Transitions of care in heart failure: a scientific statement from the American Heart Association

Background and Design of the Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure (BIOMES-HF) Study

BACKGROUND

Symptoms, which often cluster together, are a significant problem in heart failure (HF). There is considerable heterogeneity in symptom burden, particularly in the vulnerable transition period after a hospitalization for HF, and the biological underpinnings of symptom during transitions are unclear. The purpose of this paper is to describe the background and design of a study that addresses these knowledge gaps, entitled "Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure" (BIOMES-HF).

STUDY DESIGN AND METHODS

BIOMES-HF is a prospective gender- and age-balanced longitudinal study of 240 adults during the 6-month transition period after a HF hospitalization. The aims are to: 1) identify clusters of change in physical symptoms, 2) quantify longitudinal associations between biomarkers and physical symptoms, and 3) quantify longitudinal associations between physical frailty and physical symptoms among adults with heart failure. We will measure multiple symptoms, biomarkers, and physical frailty at discharge and then at 1 week and 1, 3, and 6 months post-hospitalization. We will use growth mixture modeling and longitudinal mediation modeling to examine changes in symptoms, biomarkers, and physical frailty post-HF hospitalization and associations therein.

CONCLUSIONS

This innovative study will advance HF symptom science by utilizing a multi-biomarker panel and the physical frailty phenotype to capture the multifaceted nature of HF. Using advanced quantitative modeling, we will characterize heterogeneity and identify potential mechanisms of symptoms in HF. As a result, this research will pinpoint amenable targets for intervention to provide better, individualized treatment to improve symptom burden in HF.

BRIEF LAY SUMMARY

Adults with heart failure may have significant symptom burden. This study is designed to shed light on our understanding of the role of biological and physiological mechanisms in explaining heart failure symptoms, particularly groups of co-occurring symptoms, over time. We will explore how symptoms, biomarkers, and physical frailty changes after a heart failure hospitalization. The knowledge generated from this study will be used to guide the management and self-care for adults with heart failure.

Usefulness of the 2-year iodine-123 metaiodobenzylguanidine-based risk model for post-discharge risk stratification of patients with acute decompensated heart failure

PURPOSE

A four-parameter risk model that included cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters was recently developed for prediction of 2-year cardiac mortality risk in patients with chronic heart failure. We sought to validate the ability of this risk model to predict post-discharge clinical outcomes in patients with acute decompensated heart failure (ADHF) and to compare its prognostic value with that of the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores.

METHODS

We studied 407 consecutive patients who were admitted for ADHF and survived to discharge, with definitive 2-year outcomes (death or survival). Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk was calculated using four parameters, namely age, left ventricular ejection fraction, New York Heart Association functional class, and cardiac MIBG heart-to-mediastinum ratio on delayed images. Patients were stratified into three groups based on the 2-year cardiac mortality risk: low- (< 4%), intermediate- (4-12%), and high-risk (> 12%) groups. The ADHERE and GWTG-HF risk scores were also calculated.

RESULTS

There was a significant difference in the incidence of cardiac death among the three groups stratified using the 2-year cardiac mortality risk model (p < 0.0001). The 2-year cardiac mortality risk model had a higher C-statistic (0.732) for the prediction of cardiac mortality than the ADHERE and GWTG-HF risk scores.

CONCLUSION

The 2-year MIBG-based cardiac mortality risk model is useful for predicting post-discharge clinical outcomes in patients with ADHF.

TRIAL REGISTRATION NUMBER

UMIN000015246, 25 September 2014.

Differences in needs for community collaboration for heart failure between medical and nursing care staff

The increased numbers of older and frail patients with heart failure (HF) means there is an urgent need to establish regional collaborative systems for medical and nursing care. However, expectations related to collaborative HF care among medical and care staff remain unclear. We conducted a questionnaire survey with staff in hospitals, clinics, and nursing care facilities (NCFs) who had experienced collaboration through the common HF collaborative pathway in the western region of Tottori Prefecture, Japan, from July 2019 to July 2020. We received 150 responses from hospitals and 41 responses from clinics and NCFs. Following introduction of the collaborative pathway, 57% of respondents from hospitals, 35% from clinics, and 71% from NCFs rated collaboration as improved. Staff from hospitals and clinics were most satisfied with improved education interventions following implementation of the collaborative pathway, and NCF staff were most satisfied with improved information sharing. Staff from hospitals and NCFs placed the highest importance on improving information sharing through collaboration, and clinic staff placed the highest importance on improving efficiency. The needs for collaborative HF care differ between hospitals, clinics, and NCFs. A collaboration program should be designed to meet the different needs of diverse staff in the community.

[Not Available]

INTRODUCTION

Congestiveheart failure (CHF) is associated with prolonged and recurrent hospitalizations, the prognosis remains poor. The aim of this study was to collect epidemiologic data at admission and at six month follow-up in a cohort of patients with CHF admitted to a single center between 2017 and 2019 (Saint Joseph Hospital, HSJ) and to compare these data with regional data (Ile-de-France, IdF).

METHODS

Local and regional data were provided by National Health Service, Regional Department of Ile de France(DRSM) using national data base. CHF in-hospital stay was defined by appropriate CIM 10 code reported on the final medical form.

RESULTS

From 2017 to 2019, 1967 CHF in-hospital stays were collected, mean age of the population was 81.4 (=mean) ± 11.7 yearsIC_95% [80.8; 81.9], mean length of stay was 8.6 ± 6.8 days IC_95% [8.3; 8.9], in-hospital mortality was 5.3 %, 9.6% at 2^nd month and 15.9% at 6^th month. Readmission rate was 23.7%, time to readmission was 59.5 ± 47.5 days IC_95% [57.4; 61.6]. IdF data collected 60973 CHF in-hospital stays at the same period. Compared to the IdF population, our population was older (81.4 ± 11.6 versus 80.4 ± 12.6 years, p = 0.001). Length of stay was shorter (8.6 ± 6.8 versus 11.3 ± 10.1 days p<0.001), in-hospital mortality was lower (5.3% versus 7.8% p < 0.001), 2nd month and 6^th month mortality was lower (respectively 9.6% versus 14.2% and 15.9% versus 21.3%, p <0.001), home discharge rate was higher (66.9% versus 60.8%, p < 0.001) in the HSJ population. The proportion of patients included in PRADO-IC program (Programme d'aide au retour à domicile-Insuffisance Cardiaque, Returning home support program) was higher in SJ population (22.6% versus 8.8% p < 0.001).

CONCLUSION

CHF admission involved elderly patients, the in-hospital and 6^th month mortality is high, with early and frequent readmissions. Differences between HSJ and IdF populations may be explained by the heterogeneity of health care facilities, management facilities and organization of transition of care.

Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program

BACKGROUND

Elderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients.

METHODS AND RESULTS

We prospectively analyzed data from the RICA registry on 2862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p < .001) and mortality (16% vs. 27%, respectively; p < .001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR] = 0.44; 95% confidence interval [CI] 0.32-0.60; p < .001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio = 0.58; 95% CI 0.42-0.79; p = .001) were maintained.

CONCLUSIONS

The implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

Connected care for endocarditis and heart failure patients: a hospital-at-home programme

Background

Healthcare expenditure in the Netherlands is increasing at such a rate that currently 1 in 7 employees are working in healthcare/curative care. Future increases in healthcare spending will be restricted, given that 10% of the country’s gross domestic product is spent on healthcare and the fact that there is a workforce shortage. Dutch healthcare consists of a curative sector (mostly hospitals) and nursing care at home. The two entities have separate national budgets (€25 bn + €20 bn respectively)

Aim

In a proof of concept, we explored a new hospital-at-home model combining hospital cure and nursing home care budgets. This study tests the feasibility of (1) providing hospital care at home, (2) combining financial budgets, (3) increasing workforces by combining teams and (4) improving perspectives and increasing patient and staff satisfaction.

Results

We tested the feasibility of combining the budgets of a teaching hospital and home care group for cardiology. The budgets were sufficient to hire three nurse practitioners who were trained to work together with 12 home care cardiovascular nurses to provide care in a hospital-at-home setting, including intravenous treatment. Subsequently, the hospital-at-home programme for endocarditis and heart failure treatment was developed and a virtual ward was built within the e‑patient record.

Conclusion

The current model demonstrates a proof of concept for a hospital-at-home programme providing hospital-level curative care at home by merging hospital and home care nursing staff and budgets. From the clinical perspective, ambulatory intravenous antibiotic and diuretic treatment at home was effective in safely achieving a reduced length of stay of 847 days in endocarditis patients and 201 days in heart-failure-at-home patients. We call for further studies to facilitate combined home care and hospital cure budgets in cardiology to confirm this concept.

ANMCO POSITION PAPER: Use of sacubitril/valsartan in hospitalized patients with acute heart failure

Sacubitril/valsartan (S/V) has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms in chronic heart failure with reduced ejection fraction compared with enalapril. After 7 years since the publication of the results of PARADIGM-HF, further insight has been gained with potential new indications. Two prospective randomized multicentre studies (PIONEER-HF and TRANSITION) in patients hospitalized for acute heart failure (AHF) have shown an improved clinical outcome and biomarker profile as compared with enalapril, and good tolerability, safety, and feasibility of initiating in-hospital administration of S/V. Furthermore, some studies have highlighted the favourable effects of S/V in attenuating adverse myocardial remodelling, supporting an early benefit after treatment. Observational data from non-randomized studies in AHF report that in-hospital and pre-discharge prescription of evidence-based drugs associated with better survival still remain suboptimal. Additionally, the COVID-19 pandemic has also negatively impacted on outpatient activities. Therefore, hospitalization, a real crossroad in the history of heart failure, must become a management and therapeutic opportunity for our patients. The objective of this ANMCO position paper is to encourage and facilitate early S/V administration in stabilized patients during hospitalization after an AHF episode, with the aim of improving care efficiency and clinical outcome.

Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio

BACKGROUND

This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

OBJECTIVES

This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI's programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI's Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work.

CONCLUSIONS

The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Differences in Priorities for Heart Failure Management Between Cardiologists and General Practitioners in Japan

BACKGROUND

The purpose of this study was to clarify the current status and issues of community collaboration in heart failure (HF) using a nationwide questionnaire survey.Methods and Results:We conducted a survey among hospital cardiologists and general practitioners (GPs) using a web-based questionnaire developed with the Delphi method, to assess the quality of community collaboration in HF. We received responses from 46 of the 47 prefectures in Japan, including from 281 hospital cardiologists and 145 GPs. The survey included the following characteristics and issues regarding community collaboration. (1) Hospital cardiologists prioritized medical intervention for preventing HF hospitalization and death whereas GPs prioritized supporting the daily living of patients and their families. (2) Hospital cardiologists have not provided information that meets the needs of GPs, and few regions have a community-based system that allows for the sharing of information about patients with HF. (3) In the transition to home care, there are few opportunities for direct communication between hospitals and community staff, and consultation systems are not well developed.

CONCLUSIONS

The current study clarified the real-world status and issues of community collaboration for HF in Japan, especially the differences in priorities for HF management between hospital cardiologists and GPs. Our data will contribute to the future direction and promotion of community collaboration in HF management.

A Randomized Controlled Trial of Heart Failure Disease Management vs Usual Care in Skilled Nursing Facilities

OBJECTIVE

Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.

DESIGN

Cluster-randomized controlled trial.

PARTICIPANTS

The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).

METHODS

The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.

RESULTS

Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.

CONCLUSIONS AND IMPLICATIONS

The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

The SAFEDC Model for Improving Transitions of Care: Lessons Learned from a Participatory Design Workshop (Preprint)

Background

Transition to home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require health care professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions.

Objective

This study aims to understand the usefulness of participatory design approaches in identifying the design implications of transition of care interventions in health care settings. Through a series of participatory design workshops, we have brought stakeholders of the health care system together. With a shared understanding of care transition and patient experience, we have provided participants with opportunities to generate possible design implications for care transitions.

Methods

We selected field observations in clinical settings and participatory design workshops to develop transitional care interventions that serve each hospital’s unique situation and context. Patient journey maps were created and functioned as tools for creating a shared understanding of the discharge process across different stakeholders in the health care environment. The intervention sustainability was also assessed. By applying thematic analysis methods, we analyzed the problem statements and proposed interventions collected from participatory design workshops. The findings showed patterns of major discussion during the workshop.

Results

On the basis of the workshop results, we formalized the transition of care model—the socioeconomic, active engagement, follow-up, education, discharge readiness tool, and consistency (Integrated Michigan Patient-centered Alliance in Care Transitions transition of care model)—which other organizations can apply to improve patient experiences in care transition. This model highlights the most significant themes that should necessarily be considered to improve the transition of care.

Conclusions

Our study presents the benefits of the participatory design approach in defining the challenges associated with transitions of care related to patient discharge and generating sustainable interventions to improve care transitions.

Relational processes in heart failure care transitions: A data-driven case report

BACKGROUND

Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings.

CASE

We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected.

CONCLUSIONS

Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.

Evaluation of a Clinical Pharmacist Specialist Transition of Care Pathway to Manage Heart Failure Readmissions During a Provider Shortage

BACKGROUND

Evidence supports scheduling early follow-up after heart failure (HF) hospitalization with a provider capable of managing hypervolemia. Often this service is provided by cardiologists or specialty nurse practitioners. Continuity or "familiar" providers may be better positioned to identify decompensating HF in patients who have advanced HF and/or multiple complicating medical problems. The objective of this study was to evaluate whether a clinical pharmacy specialist (CPS) service, covering the role of a "familiar" provider in an advanced HF specialty clinic (AHFC) during a staffing shortage, may prevent readmission metrics from worsening.

METHODS

We evaluated the entire, eligible concurrent cohorts, representing 175 AHFC-CPS and 273 control patient-admissions, respectively. Study- and disease-specific predictors for readmission were assessed. A matched cohort of 202 patient-admissions (101 AHFC-CPS:101 NO-CPS) were evaluated.

RESULTS

Subjects were predominantly white, elderly males. While overall "clinic [performance] profiling" outcomes for readmissions (p = 0.43) and mortality (p = 0.66) did not statistically differ between the AHFC-CPS and NO-CPS groups, an imbalance in severity of illness persisted. A survival curve and analysis were constructed, and the hazard ratio for all-cause mortality was 0.69 (p = 0.033).

CONCLUSIONS

This retrospective project supports the premise that AHFC-CPS intervention may be a suitable alternative to maintain the volume status for AHFC patients during a staffing short-fall. More work needs to be done to determine intervention effect size, predictors for readmission, specifically in advanced cardiovascular disease, and to evaluate CPS opportunities in the provision of independent HF care, particularly for patients with advanced HF.

The Effectiveness of the Transitional Care Program Among People Awaiting Coronary Artery Bypass Graft Surgery: A Randomized Control Trial

PURPOSE

This study examined the effectiveness of the Transitional Care Program (TCP) on the anxiety, depression, cardiac self-efficacy, number of hospitalizations, and satisfaction with care among people awaiting elective coronary artery bypass graft (CABG) surgery.

DESIGN

The study design was a randomized controlled trial.

METHODS

The participants with coronary artery disease who met the study criteria (n = 104) were randomly assigned to the intervention group (n = 52) receiving the TCP plus routine care, or the control group (n = 52) receiving routine care only. The TCP, developed based on the Transitional Care Model, comprised hospital discharge planning and six weekly home telephone follow-ups to provide health education, counseling, monitoring, and emotional support tailored to the individual's needs. Data were collected at baseline, and then at weeks 1, 6, and 8 after program enrollment. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and the Z test.

FINDINGS

The intervention group had lower anxiety and depression than did the control group at weeks 1, 6, and 8 after program enrollment. At weeks 6 and 8, the intervention group exhibited higher cardiac self-efficacy and satisfaction with care than the control group. Further, the intervention group had a significantly lower number of hospitalizations than the control group at week 8.

CONCLUSIONS

The TCP can reduce anxiety, depression, and number of hospitalizations, while increasing cardiac self-efficacy and satisfaction with care among people awaiting CABG.

CLINICAL RELEVANCE

Nurses are in a pivotal position to make care transitions safer. Provision of discharge education and regular telephone contacts could enhance positive outcomes regarding patients awaiting elective cardiac surgery.

An Interprofessional Collaborative Practice Can Reduce Heart Failure Hospital Readmissions and Costs in an Underserved Population

BACKGROUND

Heart failure is a leading cause of hospitalization among adults in the United States. Nurse-led interprofessional clinics have been shown to improve heart failure outcomes in patients with heart failure, specifically decreasing readmission rates. Yet, there is little information on the impact of nurse-led interprofessional collaborative practice within an underserved population with heart failure. Thus, the purpose of this study was to compare the differences in readmission days and cost in patients followed by an interprofessional collaborative practice clinic (both engaged and not engaged) and those who did not establish care with the clinic.

METHODS AND RESULTS

Demographic, clinical, and readmission data were compared among patients with heart failure (59% African American; 72% male; mean age, 49 years) stratified into 3 groups: engaged patients (n = 170), not-engaged patients (n = 103), and not-established patients (n = 111) who had an initial appointment to clinic but did not establish care. Patients with 6 months of data before and after the scheduled clinic visit were included in the study. Differences in baseline characteristics, frequency and length of hospital admissions, and costs were analyzed using analysis of variance, Wilcoxon matched-pairs testing, multivariate analysis of variance, logistic regression, and financial analytics. Overall, the number of inpatient hospital days decreased in the engaged group compared with those in the not-engaged and not-established groups (P < .001). The total cost savings were significantly greater in the engaged group ($1,987,379) (P < .001).

CONCLUSIONS

The findings of this study may steer health care providers to incorporate interprofessional collaborative practice into heart failure management with a particular focus on underserved populations.

Biomarkers-based personalized follow-up in chronic heart failure improves patient's outcomes and reduces care associate cost

BACKGROUND

Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF).

METHODS

This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient's outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data.

RESULTS

Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year.

CONCLUSIONS

A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

The use of clinical decision support in reducing readmissions for patients with heart failure: a quasi-experimental study

BACKGROUND

Heart failure is a chronic, progressive condition which affects over six million Americans and 26 million people worldwide. Evidence-based guidelines, protocols, and decision-support tools are available to enhance the quality of care delivery but are not implemented consistently.

AIMS

To examine the effect of clinical decision-making support during patient discharge on 30-day hospital readmission among patients admitted with heart failure and evaluate provider utilization and satisfaction of clinical decision support tool.

DESIGN

A quasi-experimental study.

METHODS

An intervention group of hospitalized patients (N = 55) with heart failure were provided the intervention over a 3-month period and compared to the pre-intervention comparison group (N = 109) of patients who did not receive the intervention. An evidence-based discharge checklist and a pocket guide was implemented by an advanced practice nurse to assist health providers with clinical decision making. Descriptive statistics among samples, 30-day readmission rates, and provider utilization and satisfaction were examined.

RESULTS

Readmission rates slightly decreased (N = 109, 9.2% vs. N = 55, 9.1%) in the post-intervention period, but no significant difference. Heterogeneity between the two groups were minimal related to use of specific medications, age, length-of-stay and comorbidities. Descriptively, there was a significant difference the use of diuretics among each group (p = .002).The discharge checklist was used regularly by 67% of (N = 15) providers, and 93% expressed satisfaction with use.

CONCLUSION

There was no significant reduction in 30-day readmission rates between both groups. However, a slight reduction was noted which indicates the need for further examination into how the use of checklists for clinical decision support can reduce readmissions. A well-designed evidence-based discharge plan remains a critical component of the patient discharge process. Advance practice nurses are uniquely qualified to implement evidence-based interventions that promote practice change among health care providers and improve health outcomes.

Patient, caregiver, and health care provider perspectives on barriers and facilitators to heart failure care in Kerala, India: A qualitative study

Background: Deficits in quality of care for patients with heart failure (HF) contribute to high mortality in this population. This qualitative study aimed to understand the barriers and facilitators to high-quality HF care in Kerala, India.

Methods: Semi-structured, in-depth interviews were conducted with a purposive sample of health care providers (n=13), patients and caregivers (n=14). Additionally, focus group discussions (n=3) were conducted with patients and their caregivers. All interviews and focus group discussions were transcribed verbatim. Textual data were analysed using thematic analysis.

Results: Patients’ motivation to change their lifestyle behaviours after HF diagnosis and active follow-up calls from health care providers to check on patients’ health status were important enablers of high-quality care. Health care providers’ advice on substance use often motivated patients to stop smoking and consuming alcohol. Although patients expected support from their family members, the level of caregiver support for patients varied, with some patients receiving strong support from caregivers and others receiving minimal support. Emotional stress and lack of structured care plans for patients hindered patients’ self-management of their condition. Further, high patient loads often limited the time health care providers had to provide advice on self-management options. Nevertheless, the availability of experienced nursing staff to support patients improved care within health care facilities. Finally, initiation of guideline-directed medical therapy was perceived as complex by health care providers due to multiple coexisting chronic conditions in HF patients.

Conclusions: Structured plans for self-management of HF and more time for patients and health care providers to interact during clinical visits may enable better clinical handover with patients and family members, and thereby improve adherence to self-care options. Quality improvement interventions should also address the stress and emotional concerns of HF patients.

Patient, caregiver, and health care provider perspectives on barriers and facilitators to heart failure care in Kerala, India: A qualitative study

Background: Deficits in quality of care for patients with heart failure (HF) contribute to high mortality in this population. This qualitative study aimed to understand the barriers and facilitators to high-quality HF care in Kerala, India. Methods: Semi-structured, in-depth interviews were conducted with a purposive sample of health care providers (n=13), patients and caregivers (n=14). Additionally, focus group discussions (n=3) were conducted with patients and their caregivers. All interviews and focus group discussions were transcribed verbatim. Textual data were analysed using thematic analysis. Results: Patients' motivation to change their lifestyle behaviours after HF diagnosis and active follow-up calls from health care providers to check on patients' health status were important enablers of high-quality care. Health care providers' advice on substance use often motivated patients to stop smoking and consuming alcohol. Although patients expected support from their family members, the level of caregiver support for patients varied, with some patients receiving strong support from caregivers and others receiving minimal support. Emotional stress and lack of structured care plans for patients hindered patients' self-management of their condition. Further, high patient loads often limited the time health care providers had to provide advice on self-management options. Nevertheless, the availability of experienced nursing staff to support patients improved care within health care facilities. Finally, initiation of guideline-directed medical therapy was perceived as complex by health care providers due to multiple coexisting chronic conditions in HF patients. Conclusions: Structured plans for self-management of HF and more time for patients and health care providers to interact during clinical visits may enable better clinical handover with patients and family members, and thereby improve adherence to self-care options. Quality improvement interventions should also address the stress and emotional concerns of HF patients.

Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

BACKGROUND

Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans.

PROBLEM

Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP).

METHODS

This quality improvement initiative used monthly trend data before and after HFTP implementation.

INTERVENTIONS

The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP.

RESULTS

Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466).

CONCLUSIONS

These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.

Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure

Background

The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new‐onset systolic heart failure.

Methods and Results

Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high‐performing (90th percentile) and low‐performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90–4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin‐converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all‐cause mortality (hazard ratio, 0.54; 95% CI, 0.47–0.61) compared with those without an evaluation.

Conclusions

Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline‐concordant care could lead to an improvement in clinical outcomes.

Status of Medical Care and Management Requirements of Elderly Patients With Heart Failure in a Comprehensive Community Health System - Survey of General Practitioners' Views

Background: Given the high prevalence of heart failure (HF) in the elderly, it is essential to establish medical coordination between general practitioners (GPs) and acute care hospitals (ACHs) in an aging society. The aim of this study was to elucidate the status of acceptance of elderly patients with HF and their management requirements in a comprehensive community health system. Furthermore, we investigated GPs’ interest in using information and communications technology (ICT) in patient care.

Methods and Results: We sent a questionnaire survey to 1,800 GPs in January 2015 and received 392 replies. The overall prevalence of home visits was 55%, with no differences according to GP background characteristics or geographic area. However, less than half (44%) reported accepting patients with symptomatic HF for treatment in their clinic. In addition, only 3 GPs reported accepting and providing emergency visits for patients with refractory HF. In particular, GPs who were not certificated cardiologists, female, and older showed poorer acceptance of symptomatic HF patients. More than half the GPs wanted the prompt acceptance by ACHs of emergency patients, followed by strengthening of home care support at discharge and support for end-of-life care. Half the GPs were interested in telemedicine.

Conclusions: ACHs must promptly accept patients with HF in cases of emergency and strengthen nursing care support at discharge. It is also necessary to consider how to support older and female GPs.

Perceived Versus Actual Risks of 30-Day Readmission in Patients With Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of hospitalization in the United States, and patients with CVD are at a high risk of readmission after discharge. We examined whether patients' perceived risk of readmission at discharge was associated with actual 30-day readmissions in patients hospitalized with CVD.

METHODS

We recruited 730 patients from the Duke Heart Center who were admitted for treatment of CVD between January 1, 2015, and August 31, 2017. A standardized survey was linked with electronic health records to ascertain patients' perceived risk of readmission, and other sociodemographic, psychosocial, behavioral, and clinical data before discharge. All-cause readmission within 30 days after discharge was examined.

RESULTS

Nearly 1-in-3 patients perceived a high risk of readmission at index admission and those who perceived a high risk had significantly more readmissions within 30 days than patients who perceived low risks of readmission (23.6% versus 15.8%, P=0.016). Among those who perceived a high risk of readmission, non-White patients (odds ratio [OR], 2.07 [95% CI, 1.28-3.36]), those with poor self-rated health (OR, 2.30 [95% CI, 1.38-3.85]), difficulty accessing care (OR, 2.72 [95% CI, 1.24-6.00]), and prior hospitalizations in the past year (OR, 2.13 [95% CI, 1.21-3.74]) were more likely to be readmitted. Among those who perceived a low risk of readmission, patients who were widowed (OR, 2.69 [95% CI, 1.60-4.51]) and reported difficulty accessing care (OR, 1.89 [95% CI, 1.07-3.33]) were more likely to be readmitted.

CONCLUSIONS

Patients who perceived a high risk of readmission had a higher rate of 30-day readmission than patients who perceived a low risk. These findings have important implications for identifying CVD patients at a high risk of 30-day readmission and targeting the factors associated with perceived and actual risks of readmission.

Association between ambulance use and hospitalization costs among heart failure patients

Heart failure is the main cause of hospitalization, which burdens the healthcare system. Although many hospitalizations for heart failure follow ambulance use, it is unknown whether ambulance use increases hospitalization costs. Using the Diagnosis Procedure Combination database in Japan, we examined all hospitalizations of patients with heart failure from April 2014 to March 2015. Patients were divided into those with and those without ambulance use. We performed a multiple regression analysis to examine the association between ambulance use and total hospitalization costs, adjusting for age, sex, length of day, and activities of daily living. We identified 126,067 hospitalizations for heart failure. The percentages of ambulance use were 29%, 27%, 30%, and 50% among patients with NYHA Functional Classification I, II, III, and IV, respectively. For patients categorized as NYHA I (n = 9,700), multiple linear regression analysis revealed that ambulance use was significantly associated with higher hospitalization cost (coefficient 723 USD; 95% confidence interval 109-1337; p = 0.021). Even for heart failure patients with NYHA I, ambulances were frequently used. Ambulance use was independently associated with increased hospital costs. Future research is needed on transitional care to limit unnecessary ambulance use.

Effect of family nursing therapeutic conversations on patients with heart failure and their family members: Secondary outcomes of a randomised multicentre trial

AIMS AND OBJECTIVES

This study evaluates the short-term (3 months), medium-term (6 months) and long-term (12 months) effect of family nursing therapeutic conversations added to conventional care versus conventional care on social support, family health and family functioning in outpatients with heart failure and their family members.

BACKGROUND

It has been emphasised that increased social support from nurses is an important resource to strengthen family health and family functioning and thus improve the psychological well-being of patients with heart failure and their close family members.

DESIGN

A randomised multicentre trial.

METHODS

A randomised multicentre trial adhering to the CONSORT checklist was performed in three Danish heart failure clinics. Consecutive patients (n = 468) with family members (n = 322) were randomly assigned to either the intervention or control group. Participants were asked to fill out family functioning, family health and social support questionnaires. Data were measured ahead of first consultation and again after 3, 6 and 12 months.

RESULTS

Social support scores increased statistically significant both at short-term (p = 0.002) medium-term (p = 0.008) and long-term (p = 0.018) among patients and their family members (p = <0.001; 0.007 and 0.014 respectively) in the intervention group in comparison with the control group. Both patients and their family members reported increased reinforcement, feedback, decision-making capability and collaboration with the nurse. No significant differences between the intervention and control groups were seen in the family health and family functioning scales among patients and family members.

CONCLUSIONS

Family nursing therapeutic conversations were superior to conventional care in providing social support from nurses.

RELEVANCE TO CLINICAL PRACTICE

Family nursing therapeutic conversations are suitable to improve the support from nurses among families living with heart failure.

PRADOC: a trial on the efficiency of a transition care management plan for hospitalized patients with heart failure in France

Aims

Transition care programmes are designed to improve coordination of care between hospital and home. For heart failure patients, meta‐analyses show a high efficacy but with moderate evidence level. Moreover, difficulties for implementation of such programmes limit their extrapolation.

Methods and results

We designed a mixed‐method study to assess the implementation of the PRADO‐IC, a nationwide transition programme that aims to be offered to every patient with heart failure in France. This programme consists essentially in an administrative assistance to schedule follow‐up visits and in a nurse follow‐up during 2 to 6 months and aims to reduce the annual heart failure readmission rate by 30%. This study assessed three quantitative aims: the cost to avoid a readmission for heart failure within 1 year (primary aim, intended sample size 404 patients), clinical care pathways, and system economic outcomes; and two qualitative aims: perceived problems and benefits of the PRADO‐IC. All analyses will be gathered at the end of study for a joint interpretation. Strengths of this study design are the randomized controlled design, the population included in six centres with low motivation bias, the primary efficiency analysis, the secondary efficacy analyses on care pathway and clinical outcomes, and the joint qualitative analysis. Limits are the heterogeneity of centres and of intervention in a control group and parallel development of other new therapeutic interventions in this field.

Conclusions

The results of this study may help decision‐makers to support an administratively managed transition programme.

A Narrative Review of the Patient Journey Through the Lens of Non-communicable Diseases in Low- and Middle-Income Countries

Low- and middle-income countries (LMICs) are challenged with a disproportionately high burden of noncommunicable diseases (NCDs) and limited healthcare resources at their disposal to tackle the NCD epidemic. Understanding the patient journey for NCDs from the patients' perspective can help healthcare systems in these settings evolve their NCD care models to address the unmet needs of patients, enhance patient participation in their management, and progress towards better outcomes and quality of life. This paper aims to provide a theoretical framework outlining common touchpoints along the patient journey for NCDs in LMICs. It further aims to review influencing factors and recommend strategies to improve patient experience, satisfaction, and disease outcomes at each touchpoint. The co-occurrence of major NCDs makes it possible to structure the patient journey for NCDs into five broad touchpoints: awareness, screening, diagnosis, treatment, and adherence, with integration of palliative care along the care continuum pathway. The patients' perspective must be considered at each touchpoint in order to inform interventions as they experience first-hand the impact of NCDs on their quality of life and physical function and participate substantially in their disease management. Collaboratively designed health communication programs, shared decision-making, use of appropriate risk assessment tools, therapeutic alliances between the patient and provider for treatment planning, self-management tools, and improved access to palliative care are some strategies to help improve the patient journeys in LMICs. Long-term management of NCDs entails substantial self-management by patients, which can be augmented by pharmacists and nurse-led interventions. The digital healthcare revolution has heralded an increase in patient engagement, support of home monitoring of patients, optimized accurate diagnosis, personalized care plans, and facilitated timely intervention. There is an opportunity to integrate digital technology into each touchpoint of the patient journey, while ensuring minimal interruption to patients' care in the face of global health emergencies.

Palliative Care in Acute Heart Failure

Purpose of Review

Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

Recent Findings

The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research.

Summary

Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.

Income level and outcomes in patients with heart failure with universal health coverage

Objective

We aimed to investigate the influence of income level on guideline-directed medical therapy (GDMT) prescription rates and prognosis of patients with heart failure (HF) following implementation of a nationwide health insurance programme.

Methods

A total of 633 098 hospitalised patients with HF from 1996 to 2013 were identified from Taiwan National Health Insurance Research Database. Participants were classified into low-income, median-income and high-income groups. GDMT utilisation, in-hospital mortality and postdischarge HF readmission, and mortality rates were compared.

Results

The low-income group had a higher comorbidity burden and was less likely to receive GDMT than the other two groups. The in-hospital mortality rate in the low-income group (5.07%) was higher than in the median-income (2.47%) and high-income (2.51%) groups. Compared with the high-income group, the low-income group had a significantly higher risk of postdischarge HF readmission (adjusted HR (aHR): 1.29, 95% CI 1.27 to 1.31), all-cause mortality (aHR: 1.98, 95% CI 1.95 to 2.02) and composite HF readmission/all-cause mortality (aHR: 1.54, 95% CI 1.52 to 1.56). These results were generally consistent among the population after propensity matching (low vs high: HR=2.08 for mortality and 1.36 for HF readmission; median vs high: HR=1.23 for mortality and 1.12 for HF readmission; all p<0.001) and after inverse probability of treatment weighting (low-income vs high-income group: HR: 2.19 for mortality and 1.16 for HF readmission; median-income vs high-income group: HR: 1.53 for mortality and 1.09 for HF readmission; all p<0.001). Lower utilisation of GDMT and poorer prognosis in lower-income hospitalised patients with HF appeared to mitigate over time.

Conclusions

Low-income patients with HF had nearly a twofold increase in the risk of in-hospital mortality and postdischarge events compared with the high-income group, partly due to lower GDMT utilisation. The differences between postdischarge HF outcomes among various income groups appeared to mitigate over time following the implementation of nationwide universal health coverage.

Predictors of oral anticoagulant-associated adverse events in seniors transitioning from hospital to home: a retrospective cohort study protocol

INTRODUCTION

Oral anticoagulants (OACs) are widely prescribed in older adults. High OAC-related adverse event rates in the early period following hospital discharge argue for an analysis to identify predictors. Our objective is to identify and validate clinical and continuity of care variables among seniors discharged from hospital on an OAC, which are independently associated with OAC-related adverse events within 30 days.

METHODS AND ANALYSIS

We propose a population-based retrospective cohort study of all adults aged 66 years or older who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome is a composite of the first hospitalisation or emergency department visit for a haemorrhage or thromboembolic event or mortality within 30 days of hospital discharge. A Cox proportional hazards model will be used to determine the association between the composite outcome and a set of prespecified covariates. A split sample method will be adopted to validate the variables associated with OAC-related adverse events.

ETHICS AND DISSEMINATION

The use of data in this project was authorised under section 45 of Ontario's Personal Health Information Protection Act, which does not require review by a research ethics board. Results will be disseminated via peer-reviewed publications and presentations at conferences and will determine intervention targets to improve OAC management in upcoming randomised trials.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02777047; Pre-results.

Study design of Heart failure Events reduction with Remote Monitoring and eHealth Support (HERMeS)

AIMS

The role of non-invasive telemedicine (TM) combining telemonitoring and teleintervention by videoconference (VC) in patients recently admitted due to heart failure (HF) ('vulnerable phase' HF patients) is not well established. The aim of the Heart failure Events reduction with Remote Monitoring and eHealth Support (HERMeS) trial is to assess the impact on clinical outcomes of implementing a TM service based on mobile health (mHealth), which includes remote daily monitoring of biometric data and symptom reporting (telemonitoring) combined with VC structured, nurse-based follow-up (teleintervention). The results will be compared with those of the comprehensive HF usual care (UC) strategy based on face-to-face on-site visits at the vulnerable post-discharge phase.

METHODS AND RESULTS

We designed a 24 week nationwide, multicentre, randomized, controlled, open-label, blinded endpoint adjudication trial to assess the effect on cardiovascular (CV) mortality and non-fatal HF events of a TM-based comprehensive management programme, based on mHealth, for patients with chronic HF. Approximately 508 patients with a recent hospital admission due to HF decompensation will be randomized (1:1) to either structured follow-up based on face-to-face appointments (UC group) or the delivery of health care using TM. The primary outcome will be a composite of death from CV causes or non-fatal HF events (first and recurrent) at the end of a 6 month follow-up period. Key secondary endpoints will include components of the primary event analysis, recurrent event analysis, and patient-reported outcomes.

CONCLUSIONS

The HERMeS trial will assess the efficacy of a TM-based follow-up strategy for real-world 'vulnerable phase' HF patients combining telemonitoring and teleintervention.

Differential risk of incident cancer in patients with heart failure: A nationwide population-based cohort study

BACKGROUND

Heart failure (HF) and cancer are currently two leading causes of mortality, and sometimes coexist. However, the relationship between them is not completely elucidated. We aimed to investigate whether patients with HF are predisposed to cancer development using the large Korean National Health Insurance claims database.

METHODS

This study included 128,441 HF patients without a history of cancer and 642,205 age- and sex-matched individuals with no history of cancer and HF between 1 January 2010 and 31 December 2015.

RESULTS

During a median follow-up of 4.06 years, 11,808 patients from the HF group and 40,805 participants from the control were newly diagnosed with cancer (cumulative incidence, 9.2% vs. 6.4%, p < 0.0001). Patients with HF presented a higher risk for cancer development compared to controls in multivariable Cox analysis [hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.61-1.68]. The increased risk was consistent for all site-specific cancers. To minimize potential surveillance bias, additional analysis was performed by eliminating participants who developed cancer within the initial 2 years of HF diagnosis (i.e. 2-year lag analysis). In the 2-year lag analysis, the higher risk of overall cancer remained significant in patients with HF (HR 1.09, 95% CI 1.05-1.13), although the association was weaker. Among the site-specific cancers, three types of cancer (lung, liver/biliary/pancreas, and hematologic malignancy) were consistently at higher risk in patients with HF. An exploratory analysis showed that patients with repeated HF hospitalization had a higher risk of cancer development compared to those without, in a pattern of stepwise increases across the three groups [controls vs. HF without re-hospitalization vs. HF with re-hospitalization ≥1; HR (95% CI), 1.00 (reference) vs. 1.55 (1.51-1.59) vs. 1.96 (1.89-2.03), respectively].

CONCLUSIONS

Cancer incidence is higher in patients with HF than the general population. Active surveillance of coexisting malignancy needs to be considered in these patients.

Transitioning Patients with Heart Failure to Outpatient Care

The transition from hospitalization to outpatient care is a vulnerable time for patients with heart failure. This requires specific focus on the transitional care period. Here the authors propose a framework to guide process improvement in the transitional care period. The authors extend this framework by (1) examining the role new technology might play in transitional care, and (2) offering practical advice for teams building transitional care programs.

Family Caregiving for Individuals With Heart Failure: A Scientific Statement From the American Heart Association

Many individuals living with heart failure (HF) rely on unpaid support from their partners, family members, friends, or neighbors as caregivers to help manage their chronic disease. Given the advancements in treatments and devices for patients with HF, caregiving responsibilities have expanded in recent decades to include more intensive care for increasingly precarious patients with HF—tasks that would previously have been undertaken by healthcare professionals in clinical settings. The specific tasks of caregivers of patients with HF vary widely based on the patient’s symptoms and comorbidities, the relationship between patient and caregiver, and the complexity of the treatment regimen. Effects of caregiving on the caregiver and patient range from physical and psychological to financial. Therefore, it is critically important to understand the needs of caregivers to support the increasingly complex medical care they provide to patients living with HF. This scientific statement synthesizes the evidence pertaining to caregiving of adult individuals with HF in order to (1) characterize the HF caregiving role and how it changes with illness trajectory; (2) describe the financial, health, and well-being implications of caregiving in HF; (3) evaluate HF caregiving interventions to support caregiver and patient outcomes; (4) summarize existing policies and resources that support HF caregivers; and (5) identify knowledge gaps and future directions for providers, investigators, health systems, and policymakers.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in complex comorbidities. Hospital readmissions for HF, including emergency department (ED) visits, are considered preventable. Majority of the patients with HF are often discharged early in the recovery period with inadequate self-care instructions. To address these issues, transitional care interventions have been implemented with the common objective of reducing the rate of hospital readmission, including ED visits. However, there is a lack of evidence regarding the benefits and adverse effects of transitional care interventions on clinical outcomes and patient-related outcomes of patients with HF. This integrative review aims to identify the components of transitional care interventions and the effectiveness of these interventions in improving health outcomes of patients with HF. Five databases were searched from January 2000 to December 2019, and 25 articles were included.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure

BACKGROUND

Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.

OBJECTIVE

To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care.

DESIGN

Decision analytic microsimulation model.

DATA SOURCES

Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data.

TARGET POPULATION

Patients with HF who were aged 75 years at hospital discharge.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

Disease management clinics, nurse home visits (NHVs), and nurse case management.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained.

LIMITATION

Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings.

CONCLUSION

In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF.

PRIMARY FUNDING SOURCE

Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.