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White-Williams C, Rossi LP, Bittner VA, Driscoll A, Durant RW, Granger BB, Graven LJ, Kitko L, Newlin K, Shirey M. Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e841-e863. [DOI: 10.1161/cir.0000000000000767] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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102
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Singh M, Spertus JA, Gharacholou SM, Arora RC, Widmer RJ, Kanwar A, Sanjanwala RM, Welle GA, Al-Hijji MA. Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease. Mayo Clin Proc 2020; 95:1231-1252. [PMID: 32498778 DOI: 10.1016/j.mayocp.2019.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/30/2022]
Abstract
Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.
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Affiliation(s)
- Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO
| | | | - Rakesh C Arora
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Amrit Kanwar
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Rohan M Sanjanwala
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Dionne-Odom JN, Ejem DB, Wells R, Azuero A, Stockdill ML, Keebler K, Sockwell E, Tims S, Engler S, Kvale E, Durant RW, Tucker RO, Burgio KL, Tallaj J, Pamboukian SV, Swetz KM, Bakitas MA. Effects of a Telehealth Early Palliative Care Intervention for Family Caregivers of Persons With Advanced Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial. JAMA Netw Open 2020; 3:e202583. [PMID: 32282044 PMCID: PMC7154802 DOI: 10.1001/jamanetworkopen.2020.2583] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Family caregivers of persons with advanced heart failure perform numerous daily tasks to assist their relatives and are at high risk for distress and poor quality of life. OBJECTIVE To determine the effect of a nurse-led palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart Failure for Patients and Caregivers [ENABLE CHF-PC]) on quality of life and mood of family caregivers of persons with New York Heart Association Class III/IV heart failure over 16 weeks. DESIGN, SETTING, AND PARTICIPANTS This single-blind randomized clinical trial enrolled caregivers aged 18 years and older who self-identified as an unpaid close friend or family member who knew the patient well and who was involved with their day-to-day medical care. Participants were recruited from outpatient heart failure clinics at a large academic tertiary care medical center and a Veterans Affairs medical center from August 2016 to October 2018. INTERVENTION Four weekly psychosocial and problem-solving support telephonic sessions lasting between 20 and 60 minutes facilitated by a trained nurse coach plus monthly follow-up for 48 weeks. The usual care group received no additional intervention. MAIN OUTCOMES AND MEASURES The primary outcomes were quality of life (measured using the Bakas Caregiver Outcomes Scale), mood (anxiety and/or depressive symptoms measured using the Hospital Anxiety and Depression Scale), and burden (measured using the Montgomery-Borgatta Caregiver Burden scales) over 16 weeks. Secondary outcomes were global health (measured using the PROMIS Global Health instrument) and positive aspects of caregiving. RESULTS A total of 158 family caregivers were randomized, 82 to the intervention and 76 to usual care. The mean (SD) age was 57.9 (11.6) years, 135 (85.4%) were female, 82 (51.9%) were African American, and 103 (65.2%) were the patient's spouse or partner. At week 16, the mean (SE) Bakas Caregiver Outcomes Scale score was 66.9 (2.1) in the intervention group and 63.9 (1.7) in the usual care group; over 16 weeks, the mean (SE) Bakas Caregiver Outcomes Scale score improved 0.7 (1.7) points in the intervention group and 1.1 (1.6) points in the usual care group (difference, -0.4; 95% CI, -5.1 to 4.3; Cohen d = -0.03). At week 16, no relevant between-group differences were observed between the intervention and usual care groups for the Hospital Anxiety and Depression Scale anxiety measure (mean [SE] improvement from baseline, 0.3 [0.3] vs 0.4 [0.3]; difference, -0.1 [0.5]; d = -0.02) or depression measure (mean [SE] improvement from baseline, -0.2 [0.4] vs -0.3 [0.3]; difference, 0.1 [0.5]; d = 0.03). No between-group differences were observed in the Montgomery-Borgatta Caregiver Burden scales (d range, -0.18 to 0.0). Differences in secondary outcomes were also not significant (d range, -0.22 to 0.0). CONCLUSIONS AND RELEVANCE This 2-site randomized clinical trial of a telehealth intervention for family caregivers of patients with advanced heart failure, more than half of whom were African American and most of whom were not distressed at baseline, did not demonstrate clinically better quality of life, mood, or burden compared with usual care over 16 weeks. Future interventions should target distressed caregivers and assess caregiver effects on patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02505425.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- University of Alabama at Birmingham School of Nursing
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | | | - Rachel Wells
- University of Alabama at Birmingham School of Nursing
| | - Andres Azuero
- University of Alabama at Birmingham School of Nursing
| | | | - Konda Keebler
- University of Alabama at Birmingham School of Nursing
| | | | - Sheri Tims
- University of Alabama at Birmingham School of Nursing
| | - Sally Engler
- University of Alabama at Birmingham School of Nursing
| | - Elizabeth Kvale
- Department of Medicine, Dell Medical School, The University of Texas at Austin
| | - Raegan W. Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham
| | - Rodney O. Tucker
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | | | - Jose Tallaj
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham
| | - Salpy V. Pamboukian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham
| | - Keith M. Swetz
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Marie A. Bakitas
- University of Alabama at Birmingham School of Nursing
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
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Ishak WW, Edwards G, Herrera N, Lin T, Hren K, Peterson M, Ngor A, Liu A, Kimchi A, Spiegel B, Hedrick R, Chernoff R, Diniz M, Mirocha J, Manoukian V, Ong M, Harold J, Danovitch I, Hamilton M. Depression in Heart Failure: A Systematic Review. INNOVATIONS IN CLINICAL NEUROSCIENCE 2020; 17:27-38. [PMID: 32802590 PMCID: PMC7413333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objective: This paper sought to identify the instruments used to measure depression in heart failure (HF) and elucidate the impact of treatment interventions on depression in HF. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Studies published from 1988 to 2018 covering depression and HF were identified through the review of the PubMed and PsycINFO databases using the keywords: "depres*" AND "heart failure." Two authors independently conducted a focused analysis, identifying 27 studies that met the specific selection criteria and passed the study quality checks. Results: Patient-reported questionnaires were more commonly adopted than clinician-rated questionnaires, including the Beck Depression Inventory, the Patient Health Questionnaire (PHQ-9), and the Hospital Anxiety and Depression Scale. Six common interventions were observed: antidepressant medications, collaborative care, psychotherapy, exercise, education, and other nonpharmacological interventions. Except for paroxetine, selective serotonin reuptake inhibitors failed to show a significant difference from placebo. However, the collaborative care model including the use of antidepressants showed a significant decrease in PHQ-9 score after one year. All of the psychotherapy studies included a variation of cognitive behavioral therapy and patients showed significant improvements. The evidence was mixed for exercise, education, and other nonpharmacological interventions. Conclusion: This study suggests which types of interventions are more effective in addressing depression in heart failure patients.
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Affiliation(s)
- Waguih William Ishak
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Gabriel Edwards
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Nathalie Herrera
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Tiffany Lin
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Kathryn Hren
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Michael Peterson
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Ashley Ngor
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Angela Liu
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Asher Kimchi
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Brennan Spiegel
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Rebecca Hedrick
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Robert Chernoff
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Marcio Diniz
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - James Mirocha
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Vicki Manoukian
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Michael Ong
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - John Harold
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Itai Danovitch
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
| | - Michele Hamilton
- Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California
- Drs. Ishak, Spiegel, and Ong are with the David Geffen School of Medicine at UCLA in Los Angeles, California
- Drs. Kimchi, Harold, and Hamilton are with the Smidt Heart Institute, Cedars-Sinai Medical Center in Los Angeles, California
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Kalogirou F, Forsyth F, Kyriakou M, Mantle R, Deaton C. Heart failure disease management: a systematic review of effectiveness in heart failure with preserved ejection fraction. ESC Heart Fail 2020; 7:194-212. [PMID: 31978280 PMCID: PMC7083420 DOI: 10.1002/ehf2.12559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 10/17/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS Heart failure with preserved ejection fraction (HFpEF) poses a substantial challenge for clinicians, but there is little guidance for effective management. The aim of this systematic review was to determine if there was evidence that disease management programmes (DMPs) improved outcomes for patients with HFpEF. METHODS AND RESULTS A systematic review of controlled studies in English or Greek of DMPs including patients with HFpEF from 2008 to 2018 was conducted using CINAHL, Cochrane, MEDLINE, and Embase. Interventions were assessed using a DMP taxonomy and scored for complexity and intensity. Bias was assessed using the Cochrane Collaboration tool. Initial and updated searches found 6089 titles once duplicates were removed. The final analysis included 18 studies with 5435 HF patients: 1866 patients (34%, study ranges 18-100%) had potential HFpEF (limited by variable definitions). Significant heterogeneity in terms of the population, intervention, comparisons, and outcomes prohibited meta-analysis. Statistically significant or positive trends were found in mortality, hospitalization rates, self-care ability, quality of life, anxiety, depression, and sleep, but findings were not robust or consistent. Four studies reported results separately for study-defined HFpEF, with two finding less positive effect on outcomes. CONCLUSIONS Varying definitions of HFpEF used in studies are a substantial limitation in interpretation of findings. The reduced efficacy noted in contemporary HF DMP studies may not only be due to improvements in usual care but may also reflect inclusion of heterogeneous patients with HFpEF or HF with mid-range EF who may not respond in the same way as HFrEF to individual components. Given that patients with HFpEF are older and multi-morbid, DMPs targeting HFpEF should not rely on a single-disease focus but provide care that addresses predisposing and presentation phenotypes and draws on the principles of comprehensive geriatric assessment. Other components could also be more targeted to HFpEF such as modification of lifestyle factors for which there is emerging evidence, rather than simply continuing the model of care used in HFrEF. Based on current evidence, HF DMPs may improve mortality, hospitalization rates, self-care, and quality of life in patients with HFpEF; however, further research specifically tailored to appropriately defined HFpEF is required.
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Affiliation(s)
| | - Faye Forsyth
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of Public Health and Primary Care, Forvie SiteUniversity of Cambridge School of Clinical Medicine, Cambridge Biomedical CampusCambridgeUK
| | - Martha Kyriakou
- Cyprus University of TechnologyLimassolCyprus
- American Medical CenterNicosiaCyprus
| | - Rhys Mantle
- University of Cambridge School of Clinical MedicineCambridgeUK
| | - Christi Deaton
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of Public Health and Primary Care, Forvie SiteUniversity of Cambridge School of Clinical Medicine, Cambridge Biomedical CampusCambridgeUK
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106
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Hadler RA, Curtis BR, Ikejiani DZ, Bekelman DB, Harinstein M, Bakitas MA, Hess R, Arnold RM, Kavalieratos D. "I'd Have to Basically Be on My Deathbed": Heart Failure Patients' Perceptions of and Preferences for Palliative Care. J Palliat Med 2020; 23:915-921. [PMID: 31916910 DOI: 10.1089/jpm.2019.0451] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To identify patient perceptions of how and when palliative care (PC) could complement usual heart failure (HF) management. Background: Despite guidelines calling for the integration of PC into the management of HF, PC services remain underutilized by this population. Patient preferences regarding delivery of and triggers for PC are unknown. Setting/subjects: Individuals with New York Heart Association Class II-IV disease were recruited from inpatient and outpatient settings at an academic quaternary care hospital. Measurements: Participants completed semistructured interviews discussing perceptions, knowledge, and preferences regarding PC. They also addressed barriers and facilitators to PC delivery. Two investigators independently analyzed data using template analysis. Results: We interviewed 27 adults with HF (mean age 63, 85% white, 63% male, 30% Class II, 48% Class III, and 22% Class IV). Participants frequently conflated PC with hospice; once corrected, they expressed variable preferences for primary versus specialist services. Proponents of primary PC cited continuity in care, HF-specific expertise, convenience, and cost, whereas advocates for specialist care highlighted expertise in symptom management and caregiver support, reduced time constraints, and a comprehensive approach to care. Triggers for specialist PC focused on late-stage manifestations of disease such as loss of independence and absence of disease-directed therapies. Conclusions: Patients with HF demonstrated variable conceptions of PC and its relevance to their disease management. Although preferences for delivery model were based on a variety of logistical and relational factors, triggers for initiation remained focused on late-stage disease, suggesting that patients with HF may misconceive PC is an option of last resort.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brett R Curtis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dara Z Ikejiani
- Division of Oncology, Department of Medicine, Johns Hopkins School of Medicine, Sibley Memorial Hospital, Washington, DC, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health, Aurora, Colorado, USA
| | - Matthew Harinstein
- Heart and Vascular Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marie A Bakitas
- Center for Palliative and Supportive Care, School of Nursing and Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel Hess
- Division of Health System Innovation and Research, Department of Health Sciences, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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107
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Bekelman DB, Fink RM, Sannes T, Kline DM, Borrayo EA, Turvey C, Fischer SM. Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer. Psychooncology 2019; 29:688-695. [DOI: 10.1002/pon.5313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Affiliation(s)
- David B. Bekelman
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
- Department of MedicineEastern Colorado Health Care System, VA Aurora Colorado
| | - Regina M. Fink
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Timothy Sannes
- Division of Psychosocial Oncology and Palliative CareDana Farber Cancer Institute Boston Massachusetts
| | - Danielle M. Kline
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Evelinn A. Borrayo
- Department of Community and Behavioral Health, Colorado School of Public HealthUniversity of Colorado Denver Colorado
| | - Carolyn Turvey
- Carver College of MedicineUniversity of Iowa Iowa City Iowa
| | - Stacy M. Fischer
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
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108
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Hyden K, Gelfman L, Dionne-Odom JN, Smith CB, Coats H. Update in Hospice and Palliative Care. J Palliat Med 2019; 23:165-170. [PMID: 31808708 DOI: 10.1089/jpm.2019.0500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this update is to summarize and critique research articles in Hospice and Palliative Care from 2018 that are pertinent and impactful in informing clinical practice. The articles were presented at the 2019 Annual Assembly of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA). Eight original research articles published between January 1, 2018, and December 31, 2018, were identified through a systematic PubMed search using the terms "hospice" and "palliative care," a hand search of 22 leading healthcare journals, and discussion with experts in the field. The final articles were chosen based on each study's methodological quality, its ability to be applied across different care settings, and its ability to impact clinical practice. We summarize the eight articles that were chosen and identify ways the articles can be used to inform clinical practice.
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Affiliation(s)
- Karen Hyden
- College of Nursing, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Laura Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | | | - Cardinale B Smith
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Heather Coats
- College of Nursing, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Chuzi S, Pak ES, Desai AS, Schaefer KG, Warraich HJ. Role of Palliative Care in the Outpatient Management of the Chronic Heart Failure Patient. Curr Heart Fail Rep 2019; 16:220-228. [DOI: 10.1007/s11897-019-00440-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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110
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Ernecoff NC, Check D, Bannon M, Hanson LC, Dionne-Odom JN, Corbelli J, Klein-Fedyshin M, Schenker Y, Zimmermann C, Arnold RM, Kavalieratos D. Comparing Specialty and Primary Palliative Care Interventions: Analysis of a Systematic Review. J Palliat Med 2019; 23:389-396. [PMID: 31644399 DOI: 10.1089/jpm.2019.0349] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC). Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions. Design: Systematic review secondary analysis. Setting/Subjects: RCTs of palliative care interventions. Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival. Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials. Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.
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Affiliation(s)
- Natalie C Ernecoff
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devon Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Duke Cancer Institute, Durham, North Carolina
| | - Megan Bannon
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.,Division of Geriatric Medicine & Palliative Care Program, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | | | - Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Camilla Zimmermann
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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111
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Abstract
BACKGROUND This study will assess the effects of high quality nursing care (HQNC) on psychological outcomes (PCO) in patients with chronic heart failure (CHF). METHODS We will carry out a through search in 7 databases: PUBMED, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, WANGFANG, and China National Knowledge Infrastructure. Eligibility criteria will be randomized controlled trials on assessing effects of HQNC on PCO in patients with CHF. Cochrane risk of bias evaluation will be utilized for methodological quality. RESULTS This proposed study will summarize a rational synthesis of current evidence for HQNC on PCO in patients with CHF. CONCLUSION The results of this study will provide convinced evidence for judging the effects of HQNC on PCO in patients with CHF.
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112
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Jiang L, Mendame Ehya RE. Effectiveness of a Collaborative Nursing Care Model for the Treatment of Patients with Diabetic Foot Disease by Transverse Tibial Bone Transport Technique: A Pilot Study. J Perianesth Nurs 2019; 35:60-66. [PMID: 31522954 DOI: 10.1016/j.jopan.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/17/2019] [Accepted: 06/22/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Medical staff shortages remain a serious challenge, particularly to medical administrators. We aimed to analyze the effectiveness of a collaborative nursing care model in treatment of diabetic foot. DESIGN A quasi-experimental pilot study. METHODS Twenty-eight patients with diabetic foot treated by transverse tibial bone transport between January 2017 and March 2018 were randomized. The observational group received collaborative nursing care, while the control group received usual nursing care. Postoperative dorsal foot skin temperature, visual analog scale, self-rating anxiety scale (SAS) score, and other endpoints were assessed. FINDINGS Postoperative dorsal foot skin temperature was significantly higher in the observation group than in the control group. Visual analog scale and SAS scores were significantly lower in the observational group than in the control group. CONCLUSIONS The collaborative nursing care model enhanced collaboration between patient and health care providers, shortened hospital stay, and relieved postoperative pain and anxiety.
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Affiliation(s)
- Liping Jiang
- Department of Microsurgery and Hand Surgery, Zhongnan Hospital of Wuhan University, Wuhan, P.R.China.
| | - Regis Ernest Mendame Ehya
- Department of Microsurgery and Hand Surgery, Zhongnan Hospital of Wuhan University, Wuhan, P.R.China
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113
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Solís García del Pozo J, Olmeda Brull C, de Arriba Méndez J, Corbí Pascual M. Palliative medicine for patients with advanced heart failure: New evidence. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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114
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Flint KM, Fairclough DL, Spertus JA, Bekelman DB. Does heart failure-specific health status identify patients with bothersome symptoms, depression, anxiety, and/or poorer spiritual well-being? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:233-241. [PMID: 30649237 PMCID: PMC6613596 DOI: 10.1093/ehjqcco/qcy061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/03/2018] [Accepted: 12/29/2018] [Indexed: 01/06/2023]
Abstract
AIMS Patients with heart failure often have under-recognized symptoms, depression, anxiety, and poorer spiritual well-being ('QoL domains'). Ideally all patients should have heart failure-specific health status and quality of life (QoL) domains routinely evaluated; however, lack of time and resources are limiting in most clinical settings. Therefore, we aimed to evaluate whether heart failure-specific health status was associated with QoL domains and to identify a score warranting further evaluation of QoL domain deficits. METHODS AND RESULTS Participants (N = 314) enrolled in the Collaborative Care to Alleviate Symptoms and Adjust to Illness trial completed measures of heart failure-specific health status [Kansas City Cardiomyopathy Questionnaire, KCCQ (score 0-100, 0 = worst health status)], additional symptoms (Memorial Symptom Assessment Scale), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and spiritual well-being (Facit-Sp) at baseline. Mean ± standard deviation (SD) KCCQ score was 46.9 ± 19.3, mean age was 65.5 ± 11.4, and 79% were male. Prevalence of QoL domain deficits ranged from 11% (nausea) to 47% (depression). Sensitivity/specificity of KCCQ for each QoL domain ranged from 20-40%/80-96% for KCCQ ≤ 25, 61-84%/48-62% for KCCQ ≤ 50, 84-97%/26-40% for KCCQ ≤ 60, and 96-100%/8-13% for KCCQ ≤ 75. Patients with KCCQ ≤ 60 had mean ± SD 4.5 ± 2.5 QoL domain deficits (maximum 12), vs. 1.6 ± 1.6 for KCCQ > 60 (P < 0.001). Similar results were seen for KCCQ ≤25 (6.6 ± 2.4 vs. 3.3 ± 2.4), KCCQ ≤ 50 (4.8 ± 2.6 vs. 2.5 ± 2) and KCCQ ≤ 75 (4.0 ± 2.6 vs. 1.0 ± 1.2) (all P < 00001). CONCLUSION KCCQ ≤ 60 had good sensitivity for each QoL domain deficit and for patients with at least one QoL domain deficit. Screening for QoL domain deficits should target patients with lower KCCQ scores based on a clinic's KCCQ score distribution and clinical resources for addressing QoL domain deficits.
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Affiliation(s)
- Kelsey M Flint
- Rocky Mountain Regional VA Medical Center, Cardiology, Department of Medicine, 1700 North Wheeling Street, Aurora, CO, USA
- Colorado Cardiovascular Outcomes Research Consortium, 13199 E Montview Blvd, Suite 300, Mail Stop F443, Denver, CO, USA
| | - Diane L Fairclough
- Department of Biostatics and Informatics, Colorado School of Public Health, 13199 E Montview Blvd, Suite 339, Aurora, CO, USA
| | - John A Spertus
- Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, 4401 Wornall Rd, Kansas City, MO, USA
| | - David B Bekelman
- Colorado Cardiovascular Outcomes Research Consortium, 13199 E Montview Blvd, Suite 300, Mail Stop F443, Denver, CO, USA
- Rocky Mountain Regional VA Medical Center, Palliative Care, Department of Medicine, 1700 North Wheeling Street, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, 12631 E 17th Ave, Anschutz Medical Campus, Aurora, CO, USA
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115
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Affiliation(s)
- Haider J Warraich
- From the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.J.W.); and the Department of Geriatrics and Palliative Medicine and the Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York (D.E.M.)
| | - Diane E Meier
- From the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.J.W.); and the Department of Geriatrics and Palliative Medicine and the Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York (D.E.M.)
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116
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Affiliation(s)
- David B Bekelman
- Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
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117
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Stockdill ML, Patrician PA, Bakitas M. Understanding and Measuring Symptom Burden in Heart Failure: A Concept Analysis. West J Nurs Res 2019; 41:1423-1447. [PMID: 30895895 DOI: 10.1177/0193945919833710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heart failure is a common, complex, and costly condition accompanied by a high degree of symptom burden. The concept of heart failure symptom burden has been used and measured inconsistently in research. To develop effective symptom management and palliation strategies, a clear conceptual understanding is needed. Rodgers' evolutionary method of concept analysis was used to identify articles in CINAHL, Embase, Scopus, and PubMed focused on chronic heart failure. Analysis of 20 articles revealed key attributes (subjectivity, negative impact on daily life and/or overall functioning, synergistic symptom associations, and symptom exacerbation), related terms (symptom distress and symptom experience), a surrogate term (heart failure burden), antecedents (heart failure classification or stage), and consequences (increased morbidity/mortality, decreased functioning, increased symptom prevalence/severity, decreased quality of life, and recurrent hospital admissions). No gold standard for measurement was identified. Research is needed to validate heart failure symptom burden measurement strategies across populations.
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118
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Larina VN, Chukaeva II, Larin VG. Current Trends and Possibilities of Providing Medical Palliative Care in Chronic Heart Failure. ACTA ACUST UNITED AC 2019; 59:84-92. [PMID: 30710994 DOI: 10.18087/cardio.2019.1.10219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 11/18/2022]
Abstract
Chronic heart failure (CHF) is an important healthcare problem because of high prevalence, morbidity and mortality rates. Treatment resistant symptoms, need for communication and support, unite patients with CHF and oncological diseases but despite that CHF patients rarely receive specialized palliative care (SPC). This review is devoted to the need and possible ways of providing SPC to patients with CHF and their families. We discuss here variants of CHF course in terminal phase, the term end of life appropriate care, various specialists' concepts of SPC delivering to CHF patients in accordance with their preferences.
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Affiliation(s)
- V N Larina
- Pirogov Russian National Research Medical University.
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119
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Abstract
BACKGROUND Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012. OBJECTIVES To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness. MAIN RESULTS We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective. AUTHORS' CONCLUSIONS We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.
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Affiliation(s)
- Andrea Takeda
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Nicole Martin
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Rod S Taylor
- University of Exeter Medical SchoolInstitute of Health ResearchSouth Cloisters, St Luke's Campus, Heavitree RoadExeterUKEX2 4SG
| | - Stephanie JC Taylor
- Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonCentre for Primary Care and Public Health and Asthma UK Centre for Applied ResearchYvonne Carter Building58 Turner StreetLondonUKE1 2AB
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120
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Price DM, Strodtman LK, Montagnini M, Smith HM, Ghosh B. Health Professionals Perceived Concerns and Challenges in Providing Palliative and End-of-Life Care: A Qualitative Analysis. Am J Hosp Palliat Care 2018; 36:308-315. [DOI: 10.1177/1049909118812193] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The Institute of Medicine identifies that quality palliative/end-of-life (EOL) care should be provided to patients with serious, life-limiting illnesses and their families by competently prepared health professionals. Purpose: This study assessed perceived concerns of health professionals pertaining to the delivery of palliative/EOL care in the hospital setting. The specific aim was to determine thematic concerns in the delivery of palliative/EOL care which emerged from respondents’ impressions of a memorable palliative/EOL patient experience. Methods: Interdisciplinary health professionals at a large academic health system in the Midwest were surveyed to reflect upon a memorable palliative/EOL life care patient situation (positive or negative). A Thematic Analysis approach was used to code qualitative responses to 4 open-ended questions and then extract themes and subthemes from the coded data. Results: Concerns identified by participants (N = 425) emerged around 7 themes including communication (97%), decision-making/care planning (75%), education needs (60%), EOL care (48%), ethics (24%), satisfaction with care (9%), and spiritual/cultural sensitivity (6%). Conclusion: Challenges exist in the delivery of quality palliative/EOL care in the hospital setting which may be addressed through educational initiatives that focus on recognition of cultural influences on care preferences, improving communication between patients/families and providers, education about the differences between palliative and EOL care, and increased competency of health providers in having EOL/goals-of-care discussions. Health professionals must recognize the benefit of collaborative palliative care in order to meet patient and family needs holistically and comprehensively.
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Affiliation(s)
| | | | - Marcos Montagnini
- Division of Geriatric and Palliative Medicine, University of Michigan School, and Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
| | - Heather M. Smith
- Psychiatry and Behavioral Medicine, Medical College of Wisconsin, and VA Medical Center, Milwaukee, WI, USA
| | - Bidisha Ghosh
- University of Michigan School of Nursing, Ann Arbor, MI, USA
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121
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Solís García Del Pozo J, Olmeda Brull C, de Arriba Méndez JJ, Corbí Pascual M. Palliative medicine for patients with advanced heart failure: New evidence. Rev Clin Esp 2018; 219:332-341. [PMID: 30318247 DOI: 10.1016/j.rce.2018.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 08/14/2018] [Accepted: 09/04/2018] [Indexed: 11/19/2022]
Abstract
Although heart failure is one of the most common clinical syndromes in medicine and has a high mortality rate, few patients have access to adequate palliative care for their clinical situation. Several trials have recently been published on the usefulness of starting palliative treatment along with cardiac treatment for patients with advanced heart failure. In this review, we analyse the aspects of diagnosing and controlling the symptoms of patients with advanced heart failure and provide a collection of clinical trials that have analysed the efficacy of a palliative intervention in this patient group. Physicians need to be equipped with strategies for recognizing the need for this type of intervention without it resulting in neglecting the active treatment of the patient's heart failure.
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Affiliation(s)
- J Solís García Del Pozo
- Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, España.
| | - C Olmeda Brull
- Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, España
| | - J J de Arriba Méndez
- Unidad de Medicina Paliativa, Complejo Hospitalario y Universitario de Albacete, Albacete, España
| | - M Corbí Pascual
- Servicio de Cardiología, Complejo Hospitalario y Universitario de Albacete, Albacete, España
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