The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

Multicomponent integrated care for patients with chronic heart failure: systematic review and meta-analysis

To investigate the effectiveness of multicomponent integrated care on clinical outcomes among patients with chronic heart failure. We conducted a meta-analysis of randomized clinical trials, published in English language from inception to 20 April 2022, with at least 3-month implementation of multicomponent integrated care (defined as two or more quality improvement strategies from different domains, viz. the healthcare system, healthcare providers, and patients). The study outcomes were mortality (all-cause or cardiovascular) and healthcare utilization (hospital readmission or emergency department visits). We pooled the risk ratio (RR) using Mantel-Haenszel test. A total of 105 trials (n = 37 607 patients with chronic heart failure; mean age 67.9 ± 7.3 years; median duration of intervention 12 months [interquartile range 6-12 months]) were analysed. Compared with usual care, multicomponent integrated care was associated with reduced risk for all-cause mortality [RR 0.90, 95% confidence interval (CI) 0.86-0.95], cardiovascular mortality (RR 0.73, 95% CI 0.60-0.88), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00), heart failure-related hospital readmission (RR 0.84, 95% CI 0.79-0.89), and all-cause emergency department visits (RR 0.91, 95% CI 0.84-0.98). Heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18) and cardiovascular-related hospital readmission (RR 0.90, 95% CI 0.79-1.03) were not significant. The top three quality improvement strategies for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93), facilitated patient-provider communication (RR 0.87, 95% CI 0.81-0.93), and e-health (RR 0.88, 95% CI 0.81-0.96). Multicomponent integrated care reduced risks for mortality (all-cause and cardiovascular related), hospital readmission (all-cause and heart failure related), and all-cause emergency department visits among patients with chronic heart failure.

Hospital-based quality improvement interventions for patients with heart failure: a systematic review

OBJECTIVE

To estimate the direction and magnitude of effect and quality of evidence for hospital-based heart failure (HF) quality improvement interventions on process of care measures and clinical outcomes among patients with acute HF.

REVIEW METHODS

We performed a structured search to identify relevant randomised trials evaluating the effect of in-hospital quality improvement interventions for patients hospitalised with HF through February 2017. Studies were independently reviewed in duplicate for key characteristics, outcomes were summarised and a qualitative synthesis was performed due to substantial heterogeneity.

RESULTS

From 3615 records, 14 randomised controlled trials were identified for inclusion with multifaceted interventions. There was a trend towards higher in-hospital use of ACE inhibitors (ACE-I; 57.9%vs40.0%) and beta-blockers (BBs; 46.7%vs10.2%) in the intervention than the comparator in one trial (n=429 participants). Five trials (n=78 727 participants) demonstrated no effect of the intervention on use of ACE-I or angiotensin receptor blocker at discharge. Three trials (n=89 660 participants) reported no effect on use of BB at discharge. Two trials (n=419 participants) demonstrated a trend towards lower hospital readmission up to 90 days after discharge. There was no consistent effect of the quality improvement intervention on 30-day all-cause mortality, hospital length of stay and patient-level health-related quality of life.

CONCLUSIONS

Randomised trials of hospital-based HF quality improvement interventions do not show a consistent effect on most process of care measures and clinical outcomes. The overall quality of evidence for the prespecified primary and key secondary outcomes was very low to moderate, suggesting that future research will likely influence these estimates.

TRIAL REGISTRATION NUMBER

CRD42016049545.

Disease management interventions for heart failure

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.

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study

Objective

To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate.

Design

A retrospective quasi-experimental study from June 2011 to October 2015.

Setting

A tertiary cancer hospital in China.

Participants

Patients diagnosed as non-small cell lung cancer who underwent curative resection.

Intervention(s)

Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015.

Main Outcome Measure(s)

Three length of hospital stay indicators, four process performance indicators and one outcome indicator.

Results

ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators.

Conclusions

The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

Specialist intervention is associated with improved patient outcomes in patients with decompensated heart failure: evaluation of the impact of a multidisciplinary inpatient heart failure team

Objective

The study aimed to evaluate the impact of a multidisciplinary inpatient heart failure team (HFT) on treatment, hospital readmissions and mortality of patients with decompensated heart failure (HF).

Methods

A retrospective service evaluation was undertaken in a UK tertiary centre university hospital comparing 196 patients admitted with HF in the 6 months prior to the introduction of the HFT (pre-HFT) with all 211 patients seen by the HFT (post-HFT) during its first operational year.

Results

There were no significant differences in patient baseline characteristics between the groups. Inpatient mortality (22% pre-HFT vs 6% post-HFT; p<0.0001) and 1-year mortality (43% pre-HFT vs 27% post-HFT; p=0.001) were significantly lower in the post-HFT cohort. Post-HFT patients were significantly more likely to be discharged on loop diuretics (84% vs 98%; p=<0.0001), ACE inhibitors (65% vs 76%; p=0.02), ACE inhibitors and/or angiotensin receptor blockers (83% vs 91%; p=0.02), and mineralocorticoid receptor antagonists (44% vs 68%; p<0.0001) pre-HFT versus post-HFT, respectively. There was no difference in discharge prescription rates of beta-blockers (59% pre-HFT vs 63% post-HFT; p=0.45).

The mean length of stay (17±19 days pre-HFT vs 19±18 days post-HFT; p=0.06), 1-year all-cause readmission rates (46% pre-HFT vs 47% post-HFT; p=0.82) and HF readmission rates (28% pre-HFT vs 20% post-HFT; p=0.09) were not different between the groups.

Conclusions

The introduction of a specialist inpatient HFT was associated with improved patient outcome. Inpatient and 1-year mortality were significantly reduced. Improved use of evidence-based drug therapies, more intensive diuretic use and multidisciplinary care may contribute to these differences in outcome.

Quality of life assessment in heart failure interventions: a 10-year (1996–2005) review

The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996–2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure. Eur J Cardiovasc Prev Rehabil 14:589-607 © 2007 The European Society of Cardiology

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study

RATIONALE, AIMS AND OBJECTIVES

Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF).

METHODS

Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost.

RESULTS

The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions.

CONCLUSION

Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

Structured telephone support or non-invasive telemonitoring for patients with heart failure

BACKGROUND

Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits.

SELECTION CRITERIA

We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age).

MAIN RESULTS

We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours.

AUTHORS' CONCLUSIONS

For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure

BACKGROUND

Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways.

METHODS

To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1.

RESULTS

ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively.

CONCLUSION

Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.

Effects of care pathways on the in-hospital treatment of heart failure: a systematic review

BACKGROUND

Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care.

METHODS

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case-control studies, cohort studies and time interrupted series.

RESULTS

Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials.

CONCLUSION

By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.

Clinical service organisation for heart failure

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials

Background

The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs.

Methods

An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported.

Results

Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base.

Conclusions

Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.

A comparison of criterion standard methods to diagnose acute heart failure

The authors sought to compare and contrast the clinical criterion standards currently used in a cohort of emergency department (ED) patients to diagnose acute heart failure syndromes (AHFS). In a prospective observational study of patients with signs and symptoms of AHFS, 3 criterion standards were examined: (1) the treating ED physician's diagnosis; (2) the hospital discharge diagnosis; and (3) a diagnosis based on medical record review by a panel of cardiologists. Using Cohen's kappa (κ) coefficient, the authors assessed agreement and then compared the different standards by repeatedly setting one as the criterion standard and the other two as index tests. A total of 483 patients were enrolled. Across all criterion standards, patients with AHFS were more likely to have a history of AHFS, congestion on physical examination and chest radiography, and elevated natriuretic peptide levels than those without AHFS. The standards agreed well (cardiology review vs hospital discharge diagnosis, κ=0.74; cardiology review vs ED diagnosis, κ=0.66; ED diagnosis vs hospital discharge diagnosis κ=0.59). Each method had similar sensitivity but differing specificities. Different criterion standards identify different patients from among those being evaluated for AHFS. Researchers should consider this when choosing between the various criterion standard approaches when evaluating new index tests.

The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

Effect of compliance with quality performance measures for heart failure on clinical outcomes in high-risk patients

BACKGROUND

Although effects of the Joint Commission on Accreditation of Healthcare Organizations' (TJC) performance measures on national trends in patient outcomes have been reported, little information exists on the effects of these quality measures on patient outcomes in individual centers caring for high-risk patient populations.

OBJECTIVES

To determine the effects of compliance with TJC core quality measures for heart failure on patient outcomes at a university hospital caring for high-risk patients.

METHODS

We reviewed data collected for TJC in patients admitted with heart failure at a university hospital serving an indigent population in Louisiana. Patients were divided based on compliance with TJC measures into quality-compliant or quality-deficient groups. Of 646 reviewed records, 542, representing 357 patients, were included in the analysis. There were 193 patients in the quality-compliant and 164 in the quality-deficient group. Outcome measures included rate of heart failure admission/year and readmission within 90 days. Multivariate logistic and linear regression analyses were performed to identify independent associations between patient characteristics and heart failure admission.

RESULTS

Multiple linear regression analysis demonstrated higher rates of heart failure admission/year, and multiple logistic regression revealed higher readmissions at 90 days in the quality-compliant group (parameter estimate, 0.203; p = .02; odds ratio, 2.82; 95% confidence interval, 1.46-5.44, respectively).

CONCLUSION

Compliance with TJC quality measures for heart failure at a university hospital in Louisiana was associated with higher readmission rates for heart failure. Several factors may explain this trend, including patient characteristics and focus on national reporting benchmarks rather than patient-centered health care.

Utility of daily diuretic orders for identifying acute decompensated heart failure patients for quality improvement

INTRODUCTION

Many studies have demonstrated gaps in adherence to American College of Cardiology (ACC)/American Heart Association (AHA) guidelines among patients with acute decompensated heart failure (ADHF). Quality improvement initiatives can improve compliance with guideline-recommended therapy yet a major challenge to such programs is identifying heart failure patients across the many wards and services of the complex hospital environment.

METHODS AND RESULTS

Using our hospital's electronic order-entry system, we generated a daily list of all hospitalized patients receiving a loop diuretic. Over a 3-month period, each patient on this list was screened through chart review for a diagnosis of ADHF. For those patients with ADHF, a clinical reminder about ACC/AHA recommended therapies was placed in the chart. Patient outcomes were followed using the Get With The Guidelines heart failure database.During the study period, 98.6% of patients with ADHF were identified by the diuretics list. The diuretics list had a sensitivity of 98.6% and specificity of 92.2%. The diuretic list captured more ADHF patients than alternative methods such as chest x-ray and brain natriuretic peptide level. Use of the daily diuretic list and targeted reminders to clinicians was associated with an improvement in recommended therapies including smoking-cessation education and heart failure teaching.

CONCLUSIONS

A daily list of inpatients receiving diuretics allowed real-time identification of most hospitalized heart failure patients at our institution. Targeted reminders to clinicians regarding ACC/AHA-recommended therapies for heart failure were associated with improvements in guideline adherence.

Structured telephone support or telemonitoring programmes for patients with chronic heart failure

BACKGROUND

Specialised disease management programmes for chronic heart failure (CHF) improve survival, quality of life and reduce healthcare utilisation. The overall efficacy of structured telephone support or telemonitoring as an individual component of a CHF disease management strategy remains inconclusive.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or telemonitoring compared to standard practice for patients with CHF in order to quantify the effects of these interventions over and above usual care for these patients.

SEARCH STRATEGY

Databases (the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database (HTA) on The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED and Science Citation Index Expanded and Conference Citation Index on ISI Web of Knowledge) and various search engines were searched from 2006 to November 2008 to update a previously published non-Cochrane review. Bibliographies of relevant studies and systematic reviews and abstract conference proceedings were handsearched. No language limits were applied.

SELECTION CRITERIA

Only peer reviewed, published RCTs comparing structured telephone support or telemonitoring to usual care of CHF patients were included. Unpublished abstract data was included in sensitivity analyses. The intervention or usual care could not include a home visit or more than the usual (four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

Data were presented as risk ratio (RR) with 95% confidence intervals (CI). Primary outcomes included all-cause mortality, all-cause and CHF-related hospitalisations which were meta-analysed using fixed effects models. Other outcomes included length of stay, quality of life, acceptability and cost and these were described and tabulated.

MAIN RESULTS

Twenty-five studies and five published abstracts were included. Of the 25 full peer-reviewed studies meta-analysed, 16 evaluated structured telephone support (5613 participants), 11 evaluated telemonitoring (2710 participants), and two tested both interventions (included in counts). Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI 0.54 to 0.81, P < 0.0001) with structured telephone support demonstrating a non-significant positive effect (RR 0.88, 95% CI 0.76 to 1.01, P = 0.08). Both structured telephone support (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) and telemonitoring (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008) reduced CHF-related hospitalisations. For both interventions, several studies improved quality of life, reduced healthcare costs and were acceptable to patients. Improvements in prescribing, patient knowledge and self-care, and New York Heart Association (NYHA) functional class were observed.

AUTHORS' CONCLUSIONS

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

The paradox of readmission: effect of a quality improvement program in hospitalized patients with heart failure

BACKGROUND

Congestive heart failure (CHF) is an increasingly common condition associated with significant hospital resource utilization. Initiating better disease management at the time of initial hospital admission has the potential to reduce readmissions.

OBJECTIVE

To evaluate the impact of a multifaceted quality improvement program on 12-month hospital utilization in patients admitted to hospital with CHF.

DESIGN

Prospective longitudinal study comparing baseline and intervention cohorts.

PARTICIPANTS

All consecutive patients with CHF discharged alive from 3 metropolitan hospitals during the baseline (October 1, 2000 to April 17, 2001) and intervention (February 15, 2002 to August 31, 2002) study periods. Active prospective case-finding identified 220 baseline and 235 intervention participants; full data was available on 197 baseline and 219 intervention participants.

INTERVENTIONS

Education and performance feedback for hospital and primary care practitioners; clinical decision support tools; individualized, guideline-based treatment plans; patient education and self-management support; and improved hospital-community integration.

MEASUREMENTS

Twelve-month all-cause hospital readmission, 12-month mortality, readmission-free survival, heart failure-specific readmission, and total hospital days over 12 months.

RESULTS

Intervention patients had a higher rate of all-cause readmission (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.10-2.46) but a trend to reduction in mortality (OR = 0.68; 95% CI = 0.44-1.07). There was no difference in frequency of hospitalizations per year, number of hospital days, or the composite outcome of death or readmission.

CONCLUSIONS

The intervention improved care processes and may have reduced mortality, but at the cost of higher readmission rates. Better understanding of intervention components, intensity, and targeting may optimize the effectiveness of disease management programs.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of a clinical pathway for the emergency treatment of patients with inborn errors of metabolism

OBJECTIVE

The goal was to measure the effectiveness of a clinical pathway for the emergency department care of patients with inborn errors of metabolism.

METHODS

Two years after the implementation of a multidisciplinary clinical pathway for patients with inborn errors of metabolism in our urban, academic, pediatric emergency department, we compared measures of timeliness and effectiveness for patients treated before the pathway with the same measures for patients treated after implementation of the pathway. Measures of timeliness included time to room, time to doctor, time to glucose infusion, and total emergency department length of stay. Measures of clinical effectiveness included the proportion of patients receiving adequate glucose infusions, proportion of patients admitted, inpatient length of stay, and proportion of patients requiring PICU admission.

RESULTS

A total of 214 emergency department visits for patients with inborn errors of metabolism were analyzed, 90 before and 124 after initiation of the pathway. All measures of timeliness of care except total emergency department length of stay demonstrated significant improvement in comparisons of values before and after initiation of the pathway. Measures of clinical effectiveness also demonstrated significant improvements after initiation of the pathway. There was improvement in the proportion of patients who received adequate glucose infusions, with a decrease in the proportion of patients who required admission to the PICU. Emergency department length of stay, inpatient length of stay, and the proportion of patients admitted to the hospital were not affected.

CONCLUSIONS

Most measures of timeliness and 2 measures of effectiveness showed improvement after implementation of an emergency department pathway for patients with inborn errors of metabolism. Therefore, a clinical pathway can improve the emergency care of patients with inborn errors of metabolism.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

A Practical Use of Theory to Study Adherence

Chronic heart failure (CHF) is a costly Medicare expenditure, with approximately 70% of the costs of heart failure care attributable to acute, symptom-related hospitalizations. The most common preventable cause of rehospitalization is nonadherence to the CHF regimen. Theoretic models have been used to study adherence; however, these models are predominantly designed for health behavior interventions (ie, smoking cessation, diet modification, or exercise) and focus less on conceptualizing the work involved in carrying out complex self-care regimens. The purpose of this paper was to present one approach for operationalizing the Trajectory Theory of Chronic Illness to study adherence in patients with heart failure. The trajectory model offers unique opportunities to study adherence, specifically because measurable patient attributes are clearer when evaluated in the context of the work required to adhere over time. Using trajectory theory may allow providers to better understand and facilitate patient adherence to the CHF regimen.

A taxonomy for disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group

BACKGROUND

Disease management has shown great promise as a means of reorganizing chronic care and optimizing patient outcomes. Nevertheless, disease management programs are widely heterogeneous and lack a shared definition of disease management, which limits our ability to compare and evaluate different programs. To address this problem, the American Heart Association's Disease Management Taxonomy Writing Group developed a system of classification that can be used both to categorize and compare disease management programs and to inform efforts to identify specific factors associated with effectiveness.

METHODS

The AHA Writing Group began with a conceptual model of disease management and its components and subsequently validated this model over a wide range of disease management programs. A systematic MEDLINE search was performed on the terms heart failure, diabetes, and depression, together with disease management, case management, and care management. The search encompassed articles published in English between 1987 and 2005. We then selected studies that incorporated (1) interventions designed to improve outcomes and/or reduce medical resource utilization in patients with heart failure, diabetes, or depression and (2) clearly defined protocols with at least 2 prespecified components traditionally associated with disease management. We analyzed the study protocols and used qualitative research methods to develop a disease management taxonomy with our conceptual model as the organizing framework.

RESULTS

The final taxonomy includes the following 8 domains: (1) Patient population is characterized by risk status, demographic profile, and level of comorbidity. (2) Intervention recipient describes the primary targets of disease management intervention and includes patients and caregivers, physicians and allied healthcare providers, and healthcare delivery systems. (3) Intervention content delineates individual components, such as patient education, medication management, peer support, or some form of postacute care, that are included in disease management. (4) Delivery personnel describes the network of healthcare providers involved in the delivery of disease management interventions, including nurses, case managers, physicians, pharmacists, case workers, dietitians, physical therapists, psychologists, and information systems specialists. (5) Method of communication identifies a broad range of disease management delivery systems that may include in-person visitation, audiovisual information packets, and some form of electronic or telecommunication technology. (6) Intensity and complexity distinguish between the frequency and duration of exposure, as well as the mix of program components, with respect to the target for disease management. (7) Environment defines the context in which disease management interventions are typically delivered and includes inpatient or hospital-affiliated outpatient programs, community or home-based programs, or some combination of these factors. (8) Clinical outcomes include traditional, frequently assessed primary and secondary outcomes, as well as patient-centered measures, such as adherence to medication, self-management, and caregiver burden.

CONCLUSIONS

This statement presents a taxonomy for disease management that describes critical program attributes and allows for comparisons across interventions. Routine application of the taxonomy may facilitate better comparisons of structure, process, and outcome measures across a range of disease management programs and should promote uniformity in the design and conduct of studies that seek to validate disease management strategies.

Improving the ICU: part 2

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.

Systematic review of multidisciplinary interventions in heart failure

OBJECTIVE

To determine the impact of multidisciplinary interventions on hospital admission and mortality in heart failure.

DESIGN

Systematic review. Thirteen databases were searched and reference lists from included trials and related reviews were checked. Trial authors were contacted if further information was required.

SETTING

Randomised controlled trials conducted in both hospital and community settings.

PATIENTS

Trials were included if all, or a defined subgroup of patients, had a diagnosis of heart failure.

INTERVENTIONS

Multidisciplinary interventions were defined as those in which heart failure management was the responsibility of a multidisciplinary team including medical input plus one or more of the following: specialist nurse, pharmacist, dietician, or social worker. Interventions were separated into four mutually exclusive groups: provision of home visits; home physiological monitoring or televideo link; telephone follow up but no home visits; and hospital or clinic interventions alone. Pharmaceutical and exercise based interventions were excluded.

MAIN OUTCOME MEASURES

All cause hospital admission, all cause mortality, and heart failure hospital admission.

RESULTS

74 trials were identified, of which 30 contained relevant data for inclusion in meta-analyses. Multidisciplinary interventions reduced all cause admission (relative risk (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95, p = 0.002), although significant heterogeneity was found (p = 0.002). All cause mortality was also reduced (RR 0.79, 95% CI 0.69 to 0.92, p = 0.002) as was heart failure admission (RR 0.70, 95% CI 0.61 to 0.81, p < 0.001). These results varied little with sensitivity analyses.

CONCLUSION

Multidisciplinary interventions for heart failure reduce both hospital admission and all cause mortality. The most effective interventions were delivered at least partly in the home.

Clinical service organisation for heart failure

BACKGROUND

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

OBJECTIVES

To assess the effectiveness of disease management interventions for patients with CHF.

SEARCH STRATEGY

We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary.

MAIN RESULTS

Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions.

AUTHORS' CONCLUSIONS

The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.

Australian nurses in general practice based heart failure management: implications for innovative collaborative practice

BACKGROUND

The growing global burden of heart failure (HF) necessitates the investigation of alternative methods of providing co-ordinated, integrated and client-focused primary care. Currently, the models of nurse-coordinated care demonstrated to be effective in randomized controlled trials are only available to a relative minority of clients and their families with HF. This current gap in service provision could prove fertile ground for the expansion of practice nursing [The Nurse in Family Practice: Practice Nurses and Nurse Practitioners in primary health care. 1988, Scutari Press, London: Impact of rural living on the experience of chronic illness. Australian Journal of Rural Health, 2001. 9: 235-240].

AIM

This paper aims to review the published literature describing the current and potential role of the practice nurse in HF management in Australia.

METHODS

Searches of electronic databases, the reference lists of published materials and the internet were conducted using key words including 'Australia', 'practice nurse', 'office nurse', 'nurs*', 'heart failure', 'cardiac' and 'chronic illness'. Inclusion criteria for this review were English language literature; nursing interventions for heart failure (HF) and the role of practice nurses in primary care.

RESULTS

There is currently a paucity of data evaluating the potential role for practice nurses in a reconfigured, collaborative health care system. Those studies that were identified were, largely, of a descriptive nature. In addition to identifying the practice nurse as a largely unexplored resource, key themes that emerged from the review include: (1) current general practice services face significant barriers to the implementation of evidence-based HF practice; (2) there is considerable variation in the practice nurse role between general practices; (3) there are significant barriers to the expansion of the practice nurse role; (4) multidisciplinary interventions can effectively deliver secondary prevention strategies; (5) practice nurses can potentially facilitate these multidisciplinary interventions; and (6) practice nurses are favorably perceived by consumers although there is some confusion about the nature of their role.

CONCLUSION

On the basis of this literature review, practice nurses represent a potentially useful adjunct to current models of service provision in HF management. Further research needs to comprehensively investigate the role of the practice nurse in the Australian context with a view to developing effective and sustainable frameworks for clinical practice. In particular, high-level evidence is required to evaluate the efficacy of the practice nurse role compared to current disease management strategies.

Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure

PURPOSE

To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure.

METHODS

The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure.

RESULTS

After adjusting for demographic and clinical characteristics of patients, and the number of eligible measures per patient, we observed no effect of the intervention on care of patients with myocardial infarction (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.81 to 1.17) or heart failure (OR = 1.25; 95% CI: 0.96 to 1.59). However, there was a higher likelihood of conformance with measures for patients with infarction (OR = 1.56; 95% CI: 1.29 to 1.87) or heart failure (OR = 1.71; 95% CI: 1.29 to 2.23) who had also been seen by a cardiologist during the 6-month assessment period.

CONCLUSION

Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.

Do regulations limiting residents' work hours affect patient mortality?

OBJECTIVE

To conduct a statewide analysis of the effect of New York's regulations, limiting internal medicine and family practice residents' work hours, on patient mortality.

DESIGN

Retrospective study of inpatient discharge files for 1988 (before the regulations) and 1991 (after the regulations).

SETTING AND PATIENTS

Adult patients discharged from New York teaching hospitals (170214) and nonteaching hospitals (143,455) with a principal diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia, for the years 1988 and 1991 (periods before and after Code 405 regulations went into law). Patients from nonteaching hospitals served as controls.

MEASUREMENT

In-hospital mortality.

RESULTS

Combined unadjusted mortality for congestive heart failure, acute myocardial infarction, and pneumonia patients declined between 1988 and 1991 in both teaching (14.1% to 13.0%; P =.0001) and nonteaching hospitals (14.0% to 12.5%; P =.0001). Adjusted mortality also declined between 1988 and 1991 in both teaching (odds ratio [OR], death 1991/1988, 0.868; 95% confidence interval [CI], 0.843 to 0.894; P =.0001) and nonteaching hospitals (OR, death 1991/1988, 0.853; 95% CI, 0.826 to 0.881; P =.0001). This beneficial trend toward lower mortality over time was nearly identical between teaching and nonteaching hospitals (P =.4348).

CONCLUSION

New York's mandated limitations on residents' work hours do not appear to have positively or negatively affected in-hospital mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching hospitals.

The costs and outcomes of multifaceted interventions designed to improve the care of congestive heart failure in the inpatient setting: a review of the literature

Various multifaceted interventions have been developed in response to the overwhelming burden of congestive heart failure and its costs. These interventions range from improvements in the delivery of inpatient care (e.g., by assigning multidisciplinary teams to the care of a patient or ensuring that clinical practice guidelines are followed) to comprehensive discharge planning that includes home health care. While it is intuitive that such interventions improve care, few have been evaluated in randomized controlled trials and fewer still include data on costs. In this article, the authors review the findings of randomized controlled trials of interventions designed to improve the quality of life, decrease hospital admissions, and decrease costs associated with heart disease. They conclude that inpatient-based multifaceted interventions appear to be effective and inexpensive. Future studies should attempt to tease interventions apart to ascertain which are the most effective. Formal cost-effectiveness analyses are also needed.

Quality of care of patients hospitalized with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.

AIM

To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines.

METHODS

A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions.

RESULTS

Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%).

CONCLUSIONS

Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.

The combined effect of public profiling and quality improvement efforts on heart failure management

BACKGROUND

A before-and-after study was conducted to examine the combined effect of public profiling and quality improvement activities on management of heart failure (HF) in the hospital setting.

METHODS

Thirty-one hospitals in southeastern Michigan participated in this profiling and quality improvement study. One hospital closed after the baseline measurement. Two quality indicators were developed to evaluate the key processes of HF care, and one profiling indicator was designed for public profiling. The baseline results of the profiling indicator were publicly released. The individual hospitals were identified in the profiling report by name as "having statistically higher (or lower) rates than average." Remeasurement results were compared to the baseline results by using t-tests for the individual hospitals and all 30 hospitals as an aggregate.

RESULTS

Two-thirds of the hospitals improved ejection fraction documentation; the aggregate result improved 5.4 percentage points (p < 0.05). No change was observed in the aggregate measure of prescribing angiotensin-converting enzyme inhibitors (ACEIs) to eligible HF patients at discharge. Hospitals with low baseline rates made improvement in ACEI use at discharge, but those with good baseline performance tended to decline in performance. There was a 2.2 percentage point increase (p < 0.05) in the profiling indicator.

SUMMARY AND CONCLUSIONS

There seemed to be differential impacts of interventions across indicators and hospitals. Public profiling may have the most positive impact on hospitals with low performance at baseline. Maintaining the baseline good practice was a struggle for hospitals with relatively high baseline rates.