An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it?

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews

BACKGROUND

As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings.

METHODS

Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions.

RESULTS

A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent.

CONCLUSIONS

Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.

Economic evaluation of a dedicated cardiac resynchronisation therapy preassessment clinic

Introduction

Patient evaluation before cardiac resynchronisation therapy (CRT) remains heterogeneous across centres and it is suspected a proportion of patients with unfavourable characteristics proceed to implantation. We developed a unique CRT preassessment clinic (CRT PAC) to act as a final review for patients already considered for CRT. We hypothesised that this clinic would identify some patients unsuitable for CRT through updated investigations and review. The purpose of this analysis was to determine whether the CRT PAC led to savings for the National Health Service (NHS).

Methods

A decision tree model was made to evaluate two clinical pathways; (1) standard of care where all patients initially seen in an outpatient cardiology clinic proceeded directly to CRT and (2) management of patients in CRT PAC.

Results

244 patients were reviewed in the CRT PAC; 184 patients were eligible to proceed directly for implantation and 48 patients did not meet consensus guidelines for CRT so were not implanted. Following CRT, 82.4% of patients had improvement in their clinical composite score and 57.7% had reduction in left ventricular end-systolic volume ≥15%. Using the decision tree model, by reviewing patients in the CRT PAC, the total savings for the NHS was £966 880. Taking into consideration the additional cost of the clinic and by applying this model structure throughout the NHS, the potential savings could be as much as £39 million.

Conclusions

CRT PAC appropriately selects patients and leads to substantial savings for the NHS. Adopting this clinic across the NHS has the potential to save £39 million.

[Position paper telemonitoring : From the Nucleus Members of the AG33 Telemonitoring of the DGK and associated members]

The position paper of the working group 33/Telemonitoring in the German Society for Cardiology e. V. (DGK) discusses the importance of digital solutions in the German health care system and highlights the application possibilities and potentials of telemonitoring in the treatment of patients with cardiac diseases. In addition to telemonitoring of acute ischaemic diseases, acute coronary syndrome and acute cardiac arrhythmias, telemonitoring of chronic cardiac diseases is discussed. Chronic diseases, such as chronic heart failure, are age-associated and present society with the great challenge of providing high-quality, yet cost-efficient care to an increasing number of patients in the future. Telemonitoring offers an opportunity to meet this challenge. However, the introduction of telemonitoring and the associated changes for patients, doctors and other service providers must be accompanied by measures to ensure the acceptance of telemonitoring and the secure handling of sensitive data as well as the quality of telemonitoring services.

The costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs: A systematic review of international evidence

BACKGROUND

Patients with palliative care needs do not access specialist palliative care services according to their needs. Clinical Nurse Specialists working across a variety of fields are playing an increasingly important role in the care of such patients, but there is limited knowledge of the extent to which their interventions are cost-effective.

OBJECTIVES

To present results from a systematic review of the international evidence on the costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs, defined as seriously ill patients and those with advanced disease or frailty who are unlikely to be cured, recover or stabilize.

DESIGN

Systematic review following PRISMA methodology.

DATA SOURCES

Medline, Embase, CINAHL and Cochrane Library up to 2015. Studies focusing on the outcomes of Clinical Nurse Specialist interventions for patients with palliative care needs, and including at least one economic outcome, were considered. The quality of studies was assessed using tools from the Joanna Briggs Institute.

RESULTS

A total of 79 papers were included: 37 randomized controlled trials, 22 quasi-experimental studies, 7 service evaluations and other studies, and 13 economic analyses. The studies included a wide variety of interventions including clinical, support and education, as well as care coordination activities. The quality of the studies varied greatly.

CONCLUSION

Clinical Nurse Specialist interventions may be effective in reducing specific resource use such as hospitalizations/re-hospitalizations/admissions, length of stay and health care costs. There is mixed evidence regarding their cost-effectiveness. Future studies should ensure that Clinical Nurse Specialists' roles and activities are clearly described and evaluated.

Measuring the effect of nurse practitioner (NP)-led care on health-related quality of life in adult patients with atrial fibrillation: study protocol for a randomized controlled trial

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity, mortality, and healthcare resource use. The prevalence of AF is increasing with a growing and aging population, and timely access to care for these patients is a concern. Nontraditional models of care delivery, such as nurse practitioner (NP)-led clinics, may improve access to care and quality of care, but they require formal assessment. The objective of this study is to assess the effect of NP-led care on the health-related quality of life (HRQoL) of adult patients with AF.

METHODS/DESIGN

We plan a randomized controlled trial comparing NP-led care vs. standard care. Inclusion criteria are ≥18 years of age, documented nonvalvular AF, willingness to give informed consent, and capacity to complete questionnaires. Patients referred for electrophysiological intervention who are clinically unstable or unable to attend follow-up visits will not be eligible to participate. Patients will be asked for verbal consent during the initial triage phone call from the nurse. Randomization will occur via a secure website. The intervention includes an NP consult, including medical history, physical examination, patient teaching, treatment plan, and follow-up at 3 and 6 months. The control arm involves usual cardiologist consultation with follow-up determined by the cardiologist's practice pattern. The primary outcome will be the difference in change in Atrial Fibrillation Effect on Quality of Life Survey scores at 6 months between groups. Secondary outcomes will include difference in change of EQ-5D scores at 6 months between groups, difference in composite outcomes of death resulting from cardiovascular cause, hospitalizations and emergency department visits between groups, and satisfaction with NP-led care measured by the Consultant Satisfaction Questionnaire. A sample size of 70 per group will ensure adequate power despite a potential 10% loss to follow-up.

DISCUSSION

Our study will determine the effect of NP-led AF care on HRQoL in patients with AF, as well as measure its impact on relevant outcomes such as death, hospitalization, and emergency department visits. Our findings may have implications for delivery of care to patients with AF.

TRIAL REGISTRATION

ClincalTrials.gov, NCT02745236 . Registered on 16 April 2016.

Telephone Follow-Up of Self-Care Behaviour after a Single Session Education of Patients with Heart Failure in Primary Health Care

BACKGROUND

Improved self-care behaviour is a goal in educational programmes for patients with heart failure, especially in regard to daily self-weighing and salt and fluid restriction.

AIMS

The objectives of the present study were to: (1) describe self-care with special regard to daily self-weighing and salt and fluid restriction in patients with heart failure in primary health care, during one year of monthly telephone follow-up after a single session education, (2) to describe gender differences in regard to self-care and (3) to investigate if self-care was associated with health-related quality of life.

METHODS

The present analysis is a subgroup analysis of a larger randomised trial. After one intensive educational session, a primary health care nurse evaluated 60 patients (mean age 79 years, 52% males, 60% in New York Heart Association class III-IV) by monthly telephone follow-up during 12 months.

RESULTS

The intervention had no effect on quality of life measured by EuroQol 5D and no significant associations were found between quality of life and self-care behaviour. Self-care behaviour measured by The European Self-care Behaviour Scale remained unchanged throughout the study period. No significant gender differences were shown but women had a tendency to improve adherence to daily weight control between 3- and 12 months.

CONCLUSION

The self-care behaviour and quality of life in patients with heart failure did not change during one year of monthly telephone follow-up after a single session education and this indicates a need for more extensive interventions to obtain improved self-care behaviour in these patients.

Cost-effectiveness of eplerenone in patients with systolic heart failure and mild symptoms

Aim

In the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF), aldosterone blockade with eplerenone decreased mortality and hospitalisation in patients with mild symptoms (New York Heart Association class II) and chronic systolic heart failure (HF). The present study evaluated the cost-effectiveness of eplerenone in the treatment of these patients in the UK and Spain.

Methods and results

Results from the EMPHASIS-HF trial were used to develop a discrete-event simulation model estimating lifetime direct costs and effects (life years and quality-adjusted life years (QALYs) gained) of the addition of eplerenone to standard care among patients with chronic systolic HF and mild symptoms. Eplerenone plus standard care compared with standard care alone increased lifetime direct costs per patient by £4284 for the UK and €7358 for Spain, with additional quality-adjusted life expectancy of 1.22 QALYs for the UK and 1.33 QALYs for Spain. Mean lifetime costs were £3520 per QALY in the UK and €5532 per QALY in Spain. Probabilistic sensitivity analysis suggested a 100% likelihood of eplerenone being regarded as cost-effective at a willingness-to-pay threshold of £20 000 per QALY (UK) or €30 000 per QALY (Spain).

Conclusions

By currently accepted standards of value for money, the addition of eplerenone to optimal medical therapy for patients with chronic systolic HF and mild symptoms is likely to be cost-effective.

Reducing heart failure admission rates in England 2004-2011 are not related to changes in primary care quality: national observational study

AIMS

Heart failure (HF) is an important clinical problem. Expert consensus has defined HF as a primary care-sensitive condition for which the risk of unplanned admissions may be reduced by high quality primary care, but there is little supporting evidence. We analysed time trends in HF admission rates in England and risk and protective factors for admission.

METHODS AND RESULTS

We used Hospital Episodes Statistics to produce indirectly standardized HF admission counts by general practice for 2004-2011. Clustered negative binomial regression analysis produced admission risk ratios and assessed the significance of potential explanatory covariates. These included population factors (deprivation; HF, coronary heart disease, and smoking prevalence), primary care resourcing [access; general practitioner (GP) supply], and primary care quality ('Quality and Outcomes Framework' indicator.) There were 327,756 HF admissions of patients registered with 8405 practices over the study period. There was a significant reduction in admissions over time, from 6.96/100,000 in 2004 to 5.60/100,000 in 2010 (P < 0.001). Deprivation and HF prevalence were risk factors for admission. GP supply and access protected against admission. However, these effects were small and did not explain the large and highly significant annual trend in falling admission rates.

CONCLUSIONS

The observed fall in admissions over time cannot be explained by the primary care covariates we included. This analysis suggests that the potential for further significant reduction in emergency HF admissions by improving clinical quality of primary care (as currently measured) may be limited. Further work is required to identify the reasons for the reduction in admissions.

Cost-effectiveness of a health-social partnership transitional program for post-discharge medical patients

BACKGROUND

Readmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap.

METHODS

Cost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1.

RESULTS

The readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.

CONCLUSIONS

Previous studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.

Heart failure services in the United Kingdom: rethinking the machine bureaucracy

Poor outcomes and poor uptake of evidence based therapies persist for patients with heart failure in the United Kingdom. We offer a strategic analysis of services, defining the context, organization and objectives of the service, before focusing on implementation and performance. Critical flaws in past service development and performance are apparent, a consequence of failed performance management, policy and political initiative. The barriers to change and potential solutions are common to many health care systems. Integration, information, financing, incentives, innovation and values: all must be challenged and improved if heart failure services are to succeed. Modern healthcare requires open adaptive systems, continually learning and improving. The system also needs controls. Performance indicators should be simple, clinically relevant, and outcome focused. Heart failure presents one of the greatest opportunities to improve symptoms and survival with existing technology. To do so, heart failure services require radical reorganization.

A trial-based economic evaluation of 2 nurse-led disease management programs in heart failure

BACKGROUND

Although previously conducted meta-analyses suggest that nurse-led disease management programs in heart failure (HF) can improve patient outcomes, uncertainty regarding the cost-effectiveness of such programs remains.

METHODS

To compare the relative merits of 2 variants of a nurse-led disease management program (basic or intensive support by a nurse specialized in the management of patients with HF) against care as usual (routine follow-up by a cardiologist), a trial-based economic evaluation was conducted alongside the COACH study.

RESULTS

In terms of costs per life-year, basic support was found to dominate care as usual, whereas the incremental cost-effectiveness ratio between intensive support and basic support was found to be equal to €532,762 per life-year; in terms of costs per quality-adjusted life-year (QALY), basic support was found to dominate both care as usual and intensive support. An assessment of the uncertainty surrounding these findings showed that, at a threshold value of €20,000 per life-year/€20,000 per QALY, basic support was found to have a probability of 69/62% of being optimal against 17/30% and 14/8% for care as usual and intensive support, respectively. The results of our subgroup analysis suggest that a stratified approach based on offering basic support to patients with mild to moderate HF and intensive support to patients with severe HF would be optimal if the willingness-to-pay threshold exceeds €45,345 per life-year/€59,289 per QALY.

CONCLUSIONS

Although the differences in costs and effects among the 3 study groups were not statistically significant, from a decision-making perspective, basic support still had a relatively large probability of generating the highest health outcomes at the lowest costs. Our results also substantiated that a stratified approach based on offering basic support to patients with mild to moderate HF and intensive support to patients with severe HF could further improve health outcomes at slightly higher costs.

Cost analysis and cost-effectiveness of NT-proBNP-guided heart failure specialist care in addition to home-based nurse care

BACKGROUND

Heart failure management programmes have been shown to reduce re-hospitalizations. We recently investigated a new disease management programme comparing usual care (UC) to home-based nurse care (HNC) and a HNC group in which decision-making was based on NT-proBNP levels (BNC). As re-hospitalization is the main contributing economic factor in heart failure expenditures, we hypothesized that this programme might be able to reduce costs and could be conducted cost effectively compared to UC.

METHODS

One hundred and ninety congestive heart failure patients, who were included in a randomized trial to receive UC, HNC or BNC at discharge, were analysed in a cost-effectiveness model. Different models were applied to perform analysis of all medical costs, and the costs per year survived were chosen as an effectiveness parameter.

RESULTS

Per patient costs because of heart failure treatment in the UC and the BNC group were € 7109 ± 11,687 and € 2991 ± 4885 (P=0·027), respectively. Corrected for death as a competing risk, the costs in the UC group were € 7893 ± 11,734 and were reduced by BNC to €3148 ± 4949 (P=0·012). Considering costs because of all-cause re-hospitalizations, calculated costs per year survived after discharge were € 19,694 ± 26,754 for UC, € 14,262 ± 25 330 for HNC (P > 0·05) and € 8784 ± 14,728 for BNC (t-test-based contrast P=0·015). In all models calculated, HNC was cost neutral.

CONCLUSIONS

NT-BNP-guided heart failure specialist care in addition to home-based nurse care is cost effective and cheaper than standard care, whereas HNC is cost neutral.

European Society of Cardiology Heart Failure Association Standards for delivering heart failure care

The management of heart failure (HF) is complex. As a consequence, most cardiology society guidelines now state that HF care should be delivered in a multiprofessional manner. The evidence base for this approach now means that the establishment of HF management programmes is a priority. This document aims to summarize the key elements which should be involved in, as well as some more desirable features which can improve the delivery of care in a HF management programme, while bearing in mind that the specifics of the service may vary from site to site. We envisage a situation whereby all patients have access to the best possible care, including improved access to palliative care services, informed by and responsive to advances in diagnosis management and treatment. The goal should be to provide a 'seamless' system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.

Exploring the potential to remain "Young @ Heart": initial findings of a multi-centre, randomised study of nurse-led, home-based intervention in a hybrid health care system

BACKGROUND

Disease management programs have been shown to improve health outcomes in high risk individuals in many but not all health care systems.

METHODS

Young @ Heart is a multi-centre, randomised controlled study of a nurse-led, home-based intervention (HBI) program vs. usual care (UC) in privately insured patients in Australia aged ≥ 45 years following an acute cardiac admission. Intensity of HBI is tailored to an individual's clinical stability, management and risk profile. The primary endpoint is the rate of all-cause stay during a mean of 2.5 years follow-up.

RESULTS

A target of 602 adults (72% men) were randomised to HBI (n=306) or UC (n=296); their initial profiles being well matched. At baseline, 71% were overweight (body mass index 29.7 ± 3.9 kg/m(2)) and 66% had an elevated blood pressure (153 ± 18/89 ± 7 mm Hg). Over half had a history of smoking and 39% had a sub-optimal total cholesterol level >4 mmol/L. Overall, 62% (376 cases) were treated for coronary artery disease (27% with multi-vessel disease and 39% underwent cardiac revascularisation). A further 20% (120 cases) were treated for a cardiac arrhythmia (predominantly atrial fibrillation) and 19% type 2 diabetes mellitus. At 7-14 days post-discharge, 293 (96%) HBI patients received a home visit triggering urgent clinical review and/or enhanced clinical management in many patients.

CONCLUSIONS

The Young @ Heart intervention is a well accepted and potentially effective intervention to reduce recurrent hospital stay in privately insured cardiac patients in Australia.

Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up

OBJECTIVES

The purpose of this study was to assess the rate of death and hospitalization for heart failure (HF) 1 and 3 years after a randomized trial of telephone intervention aimed to improve education and compliance in stable patients with HF ended.

BACKGROUND

The long-term effects of HF programs are not well known.

METHODS

In all, 1,518 patients with HF were randomized into the DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure). After completion of the trial, patients were followed up to 3 years to assess major outcomes. Compliance with diet, weight control, and treatment was evaluated. The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk (RR), relative risk reduction, and Cox proportional hazards model for adjusting by potential confounders.

RESULTS

The rate of death or hospitalization for HF was lower in the intervention group (37.2% vs. 42.6%, RR: 0.81, 95% confidence interval [CI]: 0.69 to 0.96; p = 0.013) 1 and 3 years (55.7% vs. 57.5%, RR: 0.88, 95% CI: 0.77 to 1.00; p = 0.05) after the intervention ended. This benefit was mainly caused by a reduction in admission for HF (28.5% vs. 35.1% after 3 years, RR: 0.72, 95% CI: 0.60 to 0.87; p = 0.0004). Patients who showed improvement in 1 or more of 3 key compliance indicators (diet, weight control, and medication) had lower risks of events.

CONCLUSIONS

The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended. This effect may be explained by the impact of the educational intervention on patients' behavior and habits.

Heart failure disease management programs: a cost-effectiveness analysis

BACKGROUND

Heart failure (HF) disease management programs have shown impressive reductions in hospitalizations and mortality, but in studies limited to short time frames and high-risk patient populations. Current guidelines thus only recommend disease management targeted to high-risk patients with HF.

METHODS

This study applied a new technique to infer the degree to which clinical trials have targeted patients by risk based on observed rates of hospitalization and death. A Markov model was used to assess the incremental life expectancy and cost of providing disease management for high-risk to low-risk patients. Sensitivity analyses of various long-term scenarios and of reduced effectiveness in low-risk patients were also considered.

RESULTS

The incremental cost-effectiveness ratio of extending coverage to all patients was $9700 per life-year gained in the base case. In aggregate, universal coverage almost quadrupled life-years saved as compared to coverage of only the highest quintile of risk. A worst case analysis with simultaneous conservative assumptions yielded an incremental cost-effectiveness ratio of $110,000 per life-year gained. In a probabilistic sensitivity analysis, 99.74% of possible incremental cost-effectiveness ratios were <$50,000 per life-year gained.

CONCLUSIONS

Heart failure disease management programs are likely cost-effective in the long-term along the whole spectrum of patient risk. Health gains could be extended by enrolling a broader group of patients with HF in disease management.

Impact of heart failure on hospital activity and healthcare costs in Belgium

Heart failure (HF) is a serious public health problem worldwide. It has a high prevalence, affects mainly the elderly and causes high mortality or disability with high economic costs. The aim of the present study was to calculate the number of admissions for HF, the total in-hospital stay, the mean length of in-hospital stay and the in-hospital costs due to HF in Belgium. Retrospective analysis of data from the national hospital registration system provided the following results. In 2001, there were 19,398 admissions with HF as a primary diagnosis, with a total in-hospital stay of 286,938 days. The mean in-hospital stay for HF was 14.8 days. The total in-hospital cost of HF as a primary diagnosis was euro 94,113,827, representing 1.8% of the total hospital expenditure. The limitations of this study are its mere focus on admissions and their characteristics in 2001, and the use of a retrospective analysis. Nevertheless, it led to the conclusion that HF was responsible for a significant number of in-hospital days, with a significant impact on healthcare costs in Belgium.

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

BACKGROUND

The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.

METHOD

In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.

RESULTS

Application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.

CONCLUSION

The model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare settings.

Improved cost-effectiveness for management of chronic heart failure by combined home-based intervention with clinical nursing specialists

BACKGROUND/PURPOSE

The influence of home- and clinic-based caring system on the economic burden of heart failure remains unknown.

METHODS

Between January 2004 and December 2004, chronic heart failure patients who were followed up by specialist nurse-led telephone visiting regularly were enrolled. Clinical and economic data half a year before enrollment were collected as control.

RESULTS

A total of 247 patients (168 males, 79 females; mean age, 60 +/- 17 years) were enrolled. The mean follow-up period was 139 +/- 96 days. The mean left ventricular ejection fraction was 35%. There were 1618 times of specialist nurse-led telephone visiting (average 8 +/- 6 times/patient). The mortality rate was 5.7%. Before enrollment, the total hospitalization fees were 624,020 US dollars. After enrollment, the cost was reduced to 362,722 US dollars (41.8% reduction). The mean functional class (New York Heart Association) also improved from 2.27 +/- 0.80 to 1.9 6 +/- 0.90 (p < 0.001). The mean duration of hospital stay due to heart failure was reduced by 5.3 days (26.2% decrement). The total numbers of admission were reduced to 36 times (33.0% decrement). The readmission rate due to etiologies other than heart failure (such as infection, gastrointestinal bleeding, etc.) was reduced from 15.9% to 7.7%. The total fees of visiting emergency station were reduced from 6528 US dollars to 6101 US dollars (6.5% decrement). On the other hand, the frequency of visiting the outpatient department (OPD) increased from 5.2 +/- 3.2 to 6.6 +/- 4.1 times/patient (p < 0.001). The total fees of visiting OPD increased from 90,783 US dollars to 94,855 US dollars(4.4% increment).

CONCLUSION

The home- and clinic-based caring system is capable of decreasing adverse outcomes, most notably hospitalization and length of stay, and could trigger significant cost savings in the management of heart failure.

Heart failure management programmes in Europe

BACKGROUND

The ESC guidelines recommend that an organised system of specialist heart failure (HF) care should be established to improve outcomes of HF patients. The aim of this study was therefore to identify the number and the content of HF management programmes in Europe.

METHOD

A two-phase descriptive study was conducted: an initial screening to identify the existence of HF management programmes; and a survey to describe the content in countries where at least 30% of the hospitals had a programme.

RESULTS

Of the 43 European countries approached, 26 (60%) estimated the percentage of HF management programmes. Seven countries reported that they had such programmes in more than 30% of their hospitals. Of the 673 hospitals responding to the questionnaire, 426 (63%) had a HF management programme. Half of the programmes (n = 205) were located in an outpatient clinic. In the UK a combination of hospital and home-based programmes was common (75%). The most programmes included physical examination, telephone consultation, patient education, drug titration and diagnostic testing. Most (89%) programmes involved nurses and physicians. Multi-disciplinary teams were active in 56% of the HF programmes. The most prominent differences between the 7 countries were the degree of collaboration with home care and GP's, the role in palliative care and the funding.

CONCLUSION

Only a few European countries have a large number of organised programmes for HF care and follow up. To improve outcomes of HF patients throughout Europe more effort should be taken to increase the number of these programmes in all countries.

ET-1 Lys198Asn and ETA Receptor H323H Polymorphisms in Heart Failure

BACKGROUND

The endothelin (ET) system plays a central role in the control of myocardial function and its pathophysiology. The aim of the present study was to explore whether genetic variations of ET-1 (G/T substitution that predicts an Lys/Asn change at codon 198) and its receptor ET(A) (T/C in exon 6, H323H) could predispose carriers to heart failure (HF).

METHODS

Genotyping at these two loci was done in 122 patients with HF [echocardiographic left ventricular ejection fraction (LVEF) < or =40%] and 216 age-matched subjects without HF. Causes of HF included ischemic (n = 96) and idiopathic cardiomyopathies (n = 26).

RESULTS

The ET-1 Lys198Asn was significantly associated with the occurrence of HF (p = 0.005). The risk of HF was independently increased among Asn/Asn in comparison to Lys carriers (OR = 3.2, p = 0.03). Moreover, homozygous carriers of both ET-1 and ET(A) variants showed a marked increase in the risk of HF (adjusted OR = 8.6, p = 0.005), displayed significantly lower LVEF (p = 0.002) and higher left ventricular end-diastolic (p = 0.03) and end-systolic diameters (p = 0.04; for Asn/Asn and TT vs. Lys and C carriers of the ET-1 and ET(A )polymorphisms, respectively). Furthermore, the extent of coronary artery disease (r = -0.62, p < 0.0001) and the Asn/Asn and TT double genotype (r = -0.30, p = 0.0001) were the only significant and independent predictors of LVEF by multivariate analysis.

CONCLUSIONS

The ET-1 Lys198Asn and ET(A) receptor H323H polymorphisms seem to act synergistically to increase the risk of HF.

Management of chronic heart failure: perceived needs of general practitioners in light of the new general medical services contract

BACKGROUND

Despite the existence of several chronic heart failure (CHF) guidelines the treatment of patients with CHF is suboptimal. The new general medical services (GMS) contract in primary care has only three specific performance indicators for patients with left ventricular dysfunction. The aim of this current questionnaire survey was to assess the views of general practitioners (GPs) on CHF treatments and services in light of the new GMS contract.

METHODS AND RESULTS

All local GPs (717) were sent a questionnaire. Fifty three per cent were returned. Forty five per cent of GPs had access to a community CHF nurse. Having read a national guideline (SIGN) and having the support of a CHF nurse did not seem to affect the knowledge of GPs in terms of perceived benefits of drug treatments. GPs with access to a specialist CHF nurse service attached more importance to it than those with no specialist nurse (p = 0.003).

CONCLUSIONS

Most GPs were aware of the existence of a national guideline but many had not read it. There was little or no difference in the knowledge level for various evidence based treatments between GPs who had or had not read the guideline suggesting that reading guidelines may not be a key factor in determining knowledge. Support for a specialist CHF nurse was higher among GPs who already had this service, suggesting that this service is valued. The new GMS contract may improve identification and diagnosis of patients with CHF but there is a danger that it may fall short of ensuring optimal treatment for patients with CHF.

[The Herz Handy--a new telemedical service concept for heart patients]

Telemedicine is a new milestone for the health care system in the care of patients with heart disease. New technologies and the possibilities of fast data transmission have enabled this step forward. The Cardiophone offers a new telemonitoring Service Concept, which is available 24 hours a day. The patient is by the aid of the Cardiophone connected with the Medical Service Center at just the press of a button, can record and transmit an ECG and can be localized by the incorporated GPS. We report about our experiences with 363 patients over 3 years. Out of 5064 patient contacts associated with 7561 calls, 559 emergency contacts occurred. From the initial main complaints, working diagnoses were established. The final confirmed diagnoses were arrhythmias (27.8%), coronary heart disease (25.9%), psychovegetative syndrome (12.7%), backbone pain (6.2%), gastrointestinal syndrome (3.6%), others (1.8%), and exclusion diagnosis (19.9%). Ten myocardial infarctions were diagnosed, of whom 3 were confirmed; the other 7 were treated as stabile angina pectoris. Overall 823 ECG were transmitted, in average 1.6 ECGs per emergency contact. In 131 ECGs changes of the ST-segment or T-wave could be documented; 26 patients showed a pacemaker ECG. Atrial and ventricular arrhythmias as well as conduction disturbances were seen. The majority of emergency contacts (n=477, 85.3%) were successfully managed by the Service Center. In 38 emergency contacts (6.8%) admission to hospital was recommended; in 4 cases (0.7%) an ambulance was activated via the local dispatcher by the Service Center and in 29 cases (5.2%) the emergency ambulance.

[Monitoring multiple cardiovascular paramaters using telemedicine in patients with chronic heart failure]

Progression of chronic heart failure depends on various additional pathophysiologic factors like blood pressure, arrhythmias, congestion. Early detection of any alteration using telemonitoring of multiple vital parameters may avoid severe decompensation requiring hospital admission. The feasibility and the clinical outcome using a new telemonitoring device for recording multiple vital parameters and allowing communication on individual state of health is investigated. Twenty-four patients with chronic heart failure (mean age 65 years, mean LV ejection fraction 35%) requiring at least one hospital admission during the past year were investigated. Twice a day, the vital-parameters were measured (weight, blood pressure, heart rate and rhythm, oxygen saturation, respiration rate) and patients information on well being, shortness of breath, medication, and request for contact were received. Intra-individual comparison was carried out between the 12 month before inclusion in this study and 12 month under telemonitoring surveillance (extrapolated, if necessary). Performing over 10 500 measurements during 5751 patient days, critical events were diagnosed for 55 events concerning relative weight gain (43 episodes), blood pressure (6), decrease in oxygen saturation (3), new onset of atrial fibrillation with tachyarrhymia (3). Of these, 45 events were controlled on an outpatient basis by changing medication or external cardioversion. Only 10 patients required re-admission. Thus, the number of admission to the hospital could be reduced by 62%, those of days spent in hospital by 69%. Non-invasive telemonitoring of multiple vital parameters combined with patients statements on their health condition and out-patient treatment on the basis of these findings is found to be an effective and reliable approach to avoid hospital readmission for patients with chronic heart failure.

[Telemonitoring in chronic heart failure patients. Which diagnostic finding prevents hospital readmission?]

Heart failure exhibits a significant clinical and health economic problem. The implementation of new therapeutic strategies favorably affecting the course of disease is still insufficient in day-to-day practice. Thus, the usage of telemedicine offers a central instrument for service and information, so that an optimized therapy can be achieved by consequent surveillance of the patient with chronic heart disease. Predefined vital parameters are automatically transmitted to the telemedicine center; if individually predefined limits are exceeded, therapeutic means are immediately initiated. For the patient, the center is attainable 24 h throughout the year in case he experiences cardio-pulmonary symptoms. This patient-oriented usage of technology should not replace the physician-patient relationship, but improves and supports the participation and self-management of patients. Furthermore, the results show that this technology can significantly reduce the amount of emergency physician services, hospital admissions and primary care physician visits, and displays for health economics purposes a clearly more cost-effective treatment strategy, while allowing for additional costs inherent to the system. The usage of telemonitoring in chronic heart failure patients may be a trendsetting form of care, which can be used to drastically optimize the information and data flow between patient, hospital and primary care physician individually and at any time.

Randomised trial of telephone intervention in chronic heart failure: DIAL trial

OBJECTIVE

To determine whether a centralised telephone intervention reduces the incidence of death or admission for worsening heart failure in outpatients with chronic heart failure.

DESIGN

Multicentre randomised controlled trial.

SETTING

51 centres in Argentina (public and private hospitals and ambulatory settings).

PARTICIPANTS

1518 outpatients with stable chronic heart failure and optimal drug treatment randomised, stratified by attending cardiologist, to telephone intervention or usual care.

INTERVENTION

Education, counselling, and monitoring by nurses through frequent telephone follow-up in addition to usual care, delivered from a single centre.

MAIN OUTCOME MEASURE

All cause mortality or admission to hospital for worsening heart failure.

RESULTS

Complete follow-up was available in 99.5% of patients. The 758 patients in the usual care group were more likely to be admitted for worsening heart failure or to die (235 events, 31%) than the 760 patients who received the telephone intervention (200 events, 26.3%) (relative risk reduction = 20%, 95% confidence interval 3 to 34, P = 0.026). This benefit was mostly due to a significant reduction in admissions for heart failure (relative risk reduction = 29%, P = 0.005). Mortality was similar in both groups. At the end of the study the intervention group had a better quality of life than the usual care group (mean total score on Minnesota living with heart failure questionnaire 30.6 v 35, P = 0.001).

CONCLUSIONS

This simple, centralised heart failure programme was effective in reducing the primary end point through a significant reduction in admissions to hospital for heart failure.

Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis

OBJECTIVES

To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics.

DATA SOURCES AND STUDY SELECTION

We searched MEDLINE (1966-November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure.

DATA EXTRACTION

Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized.

DATA SYNTHESIS

Six trials were selected (N=949, mean age 73 years [range 62-79], men 58%, LVEF 34% [27-41], and average follow-up of 8.5 months [3-12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient -0.26 [-0.49,-0.02] vs. 0.09 [-1.17, 1.34].

CONCLUSIONS

HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.

Family caregiving and congestive heart failure. Review and analysis

BACKGROUND

There is increasing evidence that discharge planning and post-discharge support for CHF patients can contribute greatly to the medical management of heart failure (CHF) in the community and that the quality of the CHF patient's close personal relationships can influence outcome in CHF. However, there has been little research on the impact of CHF on the family or the role of the family in the management of the condition. In this paper, we provide a review and analysis of studies that have explicitly investigated these issues in the informal carers of CHF patients.

RESULTS OF THE REVIEW

Sixteen papers were identified that examined the role and/or impact of informal caregiving for CHF patients. Our main findings were: demands specific to CHF caregiving were identified, e.g., monitoring complex medical and self-care regimen, disturbed sleep and frequent hospitalisation of patients. Relatively high levels of emotional distress were identified in CHF caregivers. Few studies explicitly investigated the role of informal carers in the management of CHF. Studies were limited in number, scope and quality.

CONCLUSION

Caring for a family member with CHF can affect the well-being of those responsible for care, which may have consequences for the CHF patient's health. Further studies are needed to clarify these issues and to examine the role of informal caregivers in the management of CHF in the community.

Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure

BACKGROUND

Few studies have examined the potential benefits of specialist nurse-led programs of care involving home and clinic-based follow-up to optimise the post-discharge management of chronic heart failure (CHF).

OBJECTIVE

To determine the effectiveness of a hybrid program of clinic plus home-based intervention (C+HBI) in reducing recurrent hospitalisation in CHF patients.

METHODS

CHF patients with evidence of left ventricular systolic dysfunction admitted to two hospitals in Northern England were assigned to a C+HBI lasting 6 months post-discharge (n=58) or to usual, post-discharge care (UC: n=48) via a cluster randomization protocol. The co-primary endpoints were death or unplanned readmission (event-free survival) and rate of recurrent, all-cause readmission within 6 months of hospital discharge.

RESULTS

During study follow-up, more UC patients had an unplanned readmission for any cause (44% vs. 22%: P=0.019, OR 1.95 95% CI 1.10-3.48) whilst 7 (15%) versus 5 (9%) UC and C+HBI patients, respectively, died (P=NS). Overall, 15 (26%) C+HBI versus 21 (44%) UC patients experienced a primary endpoint. C+HBI was associated with a non-significant, 45% reduction in the risk of death or readmission when adjusting for potential confounders (RR 0.55, 95% CI 0.28-1.08: P=0.08). Overall, C+HBI patients accumulated significantly fewer unplanned readmissions (15 vs. 45: P<0.01) and days of recurrent hospital stay (108 vs. 459 days: P<0.01). C+HBI was also associated with greater uptake of beta-blocker therapy (56% vs. 18%: P<0.001) and adherence to Na restrictions (P<0.05) during 6-month follow-up.

CONCLUSION

This is the first randomised study to specifically examine the impact of a hybrid, C+HBI program of care on hospital utilisation in patients with CHF. Its beneficial effects on recurrent readmission and event-free survival are consistent with those applying either a home or clinic-based approach.

Financial aspects of heart failure programs of care

As suggested by studies that have examined the economic burden imposed by heart failure and, more specifically where the greatest expenditure occurs, the key to cost-effectively minimising the impact of a sustained heart failure epidemic is to minimise recurrent hospital use--even at the expense of increasing levels of community-based care and prescribed pharmacotherapy. This paper examines the potential cost-benefits of applying specialist heart failure programs of care and the range of financial issues that need to be considered when establishing a formal heart failure service.

The crucial role of patient education in heart failure

BACKGROUND

Deterioration of heart failure causes and complicates many hospital admissions in people aged over 65 years. Frequent readmissions cause an immense burden on the individual, the family and the health care system. Heart failure management programmes, in which patient education is an important component, have been shown to be effective in improving self-care and reducing readmissions.

AIM

This paper reviews the literature on the education of patients with heart failure. The paper addresses the level of knowledge in patients with heart failure, barriers to learning, learning needs, educational methods, goals and how the effects of patient education can be evaluated.

CONCLUSION

Many patients had low levels of knowledge and lacked a clear understanding of heart failure and self-care. Educational interventions need to be designed specifically for elderly patients and need to target barriers to learning such as functional and cognitive limitations, misconceptions, low motivation and self-esteem. Health care professionals need to be skilled in assessing the requirements and level of education given to the individual. New technologies such as computer-based education and telemonitoring can be used as tools to improve the education. Patient education is an important component of heart failure care and should be provided through effective and well-evaluated strategies.

Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials

OBJECTIVES

The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients.

BACKGROUND

Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients.

METHODS

Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts.

RESULTS

Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving.

CONCLUSIONS

Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.

A New Solution for an Old Problem? Effects of a Nurse-led, Multidisciplinary, Home-based Intervention on Readmission and Mortality in Patients With Chronic Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF), the most common chronic cardiac dysrhythmia, is an important cause of cardiovascular morbidity and mortality. However, there is a paucity of studies examining the potential benefits of optimizing the postdischarge management of patients with chronic AF.

RESEARCH OBJECTIVE

To examine the effects of a nurse-led, multidisciplinary, home-based intervention (HBI) on the pattern of recurrent hospitalization and mortality in patients with chronic AF in the presence and absence of chronic heart failure (HF). PATIENT COHORT AND METHODS: Health outcomes in a total of 152 hospitalized patients (53% male) with a mean age of 73 +/- 9 years and a diagnosis of chronic AF who were randomly allocated to either HBI (n = 68) or usual postdischarge care (UC: n = 84) were examined. Specifically, the pattern of unplanned hospitalization and all-cause mortality during 5-year follow-up were compared on the basis of the presence (n = 87) and absence (n = 65) of HF at baseline.

RESULTS

Patients with concurrent HF exposed to HBI (n = 37) had fewer readmissions (2.9 vs 3.4/patient), days of associated hospital stay (22.7 vs 30.5: P = NS) and fatal events (51 % vs 66%) relative to UC (n = 50): P = NS for all comparisons. In the absence of HF, morbidity and mortality rates were significantly lower but still substantial during 5-year follow-up. In these patients, HBI was associated with a trend towards prolonged event-free survival (adjusted RR = 0.70; P = .12) and fewer fatal events (29% vs 53%, adjusted RR = 0.49; P = .08). HBI patients (n = 31) also had fewer readmissions (2.1 vs 2.6/patient) and days of associated hospital stay (16.3 vs 20.3/patient), although this did not reach statistical significance. On the basis of these data, it was calculated that a randomized study of an AF-specific HBI would require 250 patients followed for a median of 3 years to detect a 25% variation in recurrent hospital stay relative to UC.

CONCLUSIONS

These unique data provide sufficient preliminary evidence to support the hypothesis that the benefits of HBI in relation to the management of HF may extend to "high risk" patients with chronic AF in whom morbidity and mortality rates are also unacceptably high. Further, appropriately powered studies are required to confirm these benefits.

Specialist nurse management programmes: economic benefits in the management of heart failure

Chronic heart failure (CHF) is a modern-day epidemic in most developed countries. As such, it is both common and costly. Contrary to the impression given by clinical trial data, CHF mainly affects older individuals with approximately equal numbers of men and women and concurrent disease profiles likely to complicate or even prohibit the application of proven treatments. It is within this context that there has been an increasing interest in specific CHF-management programmes designed to limit costly hospital use in typically older individuals at high risk for poor quality of life, recurrent readmissions and premature death. This paper examines the evidence to suggest that CHF programmes involving individualised multidisciplinary post-discharge healthcare, with a major focus on specialist nurse management to ensure that the patient receives optimal treatment, are clinically and economically effective in reducing the typical burden imposed by CHF. These programmes appear to be most effective in 'high-risk' patients who typically have recurrent readmissions in high-cost units. Overall, the literature suggests that these programmes are able to reduce recurrent hospital stay by 30-50% relative to usual care (even in the presence of gold-standard treatment) in the short to medium term with comparable cost benefits. Recent data from a management programme involving a cohort of typically older and fragile patients with CHF in Australia showed that at 3 years post index admission, hospital utilisation costs were reduced by one-third relative to usual care. The potential for enormous cost benefits (both in terms of absolute cost savings and in terms of facilitating a more efficient healthcare system) if a specialist nurse programme of care was applied in the form of a UK-wide heart failure service was also recently examined. Based on year 2000 activity levels, it was found that for each specialist heart failure nurse appointed in the UK (with a caseload of 200-250 patients per annum), nominal savings of pound 49 000 per annum could be generated in order to make the healthcare system more efficient.