Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial

Characteristics of symptoms and symptom change across different heart failure subtypes: a sex-stratified analysis

AIMS

To examine sex-stratified differences in the association of left ventricular ejection fraction-based heart failure (HF) subtypes and the characteristics and correlates of self-reported changes in HF symptoms.

METHODS AND RESULTS

We report a secondary data analysis from 528 hospitalized individuals diagnosed with HF characterised by a reduced, mildly reduced, or preserved ejection fraction [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] who completed 12-month follow-up within a multicentre disease management trial. There were 302 men (71.1 ± 11.9 years, 58% with HFrEF) and 226 women (77.1 ± 10.6 years, 49% with HFpEF). The characteristics of self-reported symptoms measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12-month were analysed. At baseline, shortness of breath and fatigue predominated; with key differences according to HF subtypes in bilateral ankle oedema (both sexes), walking problems (women) and depressive symptoms (men). At 12-month follow-up, most KCCQ scores had not significantly changed. However, 25% of individuals reported worse symptom. In women, those with HFpEF had worse symptoms than those with HFmrEF/HFrEF (P = 0.025). On an adjusted basis, women [odds ratios (OR): 1.78, 95% confidence interval (CI): 1.00-3.16 vs. men], those with coronary artery disease (OR: 2.01, 95% CI: 1.21-3.31) and baseline acute pulmonary oedema (OR: 1.67, 95% CI: 1.02-2.75) were most likely to report worsening symptoms. Among men, worsening symptoms correlated with a history of hypertension (OR: 2.16, 95% CI: 1.07-4.35) and a non-English-speaking background (OR: 2.30, 95% CI: 1.02-5.20).

CONCLUSION

We found significant heterogeneity (with potential clinical implications) in the symptomatic characteristics and subsequent symptom trajectory according to the sex and HF subtype of those hospitalized with the syndrome.

TRIAL REGISTRATION

ANZCTR12613000921785.

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

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

Improvement in left ventricular ejection fraction after pharmacological up-titration in new-onset heart failure with reduced ejection fraction

Objective

Recent studies have reported suboptimal up-titration of heart failure (HF) therapies in patients with heart failure and a reduced ejection fraction (HFrEF). Here, we report on the achieved doses after nurse-led up-titration, reasons for not achieving the target dose, subsequent changes in left ventricular ejection fraction (LVEF), and mortality.

Methods

From 2012 to 2018, 378 HFrEF patients with a recent (< 3 months) diagnosis of HF were referred to a specialised HF-nurse led clinic for protocolised up-titration of guideline-directed medical therapy (GDMT). The achieved doses of GDMT at 9 months were recorded, as well as reasons for not achieving the optimal dose in all patients. Echocardiography was performed at baseline and after up-titration in 278 patients.

Results

Of 345 HFrEF patients with a follow-up visit after 9 months, 69% reached ≥ 50% of the recommended dose of renin-angiotensin-system (RAS) inhibitors, 73% reached ≥ 50% of the recommended dose of beta-blockers and 77% reached ≥ 50% of the recommended dose of mineralocorticoid receptor antagonists. The main reasons for not reaching the target dose were hypotension (RAS inhibitors and beta-blockers), bradycardia (beta-blockers) and renal dysfunction (RAS inhibitors). During a median follow-up of 9 months, mean LVEF increased from 27.6% at baseline to 38.8% at follow-up. Each 5% increase in LVEF was associated with an adjusted hazard ratio of 0.84 (0.75–0.94, p = 0.002) for mortality and 0.85 (0.78–0.94, p = 0.001) for the combined endpoint of mortality and/or HF hospitalisation after a mean follow-up of 3.3 years.

Conclusions

This study shows that protocolised up-titration in a nurse-led HF clinic leads to high doses of GDMT and improvement of LVEF in patients with new-onset HFrEF.

Supplementary Information

The online version of this article (10.1007/s12471-021-01591-6) contains supplementary material, which is available to authorized users.

Prevalence and Cost of Managing Paediatric Cardiac Disease in Queensland

BACKGROUND

There is a paucity of contemporary information regarding the prevalence and related health care expenditure of the most common cardiac conditions in Australian children, including congenital heart disease (CHD).

METHODS

The 10 most common cardiac conditions managed by Queensland Paediatric Cardiac Service during 2014-2015 were identified from an electronic database: ventricular septal defect (VSD), pulmonary stenosis, aortic stenosis, tetralogy of Fallot, atrioventricular septal defect, transposition, Ebstein's anomaly, long QT syndrome, dilated cardiomyopathy, and rheumatic carditis. Demographic data, clinic attendance, investigational procedures, and therapeutic interventions were extracted from the electronic health records to derive indicative population estimates and direct health care expenditure relating to CHD.

RESULTS

A total of 2,519 patients diagnosed with the 10 target conditions were being actively managed, including 456 (18.1%) new-born and 787 prevalent cases (2.5/1,000 population) aged <5 years. A total of 12,180 (4.8/case) investigations were performed (6,169 echocardiographic and 279 cardiac catheterisation procedures) costing $2.25 million/annum. A further 5,326 clinic visits (2.1/case, 22% regional) were conducted at a cost of $550,000/annum. A combined total of 804 catheter-based interventions and surgical procedures were performed in 300 cases (11.9%) at a cost of $13.6 million/annum. VSD (38.6% of cases) was the single greatest contributor ($5.1 million/annum) to total combined direct health care costs of $13.6 million/annum for the 2,519 patients.

CONCLUSIONS

These pilot data indicate a significant patient population and health care burden imposed by CHD in Queensland. Future initiatives to better quantify this burden, from an individual to health system perspective, are urgently needed.

Cost-effectiveness of dapagliflozin in chronic heart failure: an analysis from the Australian healthcare perspective

Aim

To assess the cost-effectiveness of dapagliflozin in addition to standard care versus standard care alone in patients with chronic heart failure and reduced ejection fraction.

Methods

A Markov model was constructed based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial to assess the clinical outcomes and costs of 1000 hypothetical subjects with established heart failure and reduced ejection fraction. The model consisted of three health states: ‘alive and event-free’, ‘alive after non-fatal hospitalisation for heart failure’ and ‘dead’. Costs and utilities were estimated from published sources. The main outcome was the incremental cost-effectiveness ratio per quality-adjusted life-year gained. An Australian public healthcare perspective was employed. All outcomes and costs were discounted at a rate of 5% annually.

Results

Over a lifetime horizon, the addition of dapagliflozin to standard care in patients with heart failure and reduced ejection fraction prevented 88 acute heart failure hospitalisations (including readmissions) and yielded an additional 416 years of life and 288 quality-adjusted life-years (discounted) at an additional cost of A$3,692,440 (discounted). This equated to an incremental cost-effectiveness ratio of A$12,482 per quality-adjusted life-year gained, well below the Australian willingness-to-pay threshold of A$50,000 per quality-adjusted life-year gained. Subanalyses in subjects with and without diabetes resulted in similar incremental cost-effectiveness ratios of A$13,234 and A$12,386 per quality-adjusted life-year gained, respectively.

Conclusion

Dapagliflozin is likely to be cost-effective when used as an adjunct therapy to standard care compared with standard care alone for the treatment of chronic heart failure and reduced ejection fraction.

Survival After an Acute Heart Failure Admission. Twelve-Month Outcomes From the NSW HF Snapshot Study

BACKGROUND

The New South Wales (NSW) Heart Failure Snapshot sought to provide a contemporaneous profile of patients admitted with acute heart failure. We have previously reported the baseline results, and this paper reports the 30-day and 12-month outcomes.

METHODS

A prospective audit of consecutive patients admitted to 24 teaching hospitals across NSW and the Australian Capital Territory in July-August 2013 with acute heart failure. Follow-up data were obtained by integration of hospital administrative records and follow-up phone calls with the patients.

RESULTS

Eight hundred eleven (811) patients were recruited across the 24 sites. The NSW HF Snapshot was an elderly cohort (77 ± 14 yrs) with high comorbidity (mean Charlson Comorbidity Index 3.5 ± 2.6), and 71% were frail at baseline. Twenty-four per cent (24%) of patients were readmitted within 30-days post discharge. One hundred seventy-eight (178) patients died within 12 months post discharge. The independent predictors of death were frailty (Hazard Ratio 1.98 [95% Confidence interval 1.18-3.30]; p < 0.01) Charlson Comorbidity Index (HR 1.06 [95% CI 1.00-1.13]; p = 0.05); New York Heart Association (NYHA) class 4 (HR 2.62 [95% CI 1.32-5.22]; p < 0.01); eGFR<30 ml/min/1.73 m² (HR 2.16 [95% CI 1.45-3.21]; p < 0.01); hypokalaemia at discharge (HR 2.55 [95% CI 1.44-4.51]; p < 0.01) and readmission within 30 days of baseline admission (HR 2.13 [95% CI 1.49-3.13]; p < 0.01).

CONCLUSION

In one of the largest prospective audits of acute heart failure outcomes in Australia, we found that short-term readmissions and mortality at 12 months remain high but were largely driven by patient-level factors.

Setting Up a Heart Failure Program in 2018: Moving Towards New Paradigm(s)

PURPOSE OF REVIEW

Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting.

RECENT FINDINGS

Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.

Key elements of interventions for heart failure patients with mild cognitive impairment or dementia: A systematic review

BACKGROUND

The purpose of this systematic review was to (a) examine the effects of interventions delivered by a heart failure professional for mild cognitive impairment and dementia on cognitive function, memory, working memory, instrumental activities of daily living, heart failure knowledge, self-care, quality of life and depression; and (b) identify the successful elements of these strategies for heart failure patients with mild cognitive impairment or dementia.

METHODS AND RESULTS

During March 2018, an electronic search of databases including CINAHL, MEDLINE, EMBASE and PsycINFO was conducted. All randomised controlled trials, which examined an intervention strategy to help heart failure patients with mild cognitive impairment or dementia cope with self-care, were included. An initial search yielded 1622 citations, six studies were included (N= 595 participants, mean age 68 years). There were no significant improvements in cognitive function and depression. However, significant improvements were seen in memory (p=0.015), working memory (p=0.029) and instrumental activities of daily living (p=0.006). Nurse led interventions improved the patient's heart failure knowledge (p=0.001), self-care (p<0.05) and quality of life (p=0.029). Key elements of these interventions include brain exercises, for example, syllable stacks, individualised assessment and customised education, personalised self-care schedule development, interactive problem-solving training on scenarios and association techniques to prompt self-care activities.

CONCLUSIONS

Modest evidence for nurse led interventions among heart failure patients with mild cognitive impairment or dementia was identified. These results must be interpreted with caution in light of the limited number of available included studies.

Evaluating the convergent and discriminant validity of three versions of the frailty phenotype in heart failure: results from the FRAME-HF study

BACKGROUND

Frailty is an important predictive measure of mortality and rehospitalisation in people with heart failure. To date, there are no frailty instruments validated for use in people with heart failure.

AIM

The aim of this study was to evaluate the convergent and discriminant validity of three versions of the frailty phenotype in those with heart failure.

METHODS

A single site, prospective cohort study was undertaken among individuals with a confirmed diagnosis of heart failure. Frailty was assessed concurrently using three versions of the frailty phenotype: the original frailty phenotype and two modified versions; the Survey of Health, Ageing and Retirement in Europe frailty instrument (SHARE-FI) and the St Vincent's frailty instrument. Convergent and discriminant validity were assessed by reporting the correlations between each version and related heart failure subconstructs, and by evaluating the ability of each version to discriminate between normal and abnormal scores of other physical and psychosocial scales specific to heart failure-related subconstructs.

RESULTS

The New York Heart Association classes were moderately correlated with the St Vincent's frailty instrument (r=0.47, P⩽0.001), SHARE-FI (r=0.42, P⩽0.001) and the frailty phenotype (r=0.42, P⩽0.001). The SHARE-FI and the St Vincent's frailty instrument were both able to discriminate consistently between normal and abnormal scores in three out of five of the physical and psychosocial subconstructs that were assessed. The SHARE-FI was also able to discriminate between inpatients and outpatients who were classified as frail.

CONCLUSIONS

Both the SHARE-FI and the St Vincent's frailty instrument displayed good convergent and discriminant validity.

Have Traditional Heart Failure Management Programs Reached Their "Use by" Date? Time to Apply More Nuanced Care

PURPOSE OF REVIEW

To determine the current evidence supporting the otherwise proven heart failure management programs (HFMPs) in the setting of an increasingly older and more complex patient population.

RECENT FINDINGS

Attempts to replace proven face-to-face, multidisciplinary management of HF with remote management techniques (including telemedicine and implantable remote monitoring devices) have yielded mixed results. This may well reflect the clinical cascade effect of greater surveillance paradoxically leading to worse health outcomes as well as a narrow focus on HF alone in patients with clinically significant multimorbidity. Concurrently, there is preliminary evidence that the increasing phenomenon of HF and multimorbidity in older patients is undermining the otherwise positive impact of "traditional" HFMPs. A more nuanced approach to determining who would benefit from what form of HF management, including the integration of remote surveillance techniques, is required.

Prevalence and profile of "seasonal frequent flyers" with chronic heart disease: Analysis of 1598 patients and 4588 patient-years follow-up

BACKGROUND

Peaks and troughs in cardiovascular events correlated with seasonal change is well established from an epidemiological perspective but not a clinical one.

METHODS

Retrospective analysis of the recruitment, baseline characteristics and outcomes during minimum 12-month exposure to all four seasons in 1598 disease-management trial patients hospitalised with chronic heart disease. Seasonality was prospectively defined as ≥4 hospitalisations (all-cause) AND >45% of related bed-days occurring in any one season during median 988 (IQR 653, 1394) days follow-up.

RESULTS

Patients (39% female) were aged 70 ± 12 years and had a combination of coronary artery disease (58%), heart failure (54%), atrial fibrillation (50%) and multimorbidity. Overall, 29.9% of patients displayed a pattern of seasonality. Independent correlates of seasonality were female gender (adjusted OR 1.27, 95% CI 1.01-1.61; p = 0.042), mild cognitive impairment (adjusted OR 1.51, 95% CI 1.16-1.97; p = 0.002), greater multimorbidity (OR 1.20, 95% CI 1.15-1.26 per Charlson Comorbidity Index Score; p < 0.001), higher systolic (OR 1.01, 95%CI 1.00-1.01 per 1 mmHg; p = 0.002) and lower diastolic (OR 0.99, 95% CI 0.98-1.00 per 1 mmHg; p = 0.002) blood pressure. These patients were more than two-fold more likely to die (adjusted HR 2.16, 95% CI 1.60-2.90; p < 0.001) with the highest and lowest number of deaths occurring during spring (31.7%) and summer (19.9%), respectively.

CONCLUSIONS

Despite high quality care and regardless of their diagnosis, we identified a significant proportion of "seasonal frequent flyers" with concurrent poor survival in this real-world cohort of patients with chronic heart disease.

Applying Heart Failure Management to Improve Health Outcomes: But WHICH One?

We report on our learning from many years of research testing the value of nurse-led, multidisciplinary, home-based management of heart failure. We discuss and highlight the key challenges we have experienced in testing this model of care relative to alternatives and evolving patient population. Accordingly, we propose a pragmatic approach to adapt current models of care to meet the needs of increasingly complex (and costly) patients with multimorbidity.