Effects of education and support on self-care and resource utilization in patients with heart failure

Digital health as a tool for patient activation and improving quality of care for heart failure

The clinical and economic impact of heart failure (HF) is immense and will continue to rise due to the increasing prevalence of the disease. Despite the availability of guideline-recommended medications that improve mortality, reduce hospitalizations, and enhance quality of life, there are major gaps in the implementation of such care. Quality improvement interventions have generally focused on clinicians. While certain interventions have had modest success in improving the use of heart failure medications, they remain insufficient in optimizing HF care. Here, we discuss how patient-facing interventions can add value and supplement clinician-centered interventions. We discuss how digital health can be leveraged to create patient activation tools that create a larger, sustainable impact. Small studies have suggested the promise of digital tools for patient engagement and self-care, but there are also important barriers to the adoption of such interventions that we describe. We share key principles and strategies around the design and implementation of digital health innovations to maximize patient participation and engagement. By uniquely activating patients in their own care, digital health can unlock the full potential of both existing and new quality improvement initiatives to drive forward high-quality and equitable heart failure care.

Effectiveness of Heart Failure Nursing Protocol (HF-NP) on quality of life of patients with heart failure

BACKGROUND

Effective management of heart failure (HF) requires an integrated approach involving pharmacological and non-pharmacological interventions. Available evidence shows that patients benefit from adjunctive therapies along with guideline-directed medical therapy (GDMT). Still, there is an inadequacy in the use of the best available evidence and the self-management of symptoms by the patients. This study aimed to evaluate the effectiveness of a Heart Failure Nursing Protocol (HF-NP) on selected parameters, that is, symptoms, self-care adequacy, episodes of hospitalizations, depression, exercise capacity, medication adherence, activities of daily living (ADLs), and quality of life (QOL) of the HF patients.

MATERIAL AND METHODS

A pre-experimental study was conducted in a tertiary care hospital in Northern India. A total of 101 patients were enrolled using a convenient sampling technique. Participants were trained individually through demonstrations and educational sessions about self-management of HF at home. An informational booklet was given to all the participants consisting of information about HF, dietary instructions, individual exercise schedules based on the New York Heart Association (NYHA) class, identification of worsening symptoms, daily monitoring of vital parameters, and self-management of HF at home. Telephonic encouragement was provided on day 15, 1 month, and 3 months of baseline visits. The data were checked for normality using the Kolmogorov-Smirnov test and analyzed using a paired t-test, Wilcoxon's signed-rank test, and McNemar's test as appropriate.

RESULTS

There was significant improvement in outcomes, such as breathing difficulty (P = 0.028), activity intolerance (P = 0.013), self-care adequacy (P = 0.001), depression (P = 0.001), exercise intensity (P = 0.001), QOL (P = 0.001), and medication adherence (P = 0.001) after 3 months of intervention.

CONCLUSION

HF-NP was effective in improving HF outcomes. It can be used to train patients and their family members regarding the debilitating illness, after doing a large study, and it can be incorporated into the health policy later.

Measuring the continuing care needs of inpatients in rural China

BACKGROUND

International experience shows that the suitability of a high-performance healthcare system for its given purposes is reflected in its ability to provide a continuum of services that match the changing health status of the given population. Although many low- and middle-income countries have sought to bring movement away from hospital-centered and towards patient-centered healthcare, such efforts have often had poor results, and one of the major reasons for this is the inability to accurately identify which inpatients need continuing care and what kind of continuing of care is needed.

OBJECTIVES

To measure and assess the continuing care needs of discharged patients and its influencing factors in rural China.

METHODS

Data were obtained from the hospital database of Medical Center M in County Z from May to July 2022. County Z is a county of 1 million people in central China. The database includes basic patient information, disease-related information, and information on readiness for hospital discharge. Factors related to the need for continuing care were included in the analysis. The Readiness for Hospital Discharge Scale was used to assess the need for continuing care. The statistical data are expressed in terms of both frequency and composition ratio. Finally, linear regression was used to analyze the factors influencing the need for continuing care.

RESULTS

The analysis included a total of 3,791 patients, 123 of whom (3.25%) had continuing nursing needs. The need of continuing nursing was related to patients' age group, mode of admission, occupation and major diagnostic categories (P < 0.05).

CONCLUSIONS

Developing continuing care is an important initiative for bridging the fragmentation of health services, and an appropriate supply system for continuing care, interconnected with inpatient services, should be established in rural areas in China as soon as possible. And provide more appropriate care for patients in need.

The Impact of Specialised Heart Failure Outpatient Care on the Long-Term Application of Guideline-Directed Medical Therapy and on Prognosis in Heart Failure with Reduced Ejection Fraction

(1) Background: Besides the use of guideline-directed medical therapy (GDMT), multidisciplinary heart failure (HF) outpatient care (HFOC) is of strategic importance in HFrEF. (2) Methods: Data from 257 hospitalised HFrEF patients between 2019 and 2021 were retrospectively analysed. Application and target doses of GDMT were compared between HFOC and non-HFOC patients at discharge and at 1 year. 1-year all-cause mortality (ACM) and rehospitalisation (ACH) rates were compared using the Cox proportional hazard model. The effect of HFOC on GDMT and on prognosis after propensity score matching (PSM) of 168 patients and the independent predictors of 1-year ACM and ACH were also evaluated. (3) Results: At 1 year, the application of RASi, MRA and triple therapy (TT: RASi + βB + MRA) was higher (p < 0.05) in the HFOC group, as was the proportion of target doses of ARNI, βB, MRA and TT. After PSM, the composite of 1-year ACM or ACH was more favourable with HFOC (propensity-adjusted HR = 0.625, 95% CI = 0.401-0.974, p = 0.038). Independent predictors of 1-year ACM were age, systolic blood pressure, application of TT and HFOC, while 1-year ACH was influenced by the application of TT. (4) Conclusions: HFOC may positively impact GDMT use and prognosis in HFrEF even within the first year of its initiation.

Relationship between People's Interest in Medication Adherence, Health Literacy, and Self-Care: An Infodemiological Analysis in the Pre- and Post-COVID-19 Era

The prevalence of non-communicable diseases has risen sharply in recent years, particularly among older individuals who require complex drug regimens. Patients are increasingly required to manage their health through medication adherence and self-care, but about 50% of patients struggle to adhere to prescribed treatments. This study explored the relationship between interest in medication adherence, health literacy, and self-care and how it changed during the COVID-19 pandemic. We used Google Trends to measure relative search volumes (RSVs) for these three topics from 2012 to 2022. We found that interest in self-care increased the most over time, followed by health literacy and medication adherence. Direct correlations emerged between RSVs for medication adherence and health literacy (r = 0.674, p < 0.0001), medication adherence and self-care (r = 0.466, p < 0.0001), and health literacy and self-care (r = 0.545, p < 0.0001). After the COVID-19 pandemic outbreak, interest in self-care significantly increased, and Latin countries showed a greater interest in self-care than other geographical areas. This study suggests that people are increasingly interested in managing their health, especially in the context of the recent pandemic, and that infodemiology may provide interesting information about the attitudes of the population toward chronic disease management.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Effect of self-management intervention on prognosis of patients with chronic heart failure: A meta-analysis

AIM

The purpose of this study is to explore the influence of self-management intervention on four prognostic indicators of readmission rate, mortality rate, self-management ability and quality of life in patients with chronic heart failure.

DESIGN

A meta-analysis.

METHODS

This study was selected from the related studies published from January 1999 to January 2022, and was searched by searching five databases: PubMed, Science of Website, China National Knowledge Infrastructure (CNKI), Wan Fang and Wei Pu (VIP). All standardized randomized controlled trial studies were collected, and the quality evaluation and meta-analysis of the included literature were conducted.

RESULTS

This study included 20 randomized controlled trials involving 3459 patients with chronic heart failure. Meta-analysis results showed that self-management intervention could reduce the readmission rate of patients with chronic heart failure, improved self-management ability of patients, improved quality of life, but there was no statistical significance in mortality.

Feasibility of implementing a mobile phone-based telemonitoring programme to support pregnant women at high-risk for pre-eclampsia in Karachi, Pakistan: protocol for a mixed-methods study

INTRODUCTION

High maternal mortality from pre-eclampsia/eclampsia results from lack of early identification and management of pregnant women at high-risk for pre-eclampsia. A potential tool to support pregnant women at high-risk for pre-eclampsia is telemonitoring. There is limited evidence on the use and effectiveness of telemonitoring for pregnant women in low-income and middle-income countries (LMICs) which limits the understanding of the process and mechanisms through which the intervention works in LMICs. This study will explore the feasibility of implementing a mobile phone-based telemonitoring programme for pregnant women at high-risk for pre-eclampsia in Karachi, Pakistan.

METHODS AND ANALYSIS

A convergent mixed-methods study will be conducted at the Jinnah Postgraduate Medical Center (JPMC) in Karachi, Pakistan. This study will recruit 50 pregnant women at high-risk for pre-eclampsia to assess clinical feasibility across the five foci of Bowen's framework including acceptability, demand, implementation, practicality and limited-efficacy testing. Data sources will include semi-structured interviews with the enrolled women, caregivers and clinicians, as well as quantitative data from paper medical records, research logs and server data. The quantitative and qualitative data will be analysed separately and then integrated at the interpretation and reporting levels to advance our understanding of the telemonitoring programme's feasibility across the five areas of Bowen's framework.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from JPMC, the National Bioethics Committee of Pakistan, University Health Network, Aga Khan University and the University of Toronto. The study results will be disseminated to the scientific community through publications and conference presentations. Findings of the study will provide evidence on the feasibility of using a telemonitoring programme where pregnant women at high-risk for pre-eclampsia in Pakistan will take their own blood pressure readings at home. Lessons learnt in this feasibility trial will be used to determine the appropriateness of a future effectiveness trial.

TRIAL REGISTRATION NUMBER

NCT05662696.

Suboptimal Dosing of β-Blockers in Chronic Heart Failure: A Missed Opportunity?

BACKGROUND

The evidence base for the benefits of β-blockers in heart failure with reduced ejection fraction (HFrEF) suggests that higher doses are associated with better outcomes.

OBJECTIVES

The aim of this study was to report the proportion of patients receiving optimized doses of β-blockers, outcomes, and factors associated with suboptimal dosing.

METHODS

This was a prospective cohort study of 390 patients with HFrEF undergoing clinical and echocardiography assessment at baseline and at 1 year.

RESULTS

Two hundred thirty-seven patients (61%) were receiving optimized doses (≥5-mg/d bisoprolol equivalent), 72 (18%) could not be up-titrated (because of heart rate < 60 beats/min or systolic blood pressure <100 mm Hg), and the remaining 81 (21%) should have been. Survival was similarly reduced in those who could not and should have been receiving 5 mg/d or greater, and patient factors did not explain the failure to attain optimized dosing.

CONCLUSIONS

Many patients with HFrEF are not receiving optimal dosing of β-blockers, and in around half, there was no clear contraindication in terms of heart rate or blood pressure.

Effectiveness and Cost-Effectiveness of Case Management in Advanced Heart Failure Patients Attended in Primary Care: A Systematic Review and Meta-Analysis

AIMS

Nurse-led case management (CM) may improve quality of life (QoL) for advanced heart failure (HF) patients. No systematic review (SR), however, has summarized its effectiveness/cost-effectiveness. We aimed to evaluate the effect of such programs in primary care settings in advanced HF patients. We examined and summarized evidence on QoL, mortality, hospitalization, self-care, and cost-effectiveness.

METHODS AND RESULTS

The MEDLINE, CINAHL, Embase, Clinical Trials, WHO, Registry of International Clinical Trials, and Central Cochrane were searched up to March 2022. The Consensus Health Economic Criteria instrument to assess risk-of-bias in economic evaluations, Cochrane risk-of-bias 2 for clinical trials, and an adaptation of Robins-I for quasi-experimental and cohort studies were employed. Results from nurse-led CM programs did not reduce mortality (RR 0.78, 95% CI 0.53 to 1.15; participants = 1345; studies = 6; I² = 47%). They decreased HF hospitalizations (HR 0.79, 95% CI 0.68 to 0.91; participants = 1989; studies = 8; I² = 0%) and all-cause ones (HR 0.73, 95% CI 0.60 to 0.89; participants = 1012; studies = 5; I² = 36%). QoL improved in medium-term follow-up (SMD 0.18, 95% CI 0.05 to 0.32; participants = 1228; studies = 8; I² = 28%), and self-care was not statistically significant improved (SMD 0.66, 95% CI -0.84 to 2.17; participants = 450; studies = 3; I² = 97%). A wide variety of costs ranging from USD 4975 to EUR 27,538 was observed. The intervention was cost-effective at ≤EUR 60,000/QALY.

CONCLUSIONS

Nurse-led CM reduces all-cause hospital admissions and HF hospitalizations but not all-cause mortality. QoL improved at medium-term follow-up. Such programs could be cost-effective in high-income countries.

Symptom perception management education improves self-care in patients with heart failure

BACKGROUND

Patients with heart failure often have difficulty recognizing signs and symptoms of the disease, which delays seeking help, and therefore interferes with patient engagement and self-care management. Early detection of these symptoms could lead to care-seeking and avoid hospitalizations.

OBJECTIVE

The purpose of this study was to design a complex intervention through a systematic literature review and qualitative study.

METHODS

Our design followed the Medical Research Council's recommendations. To design a complex intervention, we combined a systematic literature review on education, symptom recognition, and self-care management in patients with heart failure, and semi-structured interviews with cardiology healthcare providers and patients with heart failure admitted to a cardiology ward.

RESULTS

The systematic literature review identified 582 studies published between 2005 and 2014, of which four were included in the final review. These suggested that patient education focused on symptom recognition, combined with reinforcements, led to better self-care behaviors. Additionally, content analysis of semi-structured interviews revealed three themes: health management, behavior management, and support received.

CONCLUSIONS

Combining the findings of the literature review and the themes that emerged from the semi-structured interviews, we proposed the development and implementation of a complex intervention on symptom perception and fluid management.

Persistent effect of nurse-led education on self-care behavior and disease knowledge in heart failure patients

PURPOSE

The guidelines on the management of patients with heart failure support intensive patient education on self-care. The present study aimed to evaluate the short-term and long-term impacts of a structured education provided by a qualified heart failure nurse on patients' self-care behavior and disease knowledge.

METHODS

One hundred fifty patients (66 ± 12 years) hospitalized for heart failure participated in a structured one-hour educational session by a heart failure nurse. Patients completed a questionnaire comprising 15 questions (nine questions from the European Heart Failure Self-Care Behavior Scale [EHFScB-9] and six on the patients' disease knowledge) one day before and one day and six months after the educational session. Possible responses for each question ranged from 1 (complete agreement) to 5 (complete disagreement).

RESULTS

After the educational session, the total EHFScB-9 score improved from 24.31 ± 6.98 to 14.94 ± 6.22, and the disease knowledge score improved from 18.03 ± 5.44 to 10.74 ± 4.30 (both P < 0.001). Scores for individual questions ranged from 1.26 ± 0.81 (adherence to the medication protocol) to 3.66 ± 1.58 (everyday weighing habits) before the education. The greatest improvement after education was observed on response to weight gain (-2.00‬±1.57), daily weight control (-1.77 ± 1.64), and knowledge on the cause of patients' heart failure (-1.53 ± 1.43). At 6-month follow-up, EHFScB-9 score was 17.33 ± 7.23 and knowledge score was 12.34 ± 5.30 (both P < 0.001 compared with baseline). No factor was predictive of an insufficient teaching effect.

CONCLUSIONS

The educational program led by a qualified nurse improves patients' self-care behavior and disease knowledge with a persistent effect at 6-month follow-up. There are no patient characteristics which preclude the implementation of an educational session.

Impact of a Social Support Program Supervised by a Multidisciplinary Team on Psychosocial Distress and Knowledge About Heart Failure Among Heart Failure Patients

Background

Heart failure drains significant financial resources with morbidity and mortality higher than cancer. Social support is defined as the care provided by the family members, friends and health care workers to the patients. Absence of social support and poor perceived social support will create stress, anxiety, depression and anger which further deteriorate the underlying disease and worsen quality of life. Discussion in group creates better understanding of the disease which helps the patients improving their skills in managing their condition.

Objective

To evaluate the impact of multidisciplinary team supervised social support program on components of psychosocial distress and knowledge about heart failure among heart failure patients.

Methods

Adult patients with heart failure attending King Fahad Medical City as inpatient or outpatient were enrolled in this prospective cohort study. Patients were given questionnaire to assess their perception of social support they have at their disposal, quality of life, knowledge regarding heart failure and self-care behavior. They then had interactive education in groups supervised by multidisciplinary team members about the pathogenesis of their disease with management strategies, dietary restriction, importance of exercise and healthy life style pattern. Patients shared their experiences in the group and had opportunity to learn from each other. Patients were assessed regarding their perceived social support, quality of life, knowledge regarding heart failure and self-care behavior immediately after the session and at 1 month interval.

Results

There were total 500 patients participated in the study. Among the study participants 62% were male and majority was living with the family. Components of psychosocial distress were present in up to 40% of study participants and only 36% considered knowledgeable regarding heart failure. After the interactive social support group meeting components of psychosocial distress were significantly reduced with significant improvement in knowledge about heart failure. At 1 month follow up participants reported persistent improvement in quality of life, improvement in self-care behavior, perceived social support and wanted to continue in social group program.

Conclusion

Social support program supervised by multidisciplinary team providing education and social support improved knowledge, self-care behavior, perceived social support and quality of life among heart failure patients.

The effects of a self-regulation programme on self-care behaviour in patients with heart failure: A randomized controlled trial

BACKGROUND

Self-care behaviour is important for patients with heart failure to prevent disease progression. More than half of patients have poor self-care behaviour. Self-regulation theory emphasizes that patients need to initiate monitoring of their symptoms, identify their own problems, and perform appropriate self-care behaviour. However, studies focused on interventions based on self-regulation theory for patients with heart failure are limited.

OBJECTIVES

To investigate the effects of a self-regulation programme on self-care behaviour in patients with heart failure.

DESIGN

A randomized controlled trial.

PARTICIPANTS AND SETTING

Eighty-two patients with heart failure were recruited from a cardiovascular outpatient department at a teaching hospital in northern Taiwan.

METHODS

Participants were randomly assigned to the intervention (n = 41) or control group (n = 41). The intervention group participated in a 4-week self-regulation programme, including one 20-to-30-min, face-to-face individual self-regulation education session and 15- to 20-min telephone follow-up counselling sessions twice per week for four weeks. The control group received only routine outpatient care. Self-care behaviour was measured by the Self-Care of Heart Failure Index at baseline, 4 weeks and 8 weeks after patients were enroled.

RESULTS

The intervention group reported improvements in self-care behaviours, including self-maintenance and self-confidence subscale scores, after four weeks of the self-regulation programme. In contrast, the control group showed no significant differences. Compared with the control group, the intervention group exhibited significantly greater improvements in self-care maintenance (B = 3.74, p = 0.01), self-care management (B = 6.33, p = 0.004), and self-care confidence (B = 5.15, p = 0.003) at four weeks but showed significantly greater improvements only in self-care management (B = 6.97, p = 0.03) and self-care confidence (B = 6.24, p = 0.001) at 8 weeks.

CONCLUSIONS

This study confirmed that a self-regulation programme could effectively improve self-care behaviour in patients with heart failure. Further studies with multicentre randomized controlled trials and larger populations of heart failure patients are necessary to evaluate the effect of this self-regulation programme in various regions and countries. Tweetable abstract: A home-based self-regulation programme could effectively improve self-care behaviour in patients with heart failure.

Effect of home-based follow-up intervention on readmissions and mortality in heart failure patients: a meta-analysis

Aim: We investigated whether the home-based intervention (HBI) for heart failure (HF), restricted to education and support, improves readmissions or mortality compared with usual care. Patients & methods: We searched PubMed and Embase for randomized controlled trials that examined the impact of HBI in HF. A random-effects meta-analysis was performed using R. Result: Total 17/409 articles (3214 patients) met our inclusion criteria. The pooled estimate showed HBI was associated with a reduction in readmission rates and mortality (22 and 16% respectively; p < 0.05). Subgroup analysis confirmed that the benefit of HBI increases significantly with a longer follow-up. Conclusion: HBI in the form of education and support significantly reduces readmission rates and improves survival of HF patients. HBI should be considered in the discharge planning of HF patients.

Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis

BACKGROUND

Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term.

OBJECTIVE

To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge.

DESIGN

Meta-analysis of randomized controlled trials.

DATA SOURCES

A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits.

REVIEW METHODS

RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model.

RESULTS

Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity.

CONCLUSIONS

Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.

Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents

Unplanned hospital readmissions are the most important, preventable cost in heart failure (HF) health economics. Current professional guidelines recommend that patient self-care is an important means by which to reduce this burden. Patients with HF should be engaged in their care such as by detecting, monitoring, and managing their symptoms. A variety of educational and behavioural interventions have been designed and implemented by health care providers to encourage and support patient self-care. Meta-analyses support the use of self-care interventions to improve patient self-care and reduce hospital readmissions; however, efficacy is variable. The aim of this review was to explore methods to achieve greater clarity and consistency in the development and reporting of self-care interventions to enable ‘change agents’ to be identified. We conclude that advancement in this field requires more explicit integration and reporting on the behaviour change theories that inform the design of self-care interventions and the selection of behaviour change techniques. The systematic application of validated checklists, such as the Theory Coding Scheme and the CALO-RE taxonomy, will improve the systematic testing and refinement of interventions to enable ‘change agent/s’ to be identified and optimised.

Symptom Management and Hospital Readmission in Heart Failure Patients: A Qualitative Study From Portugal

This article reports a study aimed at identifying the factors that result in hospital readmissions for patients with heart failure. The high rates of readmission are often due to a lack of knowledge about symptoms and signs of disease progression, and these Portuguese nurses believed that readmissions could be decreased through disease management programs in which patients assumed a more active role in self-care. A study was designed to identify broad categories of problems that lead Portuguese patients with heart failure to be readmitted to hospital. Semistructured interviews were conducted, recorded, and submitted for content analysis, revealing 3 main categories for targeting: health management, behavioral management, and psychological support. This study revealed that patients with heart failure seem to struggle with management of multiple treatment regimens during the long course of their chronic illness. Based on these interviews, authors conclude that a disease management program be tailored expressly for the Portuguese culture and their lifestyle.

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.

Systematic review of economic burden of heart failure

The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.

Home Healthcare Visits Following Hospital Discharge: Does the Timing of Visits Affect 30-Day Hospital Readmission Rates for Heart Failure Patients?

The purpose of this study was to determine if the timing of home care visits post hospitalization for heart failure influenced hospital readmission rates. Using a randomized control study design, hospital readmission data were collected from 67 recently discharged patients with heart failure. The control group (n = 32) received the usual care, whereas the intervention group (n = 35) received an altered scheduling of home care visits. Seven study participants were readmitted during the study time frame (control group n = 3; intervention group n = 4). Emergency room visits occurred three times (control group n = 1; intervention group n = 2). The timing of the home healthcare visit did not affect hospital readmission. Adherence to weight monitoring, fluid restriction, and medication administration improved with the home care visits. Greater attention to these activities should be the focus of home healthcare visits as they may decrease hospital readmissions.

Controlling epidemic outbreak based on local dynamic infectiousness on complex networks

Resources are limited in epidemic containment; how to optimally allocate the limited resources in suppressing the epidemic spreading has been a challenging problem. To find an effective resource allocation strategy, we take the infectiousness of each infected node into consideration. By studying the interplay between the resource allocation and epidemic spreading, we find that the spreading dynamics of epidemic is affected by the preferential resource allocation. There are double phase transitions of the fraction of infected nodes, which are different from the classical epidemic model. More importantly, we find that the preferential resource allocation has double-edged sword effects on the disease spreading. When there is a small transmission rate, the infected fraction at the steady state decreases with the increment of degree of resource allocation preference, which indicates that resources of the healthy nodes should be allocated preferentially to the high infectious nodes to constrain the disease spreading. Moreover, when there is a large transmission rate, the fraction of infected nodes at the steady state increases with the increment of the degree of the preference, but the resource allocation is determined by the stage of epidemic spreading. Namely, in the early stage of the disease spreading, resources should be allocated preferentially to the high infectious nodes similar to the case of a small transmission rate. While after the early stage, resources should be allocated to the low infectious nodes. Based on the findings, we propose a simple resource allocation strategy that can adaptively change with the current fraction of infected nodes and the disease can be suppressed to the most extent under the proposed strategy.

Impact of Home Health Care on Health Care Resource Utilization Following Hospital Discharge: A Cohort Study

BACKGROUND

As healthcare costs rise, home health care represents an opportunity to reduce preventable adverse events and costs following hospital discharge. No studies have investigated the utility of home health care within the context of a large and diverse patient population.

METHODS

A retrospective cohort study was conducted between 1/1/2013 and 6/30/2015 at a single tertiary care institution to assess healthcare utilization after discharge with home health care. Control patients discharged with "self-care" were matched by propensity score to home health care patients. The primary outcome was total healthcare costs in the 365-day post-discharge period. Secondary outcomes included follow-up readmission and death. Multivariable linear and Cox proportional hazards regression were used to adjust for covariates.

RESULTS

Among 64,541 total patients, 11,266 controls were matched to 6,363 home health care patients across 11 disease-based Institutes. During the 365-day post-discharge period, home health care was associated with a mean unadjusted savings of $15,233 per patient, or $6,433 after adjusting for covariates (p < 0.0001). Home health care independently decreased the hazard of follow-up readmission (HR 0.82, p < 0.0001) and death (HR 0.80, p < 0.0001). Subgroup analyses revealed that home health care most benefited patients discharged from the Digestive Disease (death HR 0.72, p < 0.01), Heart & Vascular (adjusted savings of $11,453, p < 0.0001), Medicine (readmission HR 0.71, p < 0.0001), and Neurological (readmission HR 0.67, p < 0.0001) Institutes.

CONCLUSIONS

Discharge with home health care was associated with significant reduction in healthcare utilization and decreased hazard of readmission and death. These data inform development of value-based care plans.

Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review

BACKGROUND

Many discharge interventions are developed to reduce unplanned hospital readmissions, but it is unclear which interventions are more effective.

OBJECTIVES

The objective of this review was to identify discharge interventions from hospital to home that reduce hospital readmissions within three months and to understand their effect on secondary outcome measures.

INCLUSION CRITERIA

Participants were adults (18 years or older) discharged from a medical or surgical ward.The included interventions had to be designed to ease the care transition from hospital to home or to prevent problems after hospital discharge.This review considered only randomized controlled trials.The primary outcome measure was hospital readmission within three months after discharge. Secondary outcomes included patient satisfaction, return to emergency departments and mortality.

SEARCH STRATEGY

Studies in English between January 1990 and July 2014 were considered for inclusion. The databases searched were PubMed, Web of Science, Embase and CINAHL.

METHODOLOGICAL QUALITY

Methodological validity was assessed by two reviewers prior to inclusion using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Quantitative data were independently extracted by the two reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

Meta-analysis was performed by using a random effect model; data were pooled using Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of seven or more were selected.

RESULTS

Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01] (p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six studies evaluating patient satisfaction.Exploratory subgroup analysis found that interventions starting during hospital stay and continuing after discharge were more effective in reducing readmissions compared to interventions starting after discharge (between subgroup difference p=0.01). Multicomponent interventions were not more effective compared to single component interventions (between subgroup difference p=0.54). Interventions oriented towards patient empowerment were more effective compared to all other interventions (between subgroup difference p=0.02).

CONCLUSIONS

Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.

Strategies to Modify the Risk of Heart Failure Readmission: A Systematic Review and Meta-Analysis

Background:

Human factors play an important role in health-care outcomes of heart failure (HF) patients. A systematic review and meta-analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies.

Purpose:

To investigate how the 8 guiding principles of choice, rest, environment, activity, trust, interpersonal relationships, outlook, and nutrition reduce HF readmissions.

Basic Procedures:

Appropriate keywords were identified related to the (1) independent variable of hospitalization and treatment, (2) the moderating variable of care management principles, (3) the dependent variable of readmission, and (4) the disease of HF to conduct searches in 9 databases. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ERIC, MEDLINE, PubMed, PsycInfo, Science Direct, and Web of Science. Only prospective studies associated with HF hospitalization and readmissions, published in English, Chinese, Spanish, and German journals between January 1, 1990, and August 31, 2015, were included in the systematic review. In the meta-analysis, data were collected from studies that measured HF readmission for individual patients.

Main Findings:

The results indicate that an intervention involving any human factor principles may nearly double an individual’s probability of not being readmitted. Participants in interventions that incorporated single or combined principles were 1.4 to 6.8 times less likely to be readmitted.

Principal Conclusions:

Interventions with human factor principles reduce readmissions among HF patients. Overall, this review may help reconfigure the design, implementation, and evaluation of clinical practice for reducing HF readmissions in the future.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

The effectiveness of individual rehabilitation on health status in patients with heart failure: A quasi-experimental study

Patients with heart failure (HF) live with a serious disease, and need long-term rehabilitation care. Elements in rehabilitation for patients with HF are based on the recommendations from the European Society of Cardiology and focuses on self-care and adherence in general. The aim of this study is to test the effect of individually prepared rehabilitation plans measured on health status (HS). The study design is quasi-experimental. Patients in the control group follow the conventional rehabilitation. For the patients in the intervention group. an individual rehabilitation plan was prepared and followed up by telephone after 4 and 12 weeks. For all patients, HS was measured with Short Form-36. One hundred sixty-two patients are included in the study, of which 137 (84.6%) consented. There were no differences in HS before and after the intervention. There are no significant differences by use of a systematically prepared intervention compared with usual care for patients with HF measured on HS 3 months after discharge from the outpatient clinic.

Broadening the Reach of Cardiac Rehabilitation to Rural and Remote Australia

BACKGROUND

Cardiac rehabilitation (CR) has an evidence base but traditional models may not readily apply to people living in rural and remote regions.

AIM

: To outline published comprehensive and non-hospital based CR models used for people discharged from hospital after a cardiac event that have potential relevance to those living in rural and remote areas in Australia.

METHODS

The PubMed database was searched using Medical subject headings (MeSH) terms and the key word 'cardiac rehabilitation' limited to clinical trials. Articles were retrieved if they included at least two components of CR and were not based in an outpatient setting.

RESULTS

No CR models specifically developed for rural and remote areas were identified. However, 14 studies were found that outlined 11 non-conventional comprehensive CR models. All provided CR in a home-based setting. Health professionals provided support via telephone contact or home visits, and via resources such as the Heart Manual. Reported outcomes from these CR programs varied: ranging from an increase in knowledge of risk factors, to improvements in physical activity, decreased risk factor profile, improved psychological and social functioning and reductions in health service costs and mortality.

CONCLUSION

Home-based, CR models have the most substantive evidence base and, therefore the greatest potential to be developed and made accessible to eligible people living in rural and remote areas.

Telecardiology: One-lead electrocardiogram monitoring and nurse triage in chronic heart failure

We investigated a home-based intervention based on telecardiology in patients with chronic heart failure (CHF). Two hundred and thirty CHF patients, aged 59 years (SD 9), in stable condition and with optimized therapy were enrolled. The programme consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring followed by visits from a paramedical and medical team. The patient could call the centre when required (tele-assistance), while the team could call the patient at pre-scheduled times (telemonitoring). During the first 12 months, there were 3767 calls (873 ad hoc and 2894 scheduled calls). There were 648 events, including 126 episodes of asymptomatic hypotension and 168 episodes which were not due to cardiological symptoms. No actions were taken by the nurse after 2417 calls (64%). A change in therapy was suggested after 418 calls, hospital admission in 62 patients, further investigations for 243 patients and a consultation with the general practitioner in 41 patients. A total of 2303 one-lead ECG recordings were received (10 per patient); 126 recordings (6%) were diagnosed as pathological in comparison with the baseline one. The one-lead ECG recording was used for titration of beta-blockers in 79 patients (mean dosage 38 mg vs 42 mg, P<0.01). Home telenursing could be an important application of telemedicine and single-lead ECG recording seems to offer additional benefit in comparison with telephone follow-up alone.

Effect of home-based telecardiology on chronic heart failure: Costs and outcomes

Chronic heart failure (CHF) remains a common cause of disability. We have investigated the use of home-based telecardiology (HBT) in CHF patients. Four hundred and twenty-six patients were enrolled in the study: 230 in the HBT group and 196 in the usual-care group. HBT consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring, followed by visits from the paramedical and medical team. A one-lead ECG recording was transmitted to a receiving station, where a nurse was available for reporting and interactive teleconsultation. The patient could call the centre when assistance was required (tele-assistance), while the team could call the patient for scheduled appointments (telemonitoring). The one-year clinical outcomes showed that there was a significant reduction in rehospitalizations in the HBT group compared with the usual-care group (24% versus 34%, respectively). There was an increase in quality of life in the HBT group (mean Minnesota Living Questionnaire scores 29 and 23.5, respectively). The total costs were lower in the HBT group (107,494 and 140,874, respectively). The results suggest that a telecardiology service can detect and prevent clinical instability, reduce rehospitalization and lower the cost of managing CHF patients.

Chronic heart failure home-based management with a telecardiology system: A comparison between patients followed by general practitioners and by a cardiology department

A group of patients with chronic heart failure (CHF) were followed by general practitioners (GPs) with a telecardiology system, and a second group of patients were followed by a home-based telemonitoring (HBT) protocol with medical and nursing supervision. The 212 GP patients were older than the 226 HBT patients, mostly women, with CHF secondary to chronic hypertension, less self-sufficient and with a non-optimized therapy. The mean number of telephone calls was 2.6 per patient in the GP group and 16.6 per patient in the HBT group (P<0.001). These preliminary data suggest the applicability and the efficacy of both management models for CHF patients.

Educating Nurses and Patients to Manage Heart Failure

Patient education is an important component in the management of patients with heart failure and nurses are increasingly involved in this area. This paper reviews the literature on education to patients with heart failure and the education and training for heart failure nurses. Patients with heart failure need education in order to adapt to their chronic syndrome and perform self-care. The education process often starts during the hospital admission, but must continue in the outpatient setting. Nurses need to be skilled in assessing the requirements and level of the education given to the individual. Computer-based education has been found to be a preferred and effective compliment to the education provided by health care professionals. The effect of new materials and methods needs to be evaluated in order to improve the overall effectiveness of the education provided. The patient with heart failure should have an active role in this development and evaluation. The heart failure nurse needs to be experienced in cardiac care, have an ability to work independently in order to be delegated responsibilities such as drug titration and patient assessment. This requires optimal experience, training and education for advanced practice. In order to develop and evaluate the education of patients with heart failure and the overall effectiveness of heart failure nurses in this regard, national and international collaborations are needed.

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review

BACKGROUND

Rates of readmission to hospital within 30 days are highest amongst those with chronic diseases. Effective interventions to reduce unplanned readmissions are needed. Providing support to patients with chronic disease via telephone may help prevent unnecessary readmission. This systematic review aimed to determine the methodological quality and effectiveness of interventions utilising telephone follow up (TFU) alone or in combination with other components in reducing readmission within 30 days amongst patients with cardiovascular disease, chronic respiratory disease and diabetes.

METHODS

A systematic search of MEDLINE, the Cochrane Library and EMBASE were conducted for articles published from database inception to 19(th) May 2015. Interventions which included TFU alone, or in combination with other components, amongst patients with chronic disease, reported 30 day readmission outcomes and met Effective Practice and Organisation of Care design criteria were included. The titles and abstracts of all identified articles were initially assessed for relevance and rejected on initial screening by one author. Full text articles were assessed against inclusion criteria by two authors with discrepancies resolved through discussion.

RESULTS

Ten studies were identified, of which five were effective in reducing readmissions within 30 days. Overall, the methodological quality of included studies was poor. All identified studies combined TFU with other intervention components. Interventions that were effective included three studies which provided TFU in addition to pre-discharge support; and two studies which provided TFU with both pre- and post-discharge support which included education, discharge planning, physical therapy and dietary consults, medication assessment, home visits and a resident curriculum. There was no evidence that TFU and telemedicine or TFU and post-discharge interventions was effective, however, only one to two studies examined each of these types of interventions.

CONCLUSIONS

Evidence is inconclusive for the effectiveness of interventions utilising TFU alone or in combination with other components in reducing readmissions within 30 days in patients with chronic disease. High methodological quality studies examining the effectiveness of TFU in a standardised way are needed. There is also potential importance in focusing interventions on enhancing provider skills in patient education, transitional care and conducting TFU.

Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow-Up

OBJECTIVE

To compare the effectiveness of two "treatments"-early, intensive home health nursing and physician follow-up within a week-versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care.

DATA SOURCES

National Medicare administrative, claims, and patient assessment data.

STUDY DESIGN

Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week.

DATA EXTRACTION METHODS

All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files.

PRINCIPAL FINDINGS

Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = -12.3, -4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up.

CONCLUSIONS

Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.

Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization

BACKGROUND

Readmission within 30 days after hospitalization for heart failure (HF) is a major public health problem.

OBJECTIVE

To examine whether timing and type of post-discharge follow-up impacts risk of 30-day readmission in adults hospitalized for HF.

DESIGN

Nested matched case-control study (January 1, 2006-June 30, 2013).

SETTING

A large, integrated health care delivery system in Northern California.

PARTICIPANTS

Hospitalized adults with a primary diagnosis of HF discharged to home without hospice care.

MEASUREMENTS

Outpatient visits and telephone calls with cardiology and general medicine providers in non-emergency department and non-urgent care settings were counted as follow-up care. Statistical adjustments were made for differences in patient sociodemographic and clinical characteristics, acute severity of illness, hospitalization characteristics, and post-discharge medication changes and laboratory testing.

RESULTS

Among 11,985 eligible adults, early initial outpatient contact within 7 days after discharge was associated with lower odds of readmission [adjusted odds ratio (OR)=0.81; 95% CI, 0.70-0.94], whereas later outpatient contact between 8 and 30 days after hospital discharge was not significantly associated with readmission (adjusted OR=0.99; 95% CI, 0.82-1.19). Initial contact by telephone was associated with lower adjusted odds of 30-day readmission (adjusted OR=0.85; 95% CI, 0.69-1.06) but was not statistically significant.

CONCLUSIONS

In adults discharged to home after hospitalization for HF, outpatient follow-up with a cardiology or general medicine provider within 7 days was associated with a lower chance of 30-day readmission.

Testing Videotape Education for Heart Failure

This pilot study tested a videotape intervention designed to improve patient selfmanagement of heart failure (HF). Content of the video series (produced professionally under a federal grant) is based on national, scientifically validated guidelines for HF home management. Outcomes tested were HF knowledge, symptom reporting, and functional status. Participants were 10 newly diagnosed HF patients (mean age 67). After viewing the tapes, data indicated participants had a clinically relevant improvement in HF knowledge, and improved or maintained HF health status. None were rehospitalized during the 60-day follow-up period. One patient contacted his/her physician to report weight gain, as prompted by the videotapes. The cost data indicated that patients paid $177 out of pocket monthly for medications and all were low income. These results indicate the need for further testing of the videotape as a potentially cost-effective method of teaching aboutHFself-management and daily home self-monitoring.

What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? An Individual Patient Data Meta-analysis

BACKGROUND

To identify those characteristics of self-management interventions in patients with heart failure (HF) that are effective in influencing health-related quality of life, mortality, and hospitalizations.

METHODS AND RESULTS

Randomized trials on self-management interventions conducted between January 1985 and June 2013 were identified and individual patient data were requested for meta-analysis. Generalized mixed effects models and Cox proportional hazard models including frailty terms were used to assess the relation between characteristics of interventions and health-related outcomes. Twenty randomized trials (5624 patients) were included. Longer intervention duration reduced mortality risk (hazard ratio 0.99, 95% confidence interval [CI] 0.97-0.999 per month increase in duration), risk of HF-related hospitalization (hazard ratio 0.98, 95% CI 0.96-0.99), and HF-related hospitalization at 6 months (risk ratio 0.96, 95% CI 0.92-0.995). Although results were not consistent across outcomes, interventions comprising standardized training of interventionists, peer contact, log keeping, or goal-setting skills appeared less effective than interventions without these characteristics.

CONCLUSION

No specific program characteristics were consistently associated with better effects of self-management interventions, but longer duration seemed to improve the effect of self-management interventions on several outcomes. Future research using factorial trial designs and process evaluations is needed to understand the working mechanism of specific program characteristics of self-management interventions in HF patients.

Home-Based Disease Management in Congestive Heart Failure

Disease management programs have emerged as a comprehensive strategy to decrease costs and increase quality of care for patients with chronic diseases. It is a long-term strategy that emphasizes patient involvement in his or her own care and early recognition of potential worsening of the condition. Disease management programs address more than just the educational needs of patients by intervening before the problems get out of control. Because of their role in patients’ homes and lives, home care nurses are ideal agents of disease management. This discussion presents a comparison of disease management in home care and proposes a way for the best of both entities to be combined in the setting of congestive heart failure (CHF). The program developed at the Visiting Nurse Association of Maryland is presented as an example of how the two can be blended to address the complex problems of patients with CHF.

Cardiac nursing: Achieving Competent Practitioners

This paper describes how competency statements were integrated into an academic framework to provide a transparent yet flexible career pathway for the nurse working in acute cardiac care. Nurses are expanding and developing their roles and use wide ranging skills and knowledge to care for patients. Additionally, models of care delivery are changing and patients are cared for in a variety of settings. Where evidence exists, these models demonstrate improvement in the provision and quality of services and contribute to improved quality of life, maximise medication and therapy and reduce waiting times for investigations. However, whilst many studies have demonstrated benefit, translating these results into routine practice requires skilled nurses who are “fit for purpose”, and to support this, professional competencies can be used to measure competence in practice whilst informing educational initiatives. This paper outlines the development of competency statements that identify the knowledge and skills required for safe, effective and competent care and direct the cardiac nurse acquire skills and knowledge in a focused and coherent way.

Effect of Home-Based Intervention on Hospital Readmission and Quality of Life in Middle-Aged Patients with Severe Congestive Heart Failure: A 12-Month Follow Up Study

Objective: Home care surveillance has been shown to reduce hospital readmission and improve functional status and quality of life of elderly patients with mild to moderate or severe congestive heart failure and in younger patients candidates for transplantation. The present study aimed to investigate the effect of home-based intervention on hospital readmission and quality of life of middle-aged patients with severe congestive heart failure. Methods: Thirty-three patients aged 50–75 (mean age 65.4±6.7) with class III and IV congestive heart failure were included in this observational, community-based study. Intervention consisted of intensive home surveillance of patients, including frequent home visits associated with laboratory tests and telephone contacts to implement standard therapy, treat early symptoms and provide psychological support. Results: Admissions for cardiovascular reasons decreased from 2.143±1.11 for the year before the initiation of the study to 1.25±1 after its completion ( P=0.0005). Quality of life improved, as showed by a decrease of the mean score of the Minnesota Living with Heart Failure Questionnaire from 2.68±0.034 to 2.33±0.032 ( P=0.0001). Conclusion: Intensive home care of middle-aged patients with severe heart failure results in improved quality of life and a decrease in hospital readmission rates.

Living with Heart Failure; Patient and Carer Perspectives

Patients with heart failure have multiple readmissions to hospital, a poor prognosis and varying quality of life. This paper explores how patients with heart failure and their family carers cope with daily life. 36 patients and 20 family caregivers were interviewed in five centres in the UK. Analysis showed that living with heart failure can be frightening, restrictive and distressing for both patients and their family carers. Patients found most difficulty coping with functional limitation and adapting to living with heart failure, but also reported particular problems due to side effects of medications, co-morbidities and a lack of psychosocial support and rehabilitation services. Those with less socio-economic resources found it harder to cope. Patients from minority ethnic groups held different beliefs about the illness and its treatment, and some had profound problems communicating with health and social care professionals that made managing the disease even more difficult. Caring for a person with heart failure often has a considerable impact on the psychological and physical health of family caregivers. Psychosocial support and rehabilitation services provided at diagnosis and after an acute episode would enable families to better manage living with this syndrome.

Practical Application of Educational Rhetoric: A Pathway to Expert Cardiac Nurse Practice?

Cardiac nursing takes place within various spheres of health care, reaching into primary, secondary and tertiary care within theses, cardiac expertise falls within four domains: health promotion, cardiac prevention and rehabilitation, acute, chronic and episodic care and palliative care. This paper sets out the possibility for a staged development of the cardiac nurse, which could promote homogeneity in role, skill and practice. A framework ('Expert Cardiac Nurse Pathway') for the United Kingdom, is proposed here, and views on its usefulness throughout Europe are sought.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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