26,754 for UC, € 14,262 ± 25 330 for HNC (P > 0·05) and € 8784 ± 14,728 for BNC (t-test-based contrast P=0·015). In all models calculated, HNC was cost neutral.

CONCLUSIONS

NT-BNP-guided heart failure specialist care in addition to home-based nurse care is cost effective and cheaper than standard care, whereas HNC is cost neutral.

An integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning

AIMS AND OBJECTIVES

This integrative review presents and synthesises previous research investigating practices, perceptions and experiences of bedside staff nurses relative to hospital discharge planning.

BACKGROUND

Preparation for hospital discharge should begin at or prior to admission. Forces in the acute care environment, however, often impede comprehensive discharge planning. Evidence-based redesign of discharge planning processes is a priority for nurses and health care leaders.

DESIGN

An integrative review.

METHOD

The review was undertaken using eleven search terms to electronically scan CINAHL, Medline, PsycINFO and Dissertations and Theses databases for the period 1990-2009. Hand searching of reference lists and author searches was also conducted. Sixty English language articles were reviewed; 38 of these 60 publications met the study inclusion criteria.

RESULTS

Seven themes were identified across the studies. These themes were intra- and interdisciplinary communication; systems and structures; time; role confusion; care continuity; knowledge; and the invisibility of the staff nurse role in discharge planning.

CONCLUSIONS

Acute care bedside nurses frequently encounter significant barriers while providing discharge-related care. Although these barriers have been identified consistently in numerous studies spanning nearly two decades, few published reports address interventions designed to overcome identified obstacles and inefficiencies. Additional discharge planning redesign initiatives, which include rigorous evaluation of patient outcomes, are needed.

RELEVANCE TO CLINICAL PRACTICE

As the direct caregivers with the most consistent presence and knowledge of patients' postdischarge needs, acute care bedside staff nurses play a critical role in preparing patients and families for the transition from hospital to home. Nurses are uniquely positioned to identify barriers and opportunities in discharge planning processes and contribute significantly to evidence-based reform initiatives. Effective and efficient patient-centred discharge planning processes can facilitate the transition from hospital to home and begin to address the adverse events experienced by some patients in the immediate postdischarge period.

The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure

Background

Despite applications of models of care and organizational or system-level interventions to improve patient outcomes for chronic disease, consistent improvements have not been achieved. This may reflect a mismatch between the interventions and the nature of the settings in which they are attempted. The application of complex adaptive systems (CAS) framework to understand clinical systems and inform efforts to improve them may lead to more successful interventions. We performed a systematic review of interventions to improve outcomes of patients with congestive heart failure (CHF) to examine whether interventions consistent with CAS are more likely to be effective. We then examine differences between interventions that are most effective for improving outcomes for patients with CHF versus previously published data for type 2 diabetes to explore the potential impact of the nature of the disease on the types of interventions that are more likely to be effective.

Methods

We conducted a systematic review of the literature between 1998 and 2008 of organizational interventions to improve care of patients with CHF. Two independent reviewers independently assessed studies that met inclusion criteria to determine whether each reported intervention reflected one or more CAS characteristics. The effectiveness of interventions was rated as either 0 (no effect), 0.5 (mixed effect), or 1.0 (effective) based on the type, number, and significance of reported outcomes. Fisher's exact test was used to examine the association between CAS characteristics and intervention effectiveness. Specific CAS characteristics associated with intervention effectiveness for CHF were contrasted with previously published data for type 2 diabetes.

Results and discussion

Forty-four studies describing 46 interventions met eligibility criteria. All interventions utilized at least one CAS characteristic, and 85% were either 'mixed effect' or 'effective' in terms of outcomes. The number of CAS characteristics present in each intervention was associated with effectiveness (p < 0.001), supporting the idea that interventions consistent with CAS are more likely to be effective. The individual CAS characteristics associated with CHF intervention effectiveness were learning, self-organization, and co-evolution, a finding different from our previously published analysis of interventions for diabetes. We suggest this difference may be related to the degree of uncertainty involved in caring for patients with diabetes versus CHF.

Conclusion

These results suggest that for interventions to be effective, they must be consistent with the CAS nature of clinical systems. The difference in specific CAS characteristics associated with intervention effectiveness for CHF and diabetes suggests that interventions must also take into account attributes of the disease.

[Usefulness of brain natriuretic peptide levels, as compared with usual clinical control, for the treatment monitoring of patients with heart failure]

BACKGROUND AND OBJECTIVES

Chronic heart failure continues to have a poor prognosis, in spite of advances made in its therapy. It is uncertain whether symptom-guided therapy optimization is the most effective strategy in this setting. The aim of our study was to evaluate the usefulness of a brain natriuretic peptide (BNP)-guided therapy for the treatment of patients with heart failure.

PATIENTS AND METHODS

We carried out a prospective and randomized study including 60 patients consecutively discharged with the diagnosis of heart failure NYHA class III or IV in one cardiology department of a Spanish hospital; 30 patients were randomly assigned to a symptom-guided therapy group based on the clinical Framingham score, and 30 to a BNP-guided therapy group. Therapy was adjusted to obtain a clinical score <2 in the symptom-guided group and BNP levels <100pg/ml in the BNP-guided group. Follow up was 16±4 months.

RESULTS

BNP-guided group had lower BNP levels during follow up than had symptom-guided group: 14(20)pg/ml versus 111±71pg/ml at 18 months, p=0.029. Clinical score was similar in both groups: 0.42(0.33) versus 0.39(0.63) at 18 months. Probability of survival (86% in both groups) and probability of being free of readmissions for heart failure (68 versus 66%) at 18 months were similar in both groups.

CONCLUSIONS

In our experience, in patients with heart failure, BNP-guided therapy did not improve clinical outcomes compared with symptom-guided therapy.

Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review

OBJECTIVE

This review examined the effectiveness of self-management interventions compared to usual care on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

METHODS

A systematic review was performed. MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched between 1996 and 2009. Randomized controlled trials were selected evaluating self-management interventions designed for patients with chronic heart failure. Outcomes of interest are mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life.

RESULTS

Nineteen randomized controlled trials were identified. The effectiveness of heart failure management programs initiating self-management interventions in patients with chronic heart failure indicate a positive effect, although not always significant, on reduction of numbers of all-cause hospital readmitted patients and due to chronic heart failure, decrease in mortality and increasing quality of life.

CONCLUSION

This systematic review found that current available published studies show methodological shortcomings impairing validation of the effectiveness of self-management interventions on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

PRACTICE IMPLICATIONS

Further research should determine independent effects of self-management interventions and different combinations of interventions on clinical and patient reported outcomes.

Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF)

BACKGROUND

National guidelines recommend heart failure (HF) disease management programs to facilitate adherence to evidence-based practices. This study examined the influence of dedicated HF clinics on delivery of guideline-recommended therapies for cardiology practice outpatients with HF and reduced left ventricular ejection fraction.

METHODS

IMPROVE HF, a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic systolic HF. Adherence to guideline-recommended HF therapies was recorded, and the presence of a dedicated HF clinic was assessed by survey. Multivariate models identified contributions to delivery of guideline-recommended HF therapies.

RESULTS

Of practices, 41.3% had a dedicated HF clinic. Practices with a dedicated HF clinic had greater adherence to 3 of 7 guideline-recommended HF therapy measures: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (P = .02), beta-blocker (P = .025), and HF education (P = .009). After adjustment, use of a dedicated HF clinic was associated with greater conformity in 2 of 7 measures: cardiac resynchronization therapy (P = .036) and HF education (P = .005) but not angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aldosterone antagonist, implantable cardioverter-defibrillator therapy, and anticoagulation for atrial fibrillation.

CONCLUSIONS

Use of dedicated HF clinics varied in cardiology outpatient practices and was associated with greater use of cardiac resynchronization therapy and HF education but not other guideline-recommended therapies.

Are there long-term benefits in following stable heart failure patients in a heart failure clinic?

OBJECTIVES AND DESIGN

This study describes the long-term outcome of 163 patients with stable mild to moderate heart failure (NYHA II-III), who already were enrolled in a heart failure clinic and now were randomized to continued follow-up in the heart failure (HF) clinic or else to usual care (UC). The primary outcome was unplanned hospitalisations and death, the secondary endpoints were pharmacological therapy, NYHA class, six-minute-walking distances and NT-pro BNP level.

RESULTS

At the end of follow-up we found no significant differences in total number of hospitalisation (p = 0.2) or mortality (16% vs. 16%) between the two groups. Patients in the HF clinic cohort achieved a significantly better NYHA score (p < 0.01), significantly longer walking-distances (p = 0.04) and received a significantly higher dose of angiotensin-converting enzyme inhibitors (p < 0.001) and beta-blockers (p < 0.001). No significant difference was found on the level of NT-pro BNP (p = 0.4).

CONCLUSIONS

Patients with mild to moderate HF may benefit from long-term follow-up in a HF clinic in terms of pharmacological therapy and functional status, but we found no significant impact on unplanned hospitalisations or death.

Randomized clinical trial of the effectiveness of a home-based intervention in patients with heart failure: the IC-DOM study

INTRODUCTION AND OBJECTIVES

The objective of this study was to determine whether a home-based intervention can reduce mortality and hospital readmissions and improve quality of life in patients with heart failure.

METHODS

A randomized clinical trial was carried out between January 2004 and October 2006. In total, 283 patients admitted to hospital with a diagnosis of heart failure were randomly allocated to a home-based intervention (intervention group) or usual care (control group). The primary end-point was the combination of all-cause mortality and hospital readmission for worsening heart failure at 1-year follow-up.

RESULTS

The primary end-point was observed in 41.7% of patients in the intervention group and in 54.3% in the control group. The hazard ratio was 0.70 (95% confidence interval [CI] 0.55-0.99). Taking significant clinical variables into account slightly reduced the hazard ratio to 0.62 (95% CI 0.50-0.87). At the end of the study, the quality of life of patients in the intervention group was better than in the control group (18.57 vs. 31.11; P< .001).

CONCLUSIONS

A home-based intervention for patients with heart failure reduced the aggregate of mortality and hospital readmissions and improved quality of life.

Effects of a nurse-based heart failure clinic on drug utilization and admissions in a community hospital setting

OBJECTIVE

To evaluate the effect of a nurse-led heart failure clinic on drug therapy and hospitalization in a community hospital setting.

DESIGN

Prospective, observational study of outpatients referred to a heart failure clinic. Nurses directed drug uptitration and delivered patient education. Utilization and doses of ACE inhibitors and beta-blockers were analyzed as were heart failure related admissions in the years before and after establishing the clinic.

RESULTS

138 patients (median age 68.5 years) were enrolled. After three months 94% of patients were taking an ACE inhibitor and beta-blockade was prescribed for 91%. Mean ACE inhibitor dose relative to target dose after three months was 77+/-30% and mean beta-blocker dose was 53+/-31% of the target dose. Heart failure admissions decreased by 45% after the clinic was established.

CONCLUSIONS

Community hospital based heart failure clinics may promote utilization of evidence based drug therapy and cause a substantial decrease in heart failure admissions, producing results comparable to those obtained in studies of university hospital based heart failure management programs.