Mortality and Readmission Following Hospitalisation for Heart Failure in Australia: A Systematic Review and Meta-Analysis. Heart Lung Circ. 2018;27:917-927. [PMID: 29519691 DOI: 10.1016/j.hlc.2018.01.009]

Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia

Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.

Economic Considerations of Cardiovascular Implantable Electronic Devices for The Treatment of Heart Failure

PURPOSE OF REVIEW

Heart failure (HF) is a major public health problem worldwide, affecting more than 64 million people [1]. The complex and severe nature of HF presents challenges in providing cost-effective care as patients often require multiple hospitalizations and treatments. This review of relevant studies with focus on the last 10 years summarizes the health and economic implications of various HF treatment options in Europe and beyond. Although the main cost drivers in HF treatment are clinical (re)admission and decompensation of HF, an assessment of the economic impacts of various other device therapy options for HF care are included in this review. This includes: cardiovascular implantable electronic devices (CIEDs) such as cardiac-resynchronisation-therapy devices that include pacemaking (CRT-P), cardiac-resynchronisation-therapy devices that include defibrillation (CRT-D), implantable cardioverter/defibrillators (ICDs) and various types of pacemakers. The impact of (semi)automated (tele)monitoring as a relevant factor for increasing both the quality and economic impact of care is also taken into consideration. Quality of life adjusted life years (QALYs) are used in the overall context as a composite metric reflecting quantity and quality of life as a standardized measurement of incremental cost-effectiveness ratios (ICER) of different device-based HF interventions.

RECENT FINDINGS

In terms of the total cost of different devices, CRT-Ds were found in several studies to be more expensive than all other devices in regards to runtime and maintenance costs including (re)implantation. In the case of CRT combined with an implantable cardioverter-defibrillator (CRT-D) versus ICD alone, CRT-D was found to be the most cost-effective treatment in research work over the past 10 years. Further comparison between CRT-D vs. CRT-P does not show an economic advantage of CRT-D as a minority of patients require shock therapy. Furthermore, a positive health economic effect and higher survival rate is seen in CRT-P full ventricular stimulation vs. right heart only stimulation. Telemedical care has been found to provide a positive health economic impact for selected patient groups-even reducing patient mortality. For heart failure both in ICD and CRT-D subgroups the given telemonitoring benefit seems to be greater in higher-risk populations with a worse HF prognosis. In patients with HF, all CIED therapies are in the range of commonly accepted cost-effectiveness. QALY and ICER calculations provide a more nuanced understanding of the economic impact these therapies create in the healthcare landscape. For severe cases of HF, CRT-D with telemedical care seems to be the better option from a health economic standpoint, as therapy is more expensive, but costs per QALY range below the commonly accepted threshold.

Investigating the effect of an online enhanced care program on the emotional and physical wellbeing of patients discharged from hospital with acute decompensated heart failure: Study protocol for a randomised controlled trial: Enhanced care program for heart failure

Objective

Depression is highly prevalent and associated with increased hospitalisations and mortality among patients with heart failure (HF). This study will evaluate the effectiveness and cost-effectiveness of an online wellbeing program for patients discharged from hospital with acute decompensated heart failure (ADHF) in (i) improving emotional and physical wellbeing, and (ii) decreasing healthcare utilisation.

Methods

Two-arm randomised controlled trial. Eligible patients with ADHF will be recruited pre-discharge from two hospitals. Five hundred and seventy participants will be randomised to receive the intervention (online enhanced care program for HF: 'Enhanced HF Care') or usual care. Enhanced HF Care includes health education (11 micro-learning modules) and monitoring of depression and clinical outcomes via fortnightly/monthly surveys for 6 months, with participants offered tailored advice via video email and SMS. Cardiac nurses track real-time patient data from a dashboard and receive automated email alerts when patients report medium- or high-risk levels of depression or clinical symptoms, to action where needed. General practitioners also receive automated alerts if patients report medium- or high-risk survey responses and are encouraged to schedule a patient consultation.

Results

Sixty-five participants enrolled to-date. Co-primary outcomes ('Minnesota Living with Heart Failure Questionnaire' Emotional and Physical subscales) and healthcare utilisation (secondary outcome) at 1- and 6-month post-recruitment will be compared between treatment arms using linear mixed effects regression models.

Conclusions

This study has the potential to reduce the burden of depression for patients with HF by prioritising urgent mental health needs and clinical symptoms while simultaneously empowering patients with self-care knowledge.

Trial registration

The trial was prospectively registered via the Australian New Zealand Clinical Trials Registry: ACTRN12622001289707. Issue date: 4 October 2022.

The Impact of Inadequate Energy Intake on Readmission Burden of Patients With Heart Failure

BACKGROUND

Adequate energy intake is essential for good clinical outcomes. The association between energy intake and readmission burden of patients with heart failure (HF) still needs to be clarified.

OBJECTIVE

In this study, our aim was to determine the association between energy intake and readmission in patients with HF.

METHODS

A total of 311 inpatients with HF were recruited. Demographic and clinical information were collected during hospitalization; the daily diets of the participants were collected in the second week after discharge using the 3-day diet record, and the energy intake was calculated using a standardized nutrition calculator. The inadequate energy intake was defined as <70% × 25 kcal/kg of ideal body weight. The participants were followed up for 12 weeks after discharge. The number, reasons, and length of stay of unplanned readmissions were collected. Regression analyses were used to evaluate the associations between inadequate energy intake, and readmission rate and readmission days.

RESULTS

The median of the energy intake of participants was 1032 (interquartile range, 809-1266) kcal/d. The prevalence of inadequate energy intake was 40%. Patients with inadequate energy intake had a higher risk of unplanned readmission (odds ratio, 5.616; 95% confidence interval, 3.015-10.462; P < .001) and more readmission days (incidence rate ratio, 5.226; 95% confidence interval, 3.829-7.134, P < .001) after adjusting for potential confounders.

CONCLUSIONS

Patients with HF had a high incidence of inadequate dietary energy intake, and it increases the burden of readmission.

Comparing Machine Learning Classifiers for Predicting Hospital Readmission of Heart Failure Patients in Rwanda

High rates of hospital readmission and the cost of treating heart failure (HF) are significant public health issues globally and in Rwanda. Using machine learning (ML) to predict which patients are at high risk for HF hospital readmission 20 days after their discharge has the potential to improve HF management by enabling early interventions and individualized treatment approaches. In this paper, we compared six different ML models for this task, including multi-layer perceptron (MLP), K-nearest neighbors (KNN), logistic regression (LR), decision trees (DT), random forests (RF), and support vector machines (SVM) with both linear and radial basis kernels. The outputs of the classifiers are compared using performance metrics including the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. We found that RF outperforms all the remaining models with an AUC of 94% while SVM, MLP, and KNN all yield 88% AUC. In contrast, DT performs poorly, with an AUC value of 57%. Hence, hospitals in Rwanda can benefit from using the RF classifier to determine which HF patients are at high risk of hospital readmission.

Unplanned Readmissions and Long-Term Mortality Risk After Incident Heart Failure Hospitalisation in Western Australia, 2001-2015

AIMS

To investigate the frequency and predictors of unplanned readmissions after incident heart failure (HF) hospitalisation and the association between readmissions and mortality over two years.

METHODS

We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived an incident (first-ever) HF hospitalisation (principal diagnosis) between 2001-2015. Ordinal logistic regression models determined the covariates independently associated with unplanned readmission(s). Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over two years after incident HF.

RESULTS

Of 18,693 patients, 53.4% male, mean age 74.4 (standard deviation [SD] 13.6) years, 61.3% experienced 32,431 unplanned readmissions (39.7% cardiovascular-related) within two years. Leading readmission causes were HF (19.1%), respiratory diseases (12.6%), and ischaemic heart disease (9.6%). All-cause death occurred in 27.2% of the cohort, and the multivariable-adjusted mortality HR of 1 (versus 0) readmission was 2.5 (95% confidence interval [CI], 2.3-2.7) increasing to 5.0 (95% CI, 4.7-5.4) for 2+ readmissions. The adjusted mortality HR of 1 and 2+ (versus 0) HF-specific readmission was 2.0 (95% CI, 1.8-2.1) and 3.6 (95% CI, 3.2-3.9), respectively. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk.

CONCLUSION

This study underlines the high burden of recurrent unplanned cardiovascular and other readmissions within two years after incident HF hospitalisation, and their additive adverse impact on mortality. Integrated multidisciplinary management of concomitant comorbidities, in addition to HF-targeted treatments, is necessary to improve long-term prognosis in HF patients.

Global Public Health Burden of Heart Failure: An Updated Review

Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of 64 million people globally. Although the incidence of HF has stabilised worldwide and seems to be declining in developed countries, the prevalence is increasing due to the ageing of the population, improved survival after MI and improved treatment and survival of patients with HF. Yet, HF remains associated with high mortality and morbidity, poor quality of life and functional capacity, and confers a substantial burden to the healthcare system. The prevalence, incidence, mortality and morbidity rates reported show geographical variations, depending on the different aetiologies and clinical characteristics observed among patients with HF. In this review, we provide an overview of the global epidemiology of HF with updated data on prevalence, incidence, mortality and morbidity worldwide.

Mind The Gap, Aboriginal and Torres Strait Islander Cardiovascular Health: A Narrative Review

Australia's First Nations Peoples, Aboriginal and Torres Strait Islanders, have reduced life expectancy compared to the wider community. Cardiovascular diseases, mainly driven by ischaemic heart disease, are the leading contributors to this disparity. Despite over a third of First Nations Peoples living in New South Wales, the bulk of the peer-reviewed literature is from Central Australia and Far North Queensland. Regardless of the site of publication, First Nations Peoples are significantly younger at disease onset and have higher rates of comorbidities, in turn driving adverse health events. On top of this, very few First Nations Peoples specific cardiovascular interventions or programs have been shown to improve outcomes. The traditional biomedical model of care is less efficacious and non-traditional models of communication such as clinical yarning may benefit both clinicians and patients. The key purpose of this review is to highlight the deficiencies of our knowledge of cardiovascular burden of disease for First Nations Peoples; and to serve as a catalyst for more dedicated research. We need to have relationships with communities and concentrate on community improvement and partnerships. By involving First Nations Peoples researchers in collaboration with local communities in all levels of health care design and intervention will improve outcomes.

Spiritual care needs among Chinese elders hospitalized for severe chronic heart failure: An observational study

OBJECTIVES

To investigate the spiritual care needs and their attributes among Chinese elders hospitalized for severe chronic heart failure (CHF) based on the Kano model, in order to provide a reference for improving the quality and satisfaction of spiritual care.

METHODS

An observational design was implemented, and the STROBE Checklist was used to ensure quality reporting of the study. The demographic characteristics questionnaire, the Nurse Spiritual Therapeutics Scale, and the Kano model-based Nurse Spiritual Therapeutics Attributes Scale were used. A convenience sample of 451 patients were selected from 2 hospitals. Descriptive statistics, and Kano model were used to analyze the data.

RESULTS

The total score of spiritual care needs was 29.95 ± 7.51. Among the 12 items, 3 items were attractive attributes, all of which were located in Reserving Zone IV; 5 items were one-dimensional attributes, of which 3 were located in Predominance Zone I and 2 were located in Improving Zone II; 2 items were must-be attributes, all of which were located in Improving Zone II; and 2 items were indifference attributes, all of which were located in Secondary Improving Zone III.

SIGNIFICANCE OF RESULTS

The spiritual care needs among Chinese elders hospitalized for severe CHF were moderate. The must-be and one-dimensional attributes mainly focus on "creating a good atmosphere" and "sharing self-perception" dimensions, while attractive attributes mainly focus on "sharing self-perception" and "helping thinking" dimensions. It is suggested that hospital authority should develop and innovate attractive attributes on the basis of maintaining and perfecting must-be and one-dimensional attributes, and objectively analyze and optimize indifference attributes.

Global burden of heart failure: a comprehensive and updated review of epidemiology

Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. HF affects more than 64 million people worldwide. Therefore, attempts to decrease its social and economic burden have become a major global public health priority. While the incidence of HF has stabilized and seems to be declining in industrialized countries, the prevalence is increasing due to the ageing of the population, improved treatment of and survival with ischaemic heart disease, and the availability of effective evidence-based therapies prolonging life in patients with HF. There are geographical variations in HF epidemiology. There is substantial lack of data from developing countries, where HF exhibits different features compared with that observed in the Western world. In this review, we provide a contemporary overview on the global burden of HF, providing updated estimates on prevalence, incidence, outcomes, and costs worldwide.

Unplanned 30-day readmissions, comorbidity and impact on one-year mortality following incident heart failure hospitalisation in Western Australia, 2001-2015

BACKGROUND

Readmissions within 30 days after heart failure (HF) hospitalisation is considered an important healthcare quality metric, but their impact on medium-term mortality is unclear within an Australian setting. We determined the frequency, risk predictors and relative mortality risk of 30-day unplanned readmission in patients following an incident HF hospitalisation.

METHODS

From the Western Australian Hospitalisation Morbidity Data Collection we identified patients aged 25-94 years with an incident (first-ever) HF hospitalisation as a principal diagnosis between 2001 and 2015, and who survived to 30-days post discharge. Unplanned 30-day readmissions were categorised by principal diagnosis. Logistic and Cox regression analysis determined the independent predictors of unplanned readmissions in 30-day survivors and the multivariable-adjusted hazard ratio (HR) of readmission on mortality within the subsequent year.

RESULTS

The cohort comprised 18,241 patients, mean age 74.3 ± 13.6 (SD) years, 53.5% males, and one-third had a modified Charlson Comorbidity Index score of ≥ 3. Among 30-day survivors, 15.5% experienced one or more unplanned 30-day readmission, of which 53.9% were due to cardiovascular causes; predominantly HF (31.4%). The unadjusted 1-year mortality was 15.9%, and the adjusted mortality HR in patients with 1 and ≥ 2 cardiovascular or non-cardiovascular readmissions (versus none) was 1.96 (95% confidence interval (CI) 1.80-2.14) and 3.04 (95% CI, 2.51-3.68) respectively. Coexistent comorbidities, including ischaemic heart disease/myocardial infarction, peripheral arterial disease, pneumonia, chronic kidney disease, and anaemia, were independent predictors of both 30-day unplanned readmission and 1-year mortality.

CONCLUSION

Unplanned 30-day readmissions and medium-term mortality remain high among patients who survived to 30 days after incident HF hospitalisation. Any cardiovascular or non-cardiovascular readmission was associated with a two to three-fold higher adjusted HR for death over the following year, and various coexistent comorbidities were important associates of readmission and mortality risk. Our findings support the need to optimize multidisciplinary HF and multimorbidity management to potentially reduce repeat hospitalisation and improve survival.

Predicting in-hospital all-cause mortality in heart failure using machine learning

Background

The age of onset and causes of heart failure differ between high-income and low-and-middle-income countries (LMIC). Heart failure patients in LMIC also experience a higher mortality rate. Innovative ways that can risk stratify heart failure patients in this region are needed. The aim of this study was to demonstrate the utility of machine learning in predicting all-cause mortality in heart failure patients hospitalised in a tertiary academic centre.

Methods

Six supervised machine learning algorithms were trained to predict in-hospital all-cause mortality using data from 500 consecutive heart failure patients with a left ventricular ejection fraction (LVEF) less than 50%.

Results

The mean age was 55.2 ± 16.8 years. There were 271 (54.2%) males, and the mean LVEF was 29 ± 9.2%. The median duration of hospitalisation was 7 days (interquartile range: 4-11), and it did not differ between patients discharged alive and those who died. After a prediction window of 4 years (interquartile range: 2-6), 84 (16.8%) patients died before discharge from the hospital. The area under the receiver operating characteristic curve was 0.82, 0.78, 0.77, 0.76, 0.75, and 0.62 for random forest, logistic regression, support vector machines (SVM), extreme gradient boosting, multilayer perceptron (MLP), and decision trees, and the accuracy during the test phase was 88, 87, 86, 82, 78, and 76% for random forest, MLP, SVM, extreme gradient boosting, decision trees, and logistic regression. The support vector machines were the best performing algorithm, and furosemide, beta-blockers, spironolactone, early diastolic murmur, and a parasternal heave had a positive coefficient with the target feature, whereas coronary artery disease, potassium, oedema grade, ischaemic cardiomyopathy, and right bundle branch block on electrocardiogram had negative coefficients.

Conclusion

Despite a small sample size, supervised machine learning algorithms successfully predicted all-cause mortality with modest accuracy. The SVM model will be externally validated using data from multiple cardiology centres in South Africa before developing a uniquely African risk prediction tool that can potentially transform heart failure management through precision medicine.

The association between urinary sodium concentration (UNa) and outcomes of acute heart failure: a systematic review and meta-analysis

AIMS

Urinary sodium concentration (UNa) is a simple test advocated to assess diuretics efficacy and predict outcomes in acute heart failure (AHF). We performed a systematic review and meta-analysis to examine the association of UNa with outcomes of AHF.

METHODS AND RESULTS

We searched Embase and Medline for eligible studies that reported the association between UNa and outcomes of urinary output, weight loss, worsening renal function, length of hospital stay, re-hospitalization, worsening heart failure, and all-cause mortality in AHF. Nineteen observational studies out of 1592 screened records were included. For meta-analyses of outcomes, we grouped patients into high vs. low UNa, with most studies defining high UNa as &gt;48-65 mmol/L. In the high UNa group, pooled data showed a higher urinary output (mean difference 502 mL, 95% CI 323-681, P &lt; 0.01), greater weight loss (mean difference 1.6 kg, 95% CI 0.3-2.9, P = 0.01), and a shorter length of stay (mean difference -1.4 days, 95% CI -2.8 to -0.1, P = 0.03). There was no significant difference in worsening kidney function (OR 0.54, 95% CI 0.25-1.16, P = 0.1). Due to the small number of studies, we did not report pooled estimates for re-hospitalization and worsening heart failure. High UNa was associated with lower odds of 30-day (OR 0.27; 95% CI 0.14-0.49, P &lt; 0.01), 90-day (OR 0.39,95% CI 0.25-0.59, P &lt; 0.01) and 12-month (OR 0.35; 95% CI 0.20-0.61, P &lt; 0.01) mortality.

CONCLUSION

High UNa after diuretic administration is associated with higher urinary output, greater weight loss, shorter length of stay, and lower odds of death. UNa is a promising marker of diuretic efficacy in AHF which should be confirmed in randomized trials.

Relationship between mutuality and depression in patients with chronic heart failure and caregivers in China: An actor-partner interdependence model analysis

Background

Patients with chronic heart failure and their family caregivers may experience adverse emotional problems, such as depression. Mutuality, which refers to the relationship between caregivers and those they care for, is an important factor affecting depression in the dyads. The purpose of this study was to investigate the relationship between mutuality and depression in patients with CHF and their caregivers in China.

Methods

In this cross-sectional study, we used the Mutuality Scale and the Self-Rating Depression Scale to measure mutuality and depression of patients and caregivers. We used SPSS version 26.0 and AMOS version 21.0 to analyze the data. An APIM was established to analyze the actor-partner effects of patient-caregiver mutuality and depression.

Results

A total of 250 dyads of patients and caregivers were included in the study. There were statistically significant differences in mutuality and depression between CHF patients and caregivers. The 4 dimensions of patients' mutuality all have the actor effect on depression. There were 3 partner effects of caregivers' "pleasurable activities", "shared values", and "reciprocity" on depression. Regarding caregiver depression, we only found an actor effect of caregivers' "shared values" on depression.

Conclusion

The relationship between patients and caregivers should be evaluated in the clinical setting, and it is very important to develop intervention measures to improve the adverse emotional problems affecting both patients and their caregivers.

Patient characteristics, short-term and long-term outcomes after incident heart failure admissions in a regional Australian setting

AIMS

This study aims to (1) define the characteristics of patients with a first admission for heart failure (HF), stratified by type (reduced (HFrEF) vs preserved (HFpEF) ejection fraction) in a regional Australian setting; (2) compare the outcomes in terms of mortality and rehospitalisation and (3) assess adherence to the treatment guidelines.

METHODS

We identified all index hospitalisations with HF to John Hunter Hospital and Tamworth Rural Referral Hospital in the Hunter New England Local Health District over a 12 months. We used the recent Australian HF guidelines to classify HFrEF and HFpEF and assess adherence to guideline-directed therapy. The primary outcome of the study was to compare short-term (1 year) and long-term all-cause mortality and the composite of all-cause hospitalisation or all-cause mortality of patients with HFrEF and HFpEF.

RESULTS

There were 664 patients who had an index HF admission to John Hunter and Tamworth hospitals in 2014. The median age was 80 years, 47% were female and 22 (3%) were Aboriginal. In terms of HF type, 29% had HFrEF, 37% had HFpEF, while the remainder (34%) did not have an echocardiogram within 1 year of admission and could not be classified. The median follow-up was 3.3 years. HFrEF patients were predominantly male (64%) and in 48% the aetiology was ischaemic heart disease. The 1-year all-cause mortality was 23% in HFpEF subgroup and 29% in HFrEF subgroup (p=0.15). Five-year mortality was 61% in HFpEF and HFrEF patients. Of the HFrEF patients, only 61% were on renin-angiotensin-aldosterone blockers, 74% were on β-blockers and 39% were on aldosterone antagonist.

CONCLUSION

HF patients are elderly and about evenly split between HFrEF and HFpEF. In this regional cohort, both HF types are associated with similar 1-year and 5-year mortality following incident HF hospitalisation. Echocardiography and guideline-directed therapies were underused.

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial

Background

Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission.

Objective

This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission.

Methods

In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months.

Results

Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually.

Conclusions

TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945

Process Evaluation of a Randomised Controlled Trial for TeleClinical Care, a Smartphone-App Based Model of Care

Background

A novel smartphone app-based model of care (TeleClinical Care – TCC) for patients with acute coronary syndrome (ACS) and heart failure (HF) was evaluated in a two-site, pilot randomised control trial of 164 participants in Sydney, Australia. The program included a telemonitoring system whereby abnormal blood pressure, weight and heart rate readings were monitored by a central clinical team, who subsequently referred clinically significant alerts to the patients' usual general practitioner (GP, also known as primary care physician in the United States), HF nurse or cardiologist. While the primary endpoint, 30-day readmissions, was neutral, intervention arm participants demonstrated improvements in readmission rates over 6 months, cardiac rehabilitation (CR) completion and medication compliance. A process evaluation was designed to identify contextual factors and mechanisms that influenced the results, as well as strategies of improving site and participant recruitment and the delivery of the intervention, for a planned larger effectiveness trial of over 1,000 patients across the state of New South Wales, Australia (TCC-Cardiac).

Methods

Multiple data sources were used in this mixed-methods process evaluation, including interviews with four TCC team members, three GPs and three cardiologists. CR completion rates, HF outreach service (HFOS) referrals and cardiologist follow-up appointments were audited. A patient questionnaire was also analysed for evidence of improved self-care as a hypothesised mechanism of the TCC app. An implementation research logic model was used to synthesise our findings.

Results

Rates of HFOS referral (83 vs. 72%) and cardiologist follow-up (96 vs. 93%) were similarly high in the intervention and control arms, respectively. Team members were largely positive towards their orientation and training, but highlighted several implementation strategies that could be optimised for TCC-Cardiac: streamlining of the enrolment process, improving the reach of the trial by screening patients in non-cardiac wards, and ensuring team members had adequate time to recruit (>15 h per week). GPs and cardiologists viewed the intervention acceptably regarding potential benefit of closely monitoring, and responding to abnormalities for their patients, though there were concerns of the potential additional workload generated by alerts that did not merit clinical intervention. Clear delineation of which clinician (GP or cardiologist) was primarily responsible for alert management was also recommended, as well as a preference to receive regular summary data. Several patients commented on the mechanisms of improved self-management because of TCC, which could have led to the outcome of improved medication compliance.

Discussion

Use of TCC was associated with several benefits, including higher patient engagement and completion rates with CR. The conduct and delivery of TCC-Cardiac will be improved by the findings of this process evaluation to optimise recruitment, and establishing the roles of GPs and cardiologists as part of the model.

A Model for the Prediction of Mortality and Hospitalization in Chinese Heart Failure Patients

Background: Although many risk prediction models have been released internationally, the application of these models in the Chinese population still has some limitations.

Aims: The purpose of the study was to establish a heart failure (HF) prognosis model suitable for the Chinese population.

Methods: According to the inclusion criteria, we included patients with chronic heart failure (CHF) who were admitted to the Department of Cardiac Rehabilitation of Tongji Hospital from March 2007 to December 2018, recorded each patient's condition and followed up on the patient's re-admission and death. All data sets were randomly divided into derivation and validation cohorts in a ratio of 7/3. Least absolute shrinkage and selection operator regression and Cox regression were used to screen independent predictors; a nomogram chart scoring model was constructed and validated.

Results: A total of 547 patients were recruited in this cohort, and the median follow-up time was 519 days. The independent predictors screened out by the derivation cohort included age, atrial fibrillation (AF), percutaneous coronary intervention (PCI), diabetes mellitus (DM), peak oxygen uptake (peak VO₂), heart rate at the 8th minute after the cardiopulmonary exercise peaked (HR8min), C-reaction protein(CRP), and uric acid (UA). The C indexes values of the derivation and the validation cohorts were 0.69 and 0.62, respectively, and the calibration curves indicate that the model's predictions were in good agreement with the actual observations.

Conclusions: We have developed and validated a multiple Cox regression model to predict long-term mortality and readmission risk of Chinese patients with CHF.

Registration Number: ChicTR-TRC-00000235.

Effect of Shenmai Injection () on Long-Term Prognosis of Patients with Chronic Heart Failure: A Multicenter, Large Sample Capacity, Long-Term Follow-Up Retrospective Cohort Study

OBJECTIVE

To explore the effect of Shenmai Injection (, SMI) on the long-term prognosis of patients with chronic heart failure (CHF).

METHODS

The Hospital Information System was used to extract data of CHF patients, and the retrospective cohort study was conducted for analysis. In non-exposed group, standardized Western medicine treatment and Chinese patent medicine or decoction were applied without combination of SMI while in the exposed group, SMI were applied for more than 7 days. Evaluation indicators are followed with New York Heart Association functional classification (NYHA classification), left ventricular ejection fraction (LVEF), N-terminal brain natriuretic peptide precursor (NT-ProBNP), cardiogenic death and heart failure (HF) readmission. Statistical analysis includes Kaplan-Meier analysis and Cox regression which are used to explore the relationship between SMI and outcome events.

RESULTS

A total of 1,211 eligible CHF patients were involved and finally 1,047 patients were followed up successfully. After treatment, the cases of NYHA classification decline in the exposed and non-exposed groups accounted for 64.30% and 43.45%, respectively; the improvement values of LVEF were 8.89% and 7.91%, respectively; the improvement values of NT-ProBNP were 909 pg/mL and 735 pg/mL, respectively. After exposure on SMI, the rates of cardiogenic death and HF readmission reduced from 15.43% to 10.18% and 38.93% to 32.37%. According to Kaplan-Meier analysis, the log-rank P value of SMI and cardiogenic death was 0.014, while the counterpart of SMI and HF readmission was 0.025. Cox regression analysis indicated that for cardiogenic death, age, cardiomyopathy, diabetes, and NYHA classification were risk factors while β-blockers, aldosterone receptor antagonists, Chinese patent medicine/decoction and SMI were protective factors. Likewise, for HF readmission, age, cardiomyopathy, and NYHA classification were risk factors while SMI was a protective factor.

CONCLUSION

Combination with SMI on the standardized Western medicine treatment can effectively reduce cardiogenic mortality and readmission rate in CHF patients, and thereby improve the long-term prognosis.

"I Can't Go Far": Perceptions and Experiences of Heart Failure Patients Regarding Physical Activity: A Qualitative Study Using Semistructured Face-to-Face Interviews

BACKGROUND

Participation in regular physical activity (RPA) is beneficial to the quality of life and life expectancy of patients with chronic heart failure (CHF). However, it is inadequate in many patients.

AIMS

To determine the factors that influence the practice of RPA in patients with CHF managed in general practice.

METHOD

This was a qualitative study using semistructured, individual face-to-face interviews. Patients with CHF (New York Heart Association Stages 1-3) capable of participating in RPA were enrolled by their general practitioner. A longitudinal and transversal inductive thematic analysis was performed by two researchers.

RESULTS

Five themes emerged from the 19 interviews that were conducted. Poor knowledge of the disease and the benefits of participating in RPA, as well as the lack of motivation or enjoyment, in particular due to the absence of previous participation, were considered significant obstacles. Fear associated with CHF or other comorbidities was also an obstacle. Attendance at a rehabilitation center, family and social circles, and having a pet all appeared to be beneficial. Family and friends were important for motivating the patient to participate in an activity but could also be an obstacle when they were overprotective.

CONCLUSION

This study helps highlight the difficulties for patients with CHF associated with participation in RPA. Despite the obstacles, there are enabling factors on which the general practitioner may rely to motivate their patients.

Heart failure care and outcomes in a Tanzanian emergency department: A prospective observational study

BACKGROUND

The burden of heart failure is growing in sub-Saharan Africa, but there is a dearth of data characterizing care and outcomes of heart failure patients in the region, particularly in emergency department settings.

METHODS

In a prospective observational study, adult patients presenting with shortness of breath or chest pain to an emergency department in northern Tanzania were consecutively enrolled. Participants with a physician-documented clinical diagnosis of heart failure were included in the present analysis. Standardized questionnaires regarding medical history and medication use were administered at enrollment, and treatments given in the emergency department were recorded. Thirty days after enrollment, a follow-up questionnaire was administered to assess mortality and medication use. Multivariate logistic regression was performed to identify baseline predictors of thirty-day mortality.

RESULTS

Of 1020 enrolled participants enrolled from August 2018 through October 2019, 267 patients (26.2%) were diagnosed with heart failure. Of these, 139 (52.1%) reported a prior history of heart failure, 168 (62.9%) had self-reported history of hypertension, and 186 (69.7%) had NYHA Class III or IV heart failure. At baseline, 40 (15.0%) reported taking a diuretic and 67 (25.1%) reported taking any antihypertensive. Thirty days following presentation, 63 (25.4%) participants diagnosed with heart failure had died. Of 185 surviving participants, 16 (8.6%) reported taking a diuretic, 24 (13.0%) reported taking an antihypertensive, and 26 (14.1%) were rehospitalized. Multivariate predictors of thirty-day mortality included self-reported hypertension (OR = 0.42, 95% CI: 0.21-0.86], p = 0.017) and symptomatic leg swelling at presentation (OR = 2.69, 95% CI: 1.35-5.56, p = 0.006).

CONCLUSION

In a northern Tanzanian emergency department, heart failure is a common clinical diagnosis, but uptake of evidence-based outpatient therapies is poor and thirty-day mortality is high. Interventions are needed to improve care and outcomes for heart failure patients in the emergency department setting.

Temporal trends in the burden of heart failure

Heart failure is a common healthcare problem associated with high morbidity and mortality. The burden of heart failure is changing; increases secondary to an ageing population may be offset by improved primary cardiovascular prevention and advances in heart failure therapies. In this review, we evaluate recent international trends in heart failure incidence, morbidity and mortality. Although the age-standardised incidence of heart failure has been decreasing since 2000, the incidence in those age groups <55 years is increasing with patients being diagnosed at younger ages. Despite improvements in therapies for heart failure, prognosis still remains poor with up to one-third of patients not surviving beyond 1 year following diagnosis and no improvements in mortality over the past 10 years. The case-mix of heart failure patients is changing with a greater proportion having non-ischaemic aetiology and preserved ejection fraction, and a higher prevalence of non-cardiovascular comorbidity and mortality.

Biomedical, Socioeconomic and Demographic Predictors of Heart Failure Readmissions: A Systematic Review

AIMS

To identify the biomedical, socioeconomic and demographic predictors of heart failure (HF) related readmissions in adult patients with HF.

METHODS

This systematic review was conducted in March 2020 using the databases EMBASE, CINAHL and Medline to identify publications between 2015-2020. The resulting articles were systematically reviewed according to the PRISMA guidelines.

RESULTS

Eighteen (18) studies were included in this review. Unemployment (HR=1.09; 95%CI=1.05-1.14; p=0.03) was the only socioeconomic factor predictive of HF-readmissions. Socio-Economic Indexes for Areas (SEIFA) scores did not predict HF readmissions in adults with HF (p>0.05). All patients included in the studies had pre-existing HF. Based on the included studies, Indigenous status was identified as a risk factor for HF readmissions in 1 study (p<0.05), and age or sex did not affect HF readmission patterns (p>0.05). New York Heart Association (NYHA) class, brain natriuretic peptide (BNP) levels, and heart rate were also predictive of HF readmission (p<0.05). Left ventricular ejection fraction and blood pressure, however, were non-significant risk factors of HF readmissions (p>0.05).

CONCLUSIONS

This review identified unemployment, Indigenous status, NYHA class, heart rate, and BNP levels to predict HF related readmissions in adult patients with HF. Adding demographic and socioeconomic variables to readmission risk models has the potential to more accurately target patients at risk of readmissions.

Insulin-like growth factor-binding protein 7 and risk of congestive heart failure hospitalization in patients with atrial fibrillation

BACKGROUND

The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker.

OBJECTIVE

The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication.

METHODS

We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed.

RESULTS

Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend <.001). In a subgroup of 2812 patients without pre-existing CHF at baseline, the corresponding aHRs were 1.0, 0.90 (0.47-1.72), 1.69 (0.94-3.04), and 3.48 (1.94-6.24) (P for trend <.001). Patients with IGFBP-7 and NT-proBNP levels above the biomarker-specific median had a higher risk of incident CHF hospitalization (aHR 5.20; 3.35-8.09) compared to those with only 1 elevated marker (elevated IGFBP-7 aHR 2.17; 1.30-3.60); elevated NT-proBNP aHR 1.97; 1.17-3.33); or no elevated marker (reference).

CONCLUSION

Higher plasma levels of IGFBP-7 were strongly and independently associated with CHF hospitalization in AF patients. The prognostic information provided by IGFBP-7 was additive to that of NT-proBNP.

Risk factors for hospital readmission in adult patients with heart failure with reduced ejection fraction: a systematic review

OBJECTIVE

The objective of this review was to identify and synthesize evidence on risk factors associated with hospital readmission within the first year after heart failure hospitalization among patients with heart failure with reduced left ventricular ejection fraction.

INTRODUCTION

Heart failure is associated with a high risk of hospital readmission. Readmissions are associated with higher mortality and health care costs. It is a high health care priority to identify vulnerable patients with heart failure who may potentially benefit from targeted personalized care interventions aiming to reduce readmissions.

INCLUSION CRITERIA

This review considered studies including adult patients who had heart failure with a reduced left ventricular ejection fraction ≤ 40% who were discharged after a heart failure hospitalization. The authors included studies with experimental and observational designs evaluating risk factors for i) all-cause hospital readmission, ii) heart failure hospital readmission, and iii) composite outcomes within seven, 15, 30, 60, 90, 180, and 365 days after hospital discharge. Composite outcomes included end points where all-cause readmission and/or heart failure readmission were part of a defined end point (i.e. all-cause readmission or mortality; heart failure readmission or mortality; cardiovascular readmission; cardiovascular readmission or mortality; and readmission, mortality, or cardiac transplant). Studies reporting all-cause readmission and/or heart failure readmission as a primary outcome, secondary outcome, or part of a composite outcome were included.

METHODS

PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, OpenGrey, MedNar, DART-Europe, ProQuest Dissertations and Theses, and the Grey Literature Report in Public Health were searched to find both published and unpublished studies in English, Swedish, Norwegian, or Danish from 2000 to June 2018. Study selection, critical appraisal, data extraction, and data synthesis followed the JBI approach for systematic reviews. Statistical pooling was not possible due to clinical and methodological heterogeneity of the studies included and the lack of risk factors reported more than once. A narrative summary of the findings was performed.

RESULTS

Fifty-two studies, including one randomized controlled trial and 51 cohort studies with a total of 128,186 participants, were included. Risk factors for readmission were reported for 30-day outcome in 16 studies, 60-day in three studies, 90-day in 15 studies, 180-day in 12 studies, and 365-day outcome in 15 studies. Based on multivariable analyses from 43 cohort studies and results from one randomized controlled trial, the authors identified several factors associated with higher risk of all-cause readmission, heart failure readmission, and composite outcomes (e.g. readmission or death) within 30, 60, 90, 180, and 365 days after discharge for a heart failure hospitalization.

CONCLUSIONS

This review provides a comprehensive overview of factors associated with a clinical outcome after a heart failure hospitalization in patients with heart failure with left ventricular ejection fraction ≤ 40%. Owing to the heterogeneity of variables investigated and the lack of comparability of findings, the clinical impact of the identified risk factors remains uncertain. This review highlights research gaps and the need for a standardized way to define and measure all-cause readmission, heart failure readmission, and composite end points in clinical research to improve study quality and enable comparison of findings between studies.

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.

Sacubitril-valsartan versus enalapril for acute decompensated heart failure: a cost-effectiveness analysis

Background

The Comparison of Sacubitril–Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilised from an Acute Heart Failure Episode (PIONEER-HF) trial demonstrated significant reductions in N-terminal pro-B-type natriuretic peptide. Our study explored the cost-effectiveness of the use of sacubitril-valsartan versus enalapril in acute decompensated heart failure from the Australian healthcare perspective.

Methods

A Markov model was designed using data from the PIONEER-HF trial to model the clinical progress and costs of patients over a lifetime time horizon. The model consisted of three health states: ‘alive and event-free’, ‘alive after non-fatal hospitalisation for acute decompensated heart failure’ or ‘dead’. Costs and utilities were estimated from published sources. The cost of sacubitril-valsartan (per the Australian pharmaceutical benefits schedule) was AU$7.08/day. Outcomes of interest were the incremental cost-effectiveness ratios in terms of cost per quality-adjusted life year gained and cost per year of life saved. Cost and benefits were discounted at 5.0% per annum.

Results

Compared to enalapril, sacubitril-valsartan was estimated to cost an additional AU$7464 (discounted) per person, but lead to 0.127 years of life saved (discounted) and 0.096 quality-adjusted life years gained (discounted) over a lifetime analysis. These equated to incremental cost-effectiveness ratios of AU$58,629/year of life saved (US$41,795, EU€58,629, GBP£32,001) and AU$77,889/quality-adjusted life year gained (US$55,526, EU€49,202, GBP£42,504). We have assumed a threshold of AU$50,000/quality-adjusted life year gained to suggest cost-effectiveness.

Conclusions

At its current acquisition price, sacubitril-valsartan in comparison to enalapril is not likely to be cost-effective in the management of acute decompensated heart failure in Australia. A price reduction of more than 25% would confer cost-effectiveness.

Respiratory training interventions improve health status of heart failure patients: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Prior studies indicate that doing breathing exercises improves physical performance and quality of life (QoL) in heart failure patients. However, these effects remain unclear and contradictory.

AIM

To determine the effects of machine-assisted and non-machine-assisted respiratory training on physical performance and QoL in heart failure patients.

METHODS

This was a systematic review and network meta-analysis study. A literature search of electronic databases was conducted for randomized controlled trials (RCTs) on heart failure. Respiratory training interventions were grouped as seven categories: IMT_Pn (inspiratory muscle training without pressure or < 10% maximal inspiratory pressure, MIP), IMT_Pl (inspiratory muscle training with low pressure, 10%-15% MIP), IMT_Pm (inspiratory muscle training with medium pressure, 30%-40% MIP), IMT_Ph (inspiratory muscle training with high pressure, 60% MIP or MIP plus aerobics), Aerobics (aerobic exercise or weight training), Qi_Ex (tai chi, yoga, and breathing exercise), and none. The four outcomes were heart rate, peak oxygen uptake (VO₂ peak), 6-min walking distance test (6MWT), and Minnesota Living with Heart Failure QoL. The random-effects model, side-splitting model, and the surface under the cumulative ranking curve (SUCRA) were used to test and analyze the data.

RESULTS

A total of 1499 subjects from 31 RCT studies were included. IMT_Ph had the highest effect sizes for VO₂ peak and 6MWT, IMT_Pm highest for QoL, and Qi_Ex highest for heart rate. Aerobics had the second highest for VO₂ peak, Qi_Ex second highest for 6MWT, and IMT_Ph second highest for heart rate and QoL.

CONCLUSION

This study supports that high- and medium-intensity machine-assisted training improves exercise capacity and QoL in hospital-based heart failure patients. After hospital discharge, non-machine-assisted training continuously improves cardiac function.