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Núñez-Marín G, Iraola D, Lorenzo M, de la Espriella R, Villar S, Santas E, Miñana G, Sanchis J, Carratalá A, Miró Ò, Bayés-Genís A, Núñez J. An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure. Expert Rev Mol Diagn 2023:1-13. [PMID: 37216616 DOI: 10.1080/14737159.2023.2216386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification. AREAS COVERED This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF. EXPERT OPINION NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.
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Affiliation(s)
- Gonzalo Núñez-Marín
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Diego Iraola
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Sandra Villar
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Arturo Carratalá
- Clinical Chemistry Department, Hospital Clínico Universitario, INCLIVA
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Cardiology Department, Hospital Universitari Germas Trias i Pujol. Badalona, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Pedroni C, Djuric O, Bassi MC, Mione L, Caleffi D, Testa G, Prandi C, Navazio A, Giorgi Rossi P. Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review. Healthcare (Basel) 2023; 11:1227. [PMID: 37174769 PMCID: PMC10178532 DOI: 10.3390/healthcare11091227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
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.
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Affiliation(s)
- Cristina Pedroni
- Direzione delle Professioni Sanitarie, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
- Laurea Magistrale in Scienze Infermieristiche e Ostetriche, University of Modena and Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Olivera Djuric
- Epidemiology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
- Centre for Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Maria Chiara Bassi
- Medical Library, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Lorenzo Mione
- Laurea Magistrale in Scienze Infermieristiche e Ostetriche, University of Modena and Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Dalia Caleffi
- Cardiology Division, Azienda Ospedaliera Universitaria di Modena, 41124 Modena, Italy;
| | - Giacomo Testa
- UO Medicina, Ospedale Giuseppe Dossetti, Azienda Unità Sanitaria Locale di Bologna, 40053 Bologna, Italy;
| | - Cesarina Prandi
- Department of Business Economics, Health & Social Care, University of Applied Sciences & Arts of Southern Switzerland, CH-6928 Manno, Switzerland;
| | - Alessandro Navazio
- Cardiology Division, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
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Walter E, Arrigo M, Allerstorfer S, Marty P, Hülsmann M. Cost-effectiveness of NT-proBNP-supported screening of chronic heart failure in patients with or without type 2 diabetes in Austria and Switzerland. J Med Econ 2023; 26:1287-1300. [PMID: 37781889 DOI: 10.1080/13696998.2023.2264722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Heart failure (HF) is a clinical syndrome with a global burden. Signs and symptoms of HF are nonspecific and often shared with other conditions. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) serves as a useful biomarker for the diagnosis of HF not only in patients with acute symptoms but also in outpatients with an ambiguous clinical presentation. The aim of the analysis is to evaluate the cost-effectiveness of implementing NT-proBNP in the diagnostic algorithm in patients with/without type 2 diabetes mellitus (T2DM), compared with a diagnosis based primarily on clinical signs or symptoms from the perspective of the Austrian and Swiss healthcare system. METHODS A time-discrete Markov model was developed to simulate the effect/improvement (lifetime-costs, quality-adjusted life-years [QALYs], and life-years [LYs]) due to an NT-proBNP screening in undetected HF patients. Undetected HF patients are included in the model according to a distribution of New York Heart Association (NYHA) classes. The model considers disease progression by transition of NYHA classes. Undetected patients may remain undetected or be detected with the help of NT-proBNP or symptoms. Patients with known HF exhibit a slower disease progression. The probability of dying is influenced by the respective NYHA class. Direct costs (2021 € or CHF) were derived from published sources. QALYs, LYs, and costs were discounted (3% p.a.). RESULTS In the per-patient analysis (at age 60 over lifetime), the incremental cost-utility ratio (ICUR)/QALY of NT-proBNP vs. no screening was €3,042 for HF patients in Austria. Considering the total cohort of undetected HF patients (n = 9,377) with the corresponding age structure over a lifetime, the ICUR increases to €4,356. In Switzerland, the per-patient results show an ICUR of CHF 897. Considering the total cohort of undetected HF patients (n = 6,826) the ICUR amounts to CHF 4,513. If indirect costs are considered, NT-proBNP screening becomes the dominant strategy in both countries. CONCLUSION Overall, the analysis concludes that screening with NT-proBNP is a highly cost-effective or cost-saving diagnostic option for patients with HF, and a sensitivity analysis confirmed these findings.
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Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zürich Triemli, Zurich, Switzerland
| | | | - Petra Marty
- Roche Diagnostics (Switzerland) AG, Rotkreuz, Switzerland
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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Marques CRDG, de Menezes AF, Ferrari YAC, Oliveira AS, Tavares ACM, Barreto AS, Vieira RDCA, da Fonseca CD, Santana-Santos E. Educational Nursing Intervention in Reducing Hospital Readmission and the Mortality of Patients with Heart Failure: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2022; 9:jcdd9120420. [PMID: 36547417 PMCID: PMC9785661 DOI: 10.3390/jcdd9120420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022] Open
Abstract
(1) Background: Heart failure (HF) represents a public health problem due to its high morbidity and mortality, increased consumption of health resources, prolonged hospitalization, and frequent readmissions. This study was conducted to evaluate the effectiveness of a nursing educational intervention using home visits (HV) combined with telephone contact in reducing hospital readmission and the mortality of patients with HF. (2) Methods: This is systematic review and meta-analysis of randomized controlled trials (RCTs). The databases used were CINAHL, Cochrane, PubMed and SciELO. A gray literature search included Google Scholar, OpenThesis, Clinical trials and reference lists of eligible studies. RCTs of patients diagnosed with HF were included, distributed between the control group (CG) and intervention (IG), in which the IG was submitted to the nursing intervention with HV and telephone contact in association and analyzed the result of readmission and mortality. (3) Results: The search resulted in 2528 articles and, after following steps, 11 remained for final analysis. A total of 1417 patients were analyzed and distributed: 683 in the IG and 734 in the CG. As a primary outcome, the meta-analysis identified a 36% reduction in the risk of readmission [RR 0.64, 95% CI, 0.54−0.75, p < 0.01] and a 35% reduction in mortality in the IG [RR 0.65, 95% CI, 0.50−0.85, p < 0.01]. Heterogeneity was moderate for readmission and homogeneous for mortality. (4) Conclusions: HV and telephone contact are an effective intervention strategy for nurses’ educational practice.
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Affiliation(s)
| | - Andreia Freire de Menezes
- Nursing Departament, Universidade Federal de Sergipe, Aracaju 49060-108, Brazil
- Nursing Graduate Program, Universidade Federal de Sergipe, Sao Cristovao 49100-000, Brazil
| | | | - Alan Santos Oliveira
- Health’s Science Graduate Program, Universidade Federal de Sergipe, Aracaju 49060-108, Brazil
| | | | - André Sales Barreto
- Education in Health Departament, Universidade Federal de Sergipe, Lagarto 49400-000, Brazil
| | | | - Cassiane Dezoti da Fonseca
- Nursing Graduate Program, Universidade Federal de Sergipe, Sao Cristovao 49100-000, Brazil
- Medical and Surgical Nursing Departament, Federal University of Sergipe, São Paulo 04021-001, Brazil
| | - Eduesley Santana-Santos
- Nursing Departament, Universidade Federal de Sergipe, Aracaju 49060-108, Brazil
- Nursing Graduate Program, Universidade Federal de Sergipe, Sao Cristovao 49100-000, Brazil
- Correspondence:
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Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews. BMC Palliat Care 2021; 20:89. [PMID: 34162377 PMCID: PMC8223342 DOI: 10.1186/s12904-021-00782-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Heart failure disease management programs in Austria 2019 : A systematic survey of the Heart Failure Working Group and the Working Group for Cardiological Assistance and Care Personnel of the Austrian Society of Cardiology. Wien Klin Wochenschr 2020; 132:310-321. [PMID: 32072313 PMCID: PMC7297701 DOI: 10.1007/s00508-020-01615-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/22/2020] [Indexed: 11/06/2022]
Abstract
Heart failure (HF) is common and is associated with high morbidity, mortality and high health expenditure. A multidisciplinary disease management plan (DMP) can reduce morbidity and mortality, save costs and improve the quality of life. In Austria, three HF-specific DMPs are currently in a project phase and four established DMPs are active. Although programs are widely heterogeneous with respect to their intervention type, they pursue the same interventional goal by supporting seamless care between inpatient and community care settings with a multidisciplinary team. This survey presents a systematic survey of the HF-specific DMPs in Austria. Disparities between programs are highlighted and discussed. The nationwide establishment of HF-specific DMPs that integrate primary care and cardiology services including a regulation of the remuneration of stakeholders and program infrastructure is needed to decrease the burden of HF for both the individual and society.
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Jafari A, Rezapour A, Hajahmadi M. Cost-effectiveness of B-type natriuretic peptide-guided care in patients with heart failure: a systematic review. Heart Fail Rev 2019; 23:693-700. [PMID: 29744629 DOI: 10.1007/s10741-018-9710-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Measuring the level of B-type natriuretic peptide (BNP), as a guide to pharmacotherapy, can increase the survival of patients with heart failure. This study is aimed at systematically reviewing the studies conducted on the cost-effectiveness of BNP-guided care in patients with heart failure. Using the systematic review method, we reviewed the published studies on the cost-effectiveness of BNP-guided care in patients with heart failure during the years 2004 to 2017. The results showed that all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, most of the studies used the Markov model. The quality-adjusted life years (QALYs) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($32,748) and the lowest ratio was observed in Canada ($6251). Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the results of the present study, it seems that the use of BNP or N-terminal pro-BNP (NT-pro-BNP) in patients with heart failure may reduce cost compared to the symptom-based clinical care and increase QALY. In this regard, these studies were designed and conducted in high-income countries; thus, the application of these results in low- and middle-income countries will be limited.
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Affiliation(s)
- Abdosaleh Jafari
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Marjan Hajahmadi
- Cardiovascular Department, Rasoul Akram General Hospital, Iran University of Medical Sciences, Tehran, Iran
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Economic and Quality-of-Life Outcomes of Natriuretic Peptide-Guided Therapy for Heart Failure. J Am Coll Cardiol 2019; 72:2551-2562. [PMID: 30466512 DOI: 10.1016/j.jacc.2018.08.2184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The GUIDE-IT (GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial prospectively compared the efficacy of an N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided heart failure treatment strategy (target NT-proBNP level <1,000 pg/ml) with optimal medical therapy alone in high-risk patients with heart failure and reduced ejection fraction. When the study was stopped for futility, 894 patients had been enrolled. OBJECTIVES The purpose of this study was to assess treatment-related quality-of-life (QOL) and economic outcomes in the GUIDE-IT trial. METHODS The authors prospectively collected a battery of QOL instruments at baseline and 3, 6, 12, and 24 months post-randomization (collection rates 90% to 99% of those eligible). The principal pre-specified QOL measures were the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score and the Duke Activity Status Index (DASI). Cost data were collected for 735 (97%) U.S. PATIENTS RESULTS Baseline variables were well balanced in the 446 patients randomized to the NT-proBNP-guided therapy and 448 to usual care. Both the KCCQ and the DASI improved over the first 6 months, but no evidence was found for a strategy-related difference (mean difference [biomarker-guided - usual care] at 24 months of follow-up 2.0 for DASI [95% confidence interval (CI): -1.3 to 5.3] and 1.1 for KCCQ [95% CI: -3.7 to 5.9]). Total winsorized costs averaged $5,919 higher in the biomarker-guided strategy (95% CI: -$1,795, +$13,602) over 15-month median follow-up. CONCLUSIONS A strategy of NT-proBNP-guided HF therapy had higher total costs and was not more effective than usual care in improving QOL outcomes in patients with heart failure and a reduced ejection fraction. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840).
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Abstract
Normal brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) levels are helpful in excluding chronic heart failure in the ambulatory setting, although they have been studied less well and possibly less accurately than in acute care. They may also be of help in screening patients at risk to intervene and reduce the development of heart failure. Natriuretic peptides are also excellent prognostic markers of chronic heart failure, but the clinical value of such prognostic information is less clear. One possible application for this information is guiding medical therapy in chronic heart failure. Many studies have investigated this approach, but results are mixed and do not clearly show improvement in outcome. Still, it may be that in patients with reduced ejection fraction and few comorbidities, measuring NT-proBNP to uptitrate medication improves prognosis.
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Pufulete M, Maishman R, Dabner L, Mohiuddin S, Hollingworth W, Rogers CA, Higgins J, Dayer M, Macleod J, Purdy S, McDonagh T, Nightingale A, Williams R, Reeves BC. Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model. Health Technol Assess 2018; 21:1-150. [PMID: 28774374 DOI: 10.3310/hta21400] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Heart failure (HF) affects around 500,000 people in the UK. HF medications are frequently underprescribed and B-type natriuretic peptide (BNP)-guided therapy may help to optimise treatment. OBJECTIVE To evaluate the clinical effectiveness and cost-effectiveness of BNP-guided therapy compared with symptom-guided therapy in HF patients. DESIGN Systematic review, cohort study and cost-effectiveness model. SETTING A literature review and usual care in the NHS. PARTICIPANTS (a) HF patients in randomised controlled trials (RCTs) of BNP-guided therapy; and (b) patients having usual care for HF in the NHS. INTERVENTIONS Systematic review: BNP-guided therapy or symptom-guided therapy in primary or secondary care. Cohort study: BNP monitored (≥ 6 months' follow-up and three or more BNP tests and two or more tests per year), BNP tested (≥ 1 tests but not BNP monitored) or never tested. Cost-effectiveness model: BNP-guided therapy in specialist clinics. MAIN OUTCOME MEASURES Mortality, hospital admission (all cause and HF related) and adverse events; and quality-adjusted life-years (QALYs) for the cost-effectiveness model. DATA SOURCES Systematic review: Individual participant or aggregate data from eligible RCTs. Cohort study: The Clinical Practice Research Datalink, Hospital Episode Statistics and National Heart Failure Audit (NHFA). REVIEW METHODS A systematic literature search (five databases, trial registries, grey literature and reference lists of publications) for published and unpublished RCTs. RESULTS Five RCTs contributed individual participant data (IPD) and eight RCTs contributed aggregate data (1536 participants were randomised to BNP-guided therapy and 1538 participants were randomised to symptom-guided therapy). For all-cause mortality, the hazard ratio (HR) for BNP-guided therapy was 0.87 [95% confidence interval (CI) 0.73 to 1.04]. Patients who were aged < 75 years or who had heart failure with a reduced ejection fraction (HFrEF) received the most benefit [interactions (p = 0.03): < 75 years vs. ≥ 75 years: HR 0.70 (95% CI 0.53 to 0.92) vs. 1.07 (95% CI 0.84 to 1.37); HFrEF vs. heart failure with a preserved ejection fraction (HFpEF): HR 0.83 (95% CI 0.68 to 1.01) vs. 1.33 (95% CI 0.83 to 2.11)]. In the cohort study, incident HF patients (1 April 2005-31 March 2013) were never tested (n = 13,632), BNP tested (n = 3392) or BNP monitored (n = 71). Median survival was 5 years; all-cause mortality was 141.5 out of 1000 person-years (95% CI 138.5 to 144.6 person-years). All-cause mortality and hospital admission rate were highest in the BNP-monitored group, and median survival among 130,433 NHFA patients (1 January 2007-1 March 2013) was 2.2 years. The admission rate was 1.1 patients per year (interquartile range 0.5-3.5 patients). In the cost-effectiveness model, in patients aged < 75 years with HFrEF or HFpEF, BNP-guided therapy improves median survival (7.98 vs. 6.46 years) with a small QALY gain (5.68 vs. 5.02) but higher lifetime costs (£64,777 vs. £58,139). BNP-guided therapy is cost-effective at a threshold of £20,000 per QALY. LIMITATIONS The limitations of the trial were a lack of IPD for most RCTs and heterogeneous interventions; the inability to identify BNP monitoring confidently, to determine medication doses or to distinguish between HFrEF and HFpEF; the use of a simplified two-state Markov model; a focus on health service costs and a paucity of data on HFpEF patients aged < 75 years and HFrEF patients aged ≥ 75 years. CONCLUSIONS The efficacy of BNP-guided therapy in specialist HF clinics is uncertain. If efficacious, it would be cost-effective for patients aged < 75 years with HFrEF. The evidence reviewed may not apply in the UK because care is delivered differently. FUTURE WORK Identify an optimal BNP-monitoring strategy and how to optimise HF management in accordance with guidelines; update the IPD meta-analysis to include the Guiding Evidence Based Therapy Using Biomarker Intensified Treatment (GUIDE-IT) RCT; collect routine long-term outcome data for completed and ongoing RCTs. TRIAL REGISTRATION Current Controlled Trials ISRCTN37248047 and PROSPERO CRD42013005335. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 40. See the NIHR Journals Library website for further project information. The British Heart Foundation paid for Chris A Rogers' and Maria Pufulete's time contributing to the study. Syed Mohiuddin's time is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Foundation Trust. Rachel Maishman contributed to the study when she was in receipt of a NIHR Methodology Research Fellowship.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachel Maishman
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Dabner
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Syed Mohiuddin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Julian Higgins
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Dayer
- Department of Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Theresa McDonagh
- Cardiovascular Division, King's College London, King's College Hospital, London, UK
| | - Angus Nightingale
- Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Salamanca-Balen N, Seymour J, Caswell G, Whynes D, Tod A. 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. Palliat Med 2018; 32:447-465. [PMID: 28655289 PMCID: PMC5788084 DOI: 10.1177/0269216317711570] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
| | - Jane Seymour
- 2 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Glenys Caswell
- 1 School of Health Sciences, The University of Nottingham, Nottingham, UK
| | - David Whynes
- 3 School of Economics, The University of Nottingham, Nottingham, UK
| | - Angela Tod
- 2 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
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Moertl D, Altenberger J, Bauer N, Berent R, Berger R, Boehmer A, Ebner C, Fritsch M, Geyrhofer F, Huelsmann M, Poelzl G, Stefenelli T. Disease management programs in chronic heart failure : Position statement of the Heart Failure Working Group and the Working Group of the Cardiological Assistance and Care Personnel of the Austrian Society of Cardiology. Wien Klin Wochenschr 2017; 129:869-878. [PMID: 29080104 PMCID: PMC5711993 DOI: 10.1007/s00508-017-1265-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 08/17/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Deddo Moertl
- Department of Internal Medicine 3, University Hospital St. Poelten, Karl Landsteiner Private University, St. Poelten, Austria.
- Institute for Research of Ischaemic Cardiac Diseases and Rhythmology, Karl Landsteiner Society, St. Pölten, Austria.
| | - Johann Altenberger
- Rehabilitation Center, Lehrkrankenhaus der PMU, Pensionsversicherung Grossgmain, Grossgmain, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Norbert Bauer
- Department of Internal Medicine, Hospital Hartberg, Hartberg, Styria, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Robert Berent
- Center for Cardiovascular Rehabilitation, Bad Ischl, Upper Austria, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Rudolf Berger
- Department for Internal Medicine I, Convent Hospital Barmherzige Brueder, Eisenstadt, Burgenland, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Armin Boehmer
- Department of Internal Medicine 1, University Clinic Krems, Krems, Lower Austria, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Christian Ebner
- Department of Internal Medicine 2, Convent Hospital Elisabethinen, Linz, Upper Austria, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Margarethe Fritsch
- Working Group for Preventive Medicine (AVOS), Salzburg, Austria
- Working Group of the Cardiological Assistance and Care Personnel, Austrian Society of Cardiology, Vienna, Austria
| | - Friedrich Geyrhofer
- Department of Internal Medicine 2, Convent Hospital Elisabethinen, Linz, Upper Austria, Austria
- Working Group of the Cardiological Assistance and Care Personnel, Austrian Society of Cardiology, Vienna, Austria
| | - Martin Huelsmann
- University Clinic of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Gerhard Poelzl
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Tyrol, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
| | - Thomas Stefenelli
- Department of Internal Medicine 1, Donauspital/SMZ Ost, Vienna, Austria
- Heart Failure Working Group, Austrian Society for Cardiology, Vienna, Austria
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13
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Mayer S, Kiss N, Łaszewska A, Simon J. Costing evidence for health care decision-making in Austria: A systematic review. PLoS One 2017; 12:e0183116. [PMID: 28806728 PMCID: PMC5555669 DOI: 10.1371/journal.pone.0183116] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/28/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND With rising healthcare costs comes an increasing demand for evidence-informed resource allocation using economic evaluations worldwide. Furthermore, standardization of costing and reporting methods both at international and national levels are imperative to make economic evaluations a valid tool for decision-making. The aim of this review is to assess the availability and consistency of costing evidence that could be used for decision-making in Austria. It describes systematically the current economic evaluation and costing studies landscape focusing on the applied costing methods and their reporting standards. Findings are discussed in terms of their likely impacts on evidence-based decision-making and potential suggestions for areas of development. METHODS A systematic literature review of English and German language peer-reviewed as well as grey literature (2004-2015) was conducted to identify Austrian economic analyses. The databases MEDLINE, EMBASE, SSCI, EconLit, NHS EED and Scopus were searched. Publication and study characteristics, costing methods, reporting standards and valuation sources were systematically synthesised and assessed. RESULTS A total of 93 studies were included. 87% were journal articles, 13% were reports. 41% of all studies were full economic evaluations, mostly cost-effectiveness analyses. Based on relevant standards the most commonly observed limitations were that 60% of the studies did not clearly state an analytical perspective, 25% of the studies did not provide the year of costing, 27% did not comprehensively list all valuation sources, and 38% did not report all applied unit costs. CONCLUSION There are substantial inconsistencies in the costing methods and reporting standards in economic analyses in Austria, which may contribute to a low acceptance and lack of interest in economic evaluation-informed decision making. To improve comparability and quality of future studies, national costing guidelines should be updated with more specific methodological guidance and a national reference cost library should be set up to allow harmonisation of valuation methods.
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Affiliation(s)
- Susanne Mayer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Noemi Kiss
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Agata Łaszewska
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, General Hospital Vienna, Vienna, Austria
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Nuckols TK, Keeler E, Morton S, Anderson L, Doyle BJ, Pevnick J, Booth M, Shanman R, Arifkhanova A, Shekelle P. Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission: A Systematic Review and Meta-analysis. JAMA Intern Med 2017; 177:975-985. [PMID: 28558095 PMCID: PMC5710454 DOI: 10.1001/jamainternmed.2017.1136] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/02/2017] [Indexed: 01/11/2023]
Abstract
Importance Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value. Objective To systematically review economic evaluations of QI interventions designed to reduce readmissions. Data Sources Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016). Study Selection Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs. Data Extraction and Synthesis Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs. Main Outcomes and Measures Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006). Conclusions and Relevance Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.
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Affiliation(s)
- Teryl K. Nuckols
- Cedars-Sinai Medical Center, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | | | - Sally Morton
- College of Science, Virginia Polytechnic Institute and State University, Blacksburg
| | - Laura Anderson
- Cedars-Sinai Medical Center, Los Angeles, California
- Jonathan and Karin Fielding School of Public Health, University of California–Los Angeles, Los Angeles
| | - Brian J. Doyle
- Jonathan and Karin Fielding School of Public Health, University of California–Los Angeles, Los Angeles
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | | | | | | | - Paul Shekelle
- RAND Corporation, Santa Monica, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
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15
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Leahy-Warren P, Mulcahy H, Benefield L, Bradley C, Coffey A, Donohoe A, Fitzgerald S, Frawley T, Healy E, Healy M, Kelly M, McCarthy B, McLoughlin K, Meagher C, O'Connell R, O'Mahony A, Paul G, Phelan A, Stokes D, Walsh J, Savage E. Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review. BMC Nurs 2017; 16:35. [PMID: 28670202 PMCID: PMC5492933 DOI: 10.1186/s12912-017-0225-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/05/2017] [Indexed: 01/08/2023] Open
Abstract
Background Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings. The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature. Methods A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google ‘advanced’ search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes. Results The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies. Conclusion Use of a conceptual model of nursing and midwifery to inform decision-making in primary/community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance. Electronic supplementary material The online version of this article (doi:10.1186/s12912-017-0225-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patricia Leahy-Warren
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | - Helen Mulcahy
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | | | - Colin Bradley
- Department of General Practice, University College, Cork, Ireland
| | - Alice Coffey
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | - Ann Donohoe
- School of Health Sciences, University College, Dublin, Ireland
| | - Serena Fitzgerald
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | - Tim Frawley
- School of Health Sciences, University College, Dublin, Ireland
| | | | - Maria Healy
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland
| | - Marcella Kelly
- School of Nursing & Midwifery, NUI Galway, Galway, Ireland
| | | | - Kathleen McLoughlin
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | | | - Rhona O'Connell
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | - Aoife O'Mahony
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
| | - Gillian Paul
- School of Health Sciences, University College, Dublin, Ireland
| | - Amanda Phelan
- School of Health Sciences, University College, Dublin, Ireland
| | - Diarmuid Stokes
- Health Sciences Library, University College, Dublin, Ireland
| | - Jessica Walsh
- School of Health Sciences, University College, Dublin, Ireland
| | - Eileen Savage
- School of Nursing & Midwifery, Brookfield health Sciences Complex, University College, Cork, Ireland
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16
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Karakoyun I, Colak A, Arslan FD, Hasturk AG, Duman C. Anemia considerations when assessing natriuretic peptide levels in ED patients. Am J Emerg Med 2017; 35:1677-1681. [PMID: 28587950 DOI: 10.1016/j.ajem.2017.05.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/23/2017] [Accepted: 05/27/2017] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The incidence of heart failure (HF) has reached epidemic levels in western populations, and the majority of these patients are admitted to hospitals through the emergency department (ED). We aimed to aid clinicians assessing natriuretic peptide (NP) levels in cases with suspected HF. In this study, we investigated the effect of anemia on amino-terminal pro-BNP (NT-proBNP) and on B-type natriuretic peptide (BNP) levels. METHODS This retrospective study examined patients who were admitted to the ED with suspected HF. After admission, the treating physician requested complete blood count and creatinine tests with NT-proBNP (n=2.637) or BNP (n=11.159). The exclusion criteria were used to minimize the factors that could affect the NT-proBNP and BNP results. We examined the data using the Mann-Whitney U test, Chi-square test, Spearman correlation test, and multivariate linear regression analyses. RESULTS The NT-proBNP and BNP levels were statistically higher in the groups with anemia (p=0.016 and p=0.009, respectively). There was a statistically significant negative correlation between hemoglobin and NP levels (r=-0.272, p<0.001 for NT-proBNP and r=-0.179, p<0.001 for BNP). The results indicated that advanced age and low hemoglobin levels were significantly associated with the increase in NT-proBNP (p=0.024 and p=0.004, respectively). Advanced age, low hemoglobin and low GFR-MDRD levels were significantly associated with the increase in BNP (p<0.001, p=0.002 and p=0.013, respectively). DISCUSSION The data suggest that clinicians examining patients admitted to the ED with suspected HF should consider that anemia could lead to increases in NT-proBNP and BNP levels.
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Affiliation(s)
- Inanc Karakoyun
- Department of Medical Biochemistry, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey.
| | - Ayfer Colak
- Department of Medical Biochemistry, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Fatma Demet Arslan
- Department of Medical Biochemistry, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Aybike Gunaslan Hasturk
- Department of Medical Biochemistry, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Can Duman
- Department of Medical Biochemistry, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
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17
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Van Spall HGC, Rahman T, Mytton O, Ramasundarahettige C, Ibrahim Q, Kabali C, Coppens M, Brian Haynes R, Connolly S. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis. Eur J Heart Fail 2017; 19:1427-1443. [PMID: 28233442 DOI: 10.1002/ejhf.765] [Citation(s) in RCA: 216] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 12/15/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022] Open
Abstract
AIMS To compare the effectiveness of transitional care services in decreasing all-cause death and all-cause readmissions following hospitalization for heart failure (HF). METHODS AND RESULTS We searched PubMed, Embase, CINAHL, and Cochrane Clinical Trials Register for randomized controlled trials (RCTs) published in 2000-2015 that tested the efficacy of transitional care services in patients hospitalized for HF, provided ≥1 month of follow-up, and reported all-cause mortality or all-cause readmissions. Our network meta-analysis included 53 RCTs (12 356 patients). Among services that significantly decreased all-cause mortality compared with usual care, nurse home visits were most effective [ranking P-score 0.6794; relative risk (RR) 0.78, 95% confidence intervals (CI) 0.62-0.98], followed by disease management clinics (DMCs) (ranking P-score 0.6368; RR 0.80, 95% CI 0.67-0.97). Among services that significantly decreased all-cause readmission, nurse home visits were most effective [ranking P-score 0.8365; incident rate ratio (IRR) 0.65, 95% CI 0.49-0.86], followed by nurse case management (NCM) (ranking P-score 0.6168; IRR 0.77, 95% CI 0.63-0.95), and DMCs (ranking P-score 0.5691; IRR 0.80, 95% CI 0.66-0.97). There was no significant difference in the comparative effectiveness of services that improved each outcome. Nurse home visits had the greatest pooled cost-savings (3810 USD, 95% CI 3682-3937), followed by NCM (3435 USD, 95% CI 3224-3645), and DMCs (245 USD, 95% CI -70 to 559). Telephone, telemonitoring, pharmacist, and education interventions did not significantly improve clinical outcomes. CONCLUSION Nurse home visits and DMCs decrease all-cause mortality after hospitalization for HF. Along with NCM, they also reduce all-cause readmissions, with no significant difference in comparative effectiveness. These services reduce healthcare system costs to varying degrees.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine, McMaster University, and Population Health Research Institute, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Tahseen Rahman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Oliver Mytton
- MRC Epidemiology Unit and UKCRC Centre for Diet and Activity Research (CEDAR), University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Quazi Ibrahim
- Department of Medicine, McMaster University, and Population Health Research Institute, Hamilton, ON, Canada
| | - Conrad Kabali
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Michiel Coppens
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - R Brian Haynes
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Stuart Connolly
- Department of Medicine, McMaster University, and Population Health Research Institute, Hamilton, ON, Canada
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18
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Mohiuddin S, Reeves B, Pufulete M, Maishman R, Dayer M, Macleod J, McDonagh T, Purdy S, Rogers C, Hollingworth W. Model-based cost-effectiveness analysis of B-type natriuretic peptide-guided care in patients with heart failure. BMJ Open 2016; 6:e014010. [PMID: 28031211 PMCID: PMC5223729 DOI: 10.1136/bmjopen-2016-014010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Monitoring B-type natriuretic peptide (BNP) to guide pharmacotherapy might improve survival in patients with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). However, the cost-effectiveness of BNP-guided care is uncertain and guidelines do not uniformly recommend it. We assessed the cost-effectiveness of BNP-guided care in patient subgroups defined by age and ejection fraction. METHODS We used a Markov model with a 3-month cycle length to estimate the lifetime health service costs, quality-adjusted life years (QALYs) and incremental net monetary benefits (iNMBs) of BNP-guided versus clinically guided care in 3 patient subgroups: (1) HFrEF patients <75 years; (2) HFpEF patients <75 years; and (3) HFrEF patients ≥75 years. There is no evidence of benefit in patients with HFpEF aged ≥75 years. We used individual patient data meta-analyses and linked primary care, hospital and mortality data to inform the key model parameters. We performed probabilistic analysis to assess the uncertainty in model results. RESULTS In younger patients (<75 years) with HFrEF, the mean QALYs (5.57 vs 5.02) and costs (£63 527 vs £58 139) were higher with BNP-guided care. At the willingness-to-pay threshold of £20 000 per QALY, the positive iNMB (£5424 (95% CI £987 to £9469)) indicates that BNP-guided care is cost-effective in this subgroup. The evidence of cost-effectiveness of BNP-guided care is less strong for younger patients with HFpEF (£3155 (-£10 307 to £11 613)) and older patients (≥75 years) with HFrEF (£2267 (-£1524 to £6074)). BNP-guided care remained cost-effective in the sensitivity analyses, albeit the results were sensitive to assumptions on its sustained effect. CONCLUSIONS We found strong evidence that BNP-guided care is a cost-effective alternative to clinically guided care in younger patients with HFrEF. It is potentially cost-effective in younger patients with HFpEF and older patients with HFrEF, but more evidence is required, particularly with respect to the frequency, duration and BNP target for monitoring. Cost-effectiveness results from trials in specialist settings cannot be generalised to primary care.
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Affiliation(s)
- Syed Mohiuddin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Barnaby Reeves
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Maria Pufulete
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachel Maishman
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Mark Dayer
- NHS Practice, Taunton and Somerset NHS Trust, Somerset, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Theresa McDonagh
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Rogers
- School of Clinical Sciences, University of Bristol, Bristol, UK
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McLellan J, Heneghan CJ, Perera R, Clements AM, Glasziou PP, Kearley KE, Pidduck N, Roberts NW, Tyndel S, Wright FL, Bankhead C. B-type natriuretic peptide-guided treatment for heart failure. Cochrane Database Syst Rev 2016; 12:CD008966. [PMID: 28102899 PMCID: PMC5449577 DOI: 10.1002/14651858.cd008966.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Heart failure is a condition in which the heart does not pump enough blood to meet all the needs of the body. Symptoms of heart failure include breathlessness, fatigue and fluid retention. Outcomes for patients with heart failure are highly variable; however on average, these patients have a poor prognosis. Prognosis can be improved with early diagnosis and appropriate use of medical treatment, use of devices and transplantation. Patients with heart failure are high users of healthcare resources, not only due to drug and device treatments, but due to high costs of hospitalisation care. B-type natriuretic peptide levels are already used as biomarkers for diagnosis and prognosis of heart failure, but could offer to clinicians a possible tool to guide drug treatment. This could optimise drug management in heart failure patients whilst allaying concerns over potential side effects due to drug intolerance. OBJECTIVES To assess whether treatment guided by serial BNP or NT-proBNP (collectively referred to as NP) monitoring improves outcomes compared with treatment guided by clinical assessment alone. SEARCH METHODS Searches were conducted up to 15 March 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (OVID), Embase (OVID), the Database of Abstracts of Reviews of Effects (DARE) and the NHS Economic Evaluation Database in the Cochrane Library. Searches were also conducted in the Science Citation Index Expanded, the Conference Proceedings Citation Index on Web of Science (Thomson Reuters), World Health Organization International Clinical Trials Registry and ClinicalTrials.gov. We applied no date or language restrictions. SELECTION CRITERIA We included randomised controlled trials of NP-guided treatment of heart failure versus treatment guided by clinical assessment alone with no restriction on follow-up. Adults treated for heart failure, in both in-hospital and out-of-hospital settings, and trials reporting a clinical outcome were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and evaluated risk of bias. Risk ratios (RR) were calculated for dichotomous data, and pooled mean differences (MD) (with 95% confidence intervals (CI)) were calculated for continuous data. We contacted trial authors to obtain missing data. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS We included 18 randomised controlled trials with 3660 participants (range of mean age: 57 to 80 years) comparing NP-guided treatment with clinical assessment alone. The evidence for all-cause mortality using NP-guided treatment showed uncertainty (RR 0.87, 95% CI 0.76 to 1.01; patients = 3169; studies = 15; low quality of the evidence), and for heart failure mortality (RR 0.84, 95% CI 0.54 to 1.30; patients = 853; studies = 6; low quality of evidence).The evidence suggested heart failure admission was reduced by NP-guided treatment (38% versus 26%, RR 0.70, 95% CI 0.61 to 0.80; patients = 1928; studies = 10; low quality of evidence), but the evidence showed uncertainty for all-cause admission (57% versus 53%, RR 0.93, 95% CI 0.84 to 1.03; patients = 1142; studies = 6; low quality of evidence).Six studies reported on adverse events, however the results could not be pooled (patients = 1144; low quality of evidence). Only four studies provided cost of treatment results, three of these studies reported a lower cost for NP-guided treatment, whilst one reported a higher cost (results were not pooled; patients = 931, low quality of evidence). The evidence showed uncertainty for quality of life data (MD -0.03, 95% CI -1.18 to 1.13; patients = 1812; studies = 8; very low quality of evidence).We completed a 'Risk of bias' assessment for all studies. The impact of risk of bias from lack of blinding of outcome assessment and high attrition levels was examined by restricting analyses to only low 'Risk of bias' studies. AUTHORS' CONCLUSIONS In patients with heart failure low-quality evidence showed a reduction in heart failure admission with NP-guided treatment while low-quality evidence showed uncertainty in the effect of NP-guided treatment for all-cause mortality, heart failure mortality, and all-cause admission. Uncertainty in the effect was further shown by very low-quality evidence for patient's quality of life. The evidence for adverse events and cost of treatment was low quality and we were unable to pool results.
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Affiliation(s)
- Julie McLellan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Carl J Heneghan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Alison M Clements
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Karen E Kearley
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nicola Pidduck
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Sally Tyndel
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - F Lucy Wright
- University of OxfordCancer Epidemiology Unit, Nuffield Department of Population HealthRichard doll BldgOld Road Campus, Roosevelt DriverOxfordUKOX3 7LF
| | - Clare Bankhead
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Athanasakis K, Arista I, Balasopoulos T, Boubouchairopoulou N, Kyriopoulos J. How peptide technology has improved costs and outcomes in patients with heart failure. Expert Rev Pharmacoecon Outcomes Res 2016; 16:371-82. [PMID: 27160541 DOI: 10.1080/14737167.2016.1187066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart failure (HF) is characterized by substantial health and economic burden, mainly attributed to increased hospitalizations and readmissions. Its diagnosis remains challenging due to the non-specific nature of the initial symptoms of the disease. Recently, scientific evidence has highlighted the potential of natriuretic peptides (NP) in improving the diagnosis and prognosis of HF and, by extension, in restraining healthcare costs. The present review aimed at providing evidence of their optimal use in terms of economic and health outcomes. AREAS COVERED Systematic literature research limited to studies published from February 2006 to February 2016 was performed with the aim of identifying and analyzing all cost-effectiveness and other economic evaluation studies that investigated the economic and health outcomes of NPs use as screening and management tools for HF. Expert commentary: NP testing either added in the standard of care, or substituting frequently used diagnostic procedures for the diagnosis and management of HF, regardless of the healthcare setting of interest, was proved to be a valid tool for clinical decision-making. Moreover it was associated with improved patient outcomes and important cost-savings mainly attributed to lower admission and readmission rates, shorter hospitalization length and improved health-related quality of life.
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Affiliation(s)
- Kostas Athanasakis
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | - Ioli Arista
- b Health Economist, Independent Researcher , Athens , Greece
| | - Thanos Balasopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | | | - John Kyriopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
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Vedel I, Khanassov V. Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis. Ann Fam Med 2015; 13:562-71. [PMID: 26553896 PMCID: PMC4639382 DOI: 10.1370/afm.1844] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 06/30/2015] [Accepted: 07/10/2015] [Indexed: 02/04/2023] Open
Abstract
PURPOSE We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration. RESULTS We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious. CONCLUSIONS Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.
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Affiliation(s)
- Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Canada
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Brunner-La Rocca HP, Bektas S. Biomarker Guided Therapy in Chronic Heart Failure. Card Fail Rev 2015; 1:96-101. [PMID: 28785440 PMCID: PMC5490943 DOI: 10.15420/cfr.2015.1.2.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/21/2015] [Indexed: 11/04/2022] Open
Abstract
This review article addresses the question of whether biomarker-guided therapy is ready for clinical implementation in chronic heart failure. The most well-known biomarkers in heart failure are natriuretic peptides, namely B-type natriuretic peptide (BNP) and N-terminal pro-BNP. They are well-established in the diagnostic process of acute heart failure and prediction of disease prognosis. They may also be helpful in screening patients at risk of developing heart failure. Although studied by 11 small- to medium-scale trials resulting in several positive meta-analyses, it is less well-established whether natriuretic peptides are also helpful for guiding chronic heart failure therapy. This uncertainty is expressed by differences in European and American guideline recommendations. In addition to reviewing the evidence surrounding the use of natriuretic peptides to guide chronic heart failure therapy, this article gives an overview of the shortcomings of the trials, how the results may be interpreted and the future directions necessary to fill the current gaps in knowledge. Therapy guidance in chronic heart failure using other biomarkers has not been prospectively tested to date. Emerging biomarkers, such as galectin-3 and soluble ST2, might be useful in this regard, as suggested by several post-hoc analyses.
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Affiliation(s)
| | - Sema Bektas
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Durtschi A, Jülicher P. Assessing the value of cardiac biomarkers: going beyond diagnostic accuracy? Future Cardiol 2015; 10:367-80. [PMID: 24976474 DOI: 10.2217/fca.14.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In this era of scrutinized resource utilization, providers and payers are focused on the value of healthcare interventions more than ever. Cost-effectiveness evaluations are required by some health authorities and requested by others in order to guide budget allocation decisions. In the past, these evaluations did not methodologically consider laboratory diagnostics. We set out to explore the current requirements of health technology agencies that include laboratory diagnostics and describe, through a review of the literature, alternative methods for establishing the value of a biomarker or labroatory diagnostic beyond assay specifications and performance. The aim of this study was to evaluate the current use of a linked evidence approach in cost-effectiveness studies for cardiac laboratory tests in the last 5 years.
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Affiliation(s)
- Amy Durtschi
- Abbott, 100 Abbott Park Road, CP1-3NW, Abbott Park, IL 60064-6094, USA
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Wong FKY, So C, Chau J, Law AKP, Tam SKF, McGhee S. Economic evaluation of the differential benefits of home visits with telephone calls and telephone calls only in transitional discharge support. Age Ageing 2015; 44:143-7. [PMID: 25355620 PMCID: PMC4255617 DOI: 10.1093/ageing/afu166] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: home visits and telephone calls are two often used approaches in transitional care, but their differential economic effects are unknown. Objective: to examine the differential economic benefits of home visits with telephone calls and telephone calls only in transitional discharge support. Design: cost-effectiveness analysis conducted alongside a randomised controlled trial (RCT). Participants: patients discharged from medical units randomly assigned to control (control, N = 210), home visits with calls (home, N = 196) and calls only (call, N = 204). Methods: cost-effectiveness analyses were conducted from the societal perspective comparing monetary benefits and quality-adjusted life years (QALYs) gained. Results: the home arm was less costly but less effective at 28 days and was dominating (less costly and more effective) at 84 days. The call arm was dominating at both 28 and 84 days. The incremental QALY for the home arm was −0.0002/0.0008 (28/84 days), and the call arm was 0.0022/0.0104 (28/84 days). When the three groups were compared, the call arm had a higher probability being cost-effective at 84 days but not at 28 days (home: 53%, call: 35% (28 days) versus home: 22%, call: 73% (84 days)) measuring against the NICE threshold of £20,000. Conclusion: the original RCT showed that the bundled intervention involving home visits and calls was more effective than calls only in the reduction of hospital readmissions. This study adds a cost perspective to inform policymakers that both home visits and calls only are cost-effective for transitional care support, but calls only have a higher chance of being cost-effective for a sustained period after intervention.
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Affiliation(s)
- Frances Kam Yuet Wong
- School of Nursing, The Hong Kong Polytechnic University, Hunghom, Kowloon, Hong Kong, China
| | - Ching So
- Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, China
| | - June Chau
- Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, China
| | - Antony Kwan Pui Law
- School of Nursing, The Hong Kong Polytechnic University, Hunghom, Kowloon, Hong Kong, China
| | - Stanley Ku Fu Tam
- Department of Medicine, Queen Elizabeth Hospital/Hong Kong Buddhist Hospital, Hong Kong, China
| | - Sarah McGhee
- Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, China
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Maru S, Byrnes J, Carrington MJ, Stewart S, Scuffham PA. Systematic review of trial-based analyses reporting the economic impact of heart failure management programs compared with usual care. Eur J Cardiovasc Nurs 2014; 15:82-90. [PMID: 25322749 DOI: 10.1177/1474515114556031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/27/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The cost-effectiveness of heart failure management programs (HF-MPs) is highly variable. We explored intervention and clinical characteristics likely to influence cost outcomes. METHODS A systematic review of economic analyses alongside randomized clinical trials comparing HF-MPs and usual care. Electronic databases were searched for English peer-reviewed articles published between 1990 and 2013. RESULTS Of 511 articles identified, 34 comprising 35 analyses met the inclusion criteria. Eighteen analyses (51%) reported a HF-MP as more effective and less costly; four analyses (11%), and five analyses (14%) also reported they were more effective but with no significant or an increased cost difference, respectively. Alternatively, five analyses (14%) reported no statistically significant difference in effects or costs, and one analysis (3%) reported no statistically significant effect difference but was less costly. Finally, two analyses (6%) reported no statistically significant effect difference but were more costly. Interventions that reduced hospital admissions tended to result in favorable cost outcomes, moderated by increased resource use, intervention cost and/or the durability of the intervention effect. The reporting quality of economic evaluation assessed by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist varied substantially between 5% and 91% (median 45%; 34 articles) of the checklist criteria adequately addressed. Overall, none of the study, patient or intervention characteristics appeared to independently influence the cost-effectiveness of a HF-MP. CONCLUSION The extent that HF-MPs reduce hospital readmissions appears to be associated with favorable cost outcomes. The current evidence does not provide a sufficient evidence base to explain what intervention or clinical attributes may influence the cost implications.
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Affiliation(s)
- Shoko Maru
- Centre for Applied Health Economics, Griffith University, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, Griffith University, Australia
| | - Melinda J Carrington
- NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
| | - Simon Stewart
- NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, Griffith University, Australia
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Hammerer-Lercher A, Collinson P, van Dieijen-Visser MP, Pulkki K, Suvisaari J, Ravkilde J, Stavljenic-Rukavina A, Baum H, Laitinen P. Do laboratories follow heart failure recommendations and guidelines and did we improve? The CARdiac MArker Guideline Uptake in Europe (CARMAGUE). Clin Chem Lab Med 2014; 51:1301-6. [PMID: 23334056 DOI: 10.1515/cclm-2012-0510] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 12/03/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Natriuretic peptides (NP) are well-established markers of heart failure (HF). During the past 5 years, analytical and clinical recommendations for measurement of these biomarkers have been published in guidelines. The aim of this follow-up survey was to investigate how well these guidelines for measurement of NP have been implemented in laboratory practice in Europe. METHODS Member societies of the European Federation of Clinical Chemistry and Laboratory Medicine were invited in 2009 to participate in a web-based audit questionnaire. The questionnaire requested information on type of tests performed, decision limits for HF, turn-around time and frequency of testing. RESULTS There was a moderate increase (12%) of laboratories measuring NP compared to the initial survey in 2006. The most frequently used HF decision limits for B-type NP (BNP) and N-terminal BNP (NT-proBNP) were, respectively, 100 ng/L and 125 ng/L, derived from the package inserts in 55%. Fifty laboratories used a second decision limit. Age or gender dependent decision limits were applied in 10% (8.5% in 2006). The vast majority of laboratories (80%) did not have any criteria regarding frequency of testing, compared to 33% in 2006. CONCLUSIONS The implementation of NP measurement for HF management was a slow process between 2006 and 2009 at a time when guidelines had just been established. The decision limits were derived from package insert information and literature. There was great uncertainty concerning frequency of testing which may reflect the debate about the biological variability which was not published for most of the assays in 2009.
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Affiliation(s)
- Angelika Hammerer-Lercher
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital Innsbruck, Austria.
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Abete P, Adlbrecht C, Assimakopoulos SF, Côté N, Dullaart RP, Evsyukova HV, Fang TC, Goswami N, Hinghofer-Szalkay H, Ho YL, Hoebaus C, Hülsmann M, Indridason OS, Kholová I, Lin YH, Maniscalco M, Mathieu P, Mizukami H, Ndrepepa G, Roessler A, Sánchez-Ramón S, Santamaria F, Schernthaner GH, Scopa CD, Sharp KM, Skuladottir GV, Steichen O, Stenvinkel P, Tejera-Alhambra M, Testa G, Visseren FL, Westerink J, Witasp A, Yagihashi S, Ylä-Herttuala S. Research update for articles published in EJCI in 2011. Eur J Clin Invest 2013. [DOI: 10.1111/eci.12131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Pasquale Abete
- Dipartimento di Scienze Mediche Traslazionali; Università degli Studi di Napoli “Federico II”; Naples Italy
| | - Christopher Adlbrecht
- Division of Cardiology; Department of Internal Medicine II; Medical University of Vienna; Vienna Austria
| | | | - Nancy Côté
- Department of Surgery; Laboratoire d'Études Moléculaires des Valvulopathies (LEMV); Institut Universitaire de Cardiologie et de Pneumologie de Québec/Research Center; Laval University; Québec Canada
| | - Robin P.F. Dullaart
- Department of Endocrinology; University of Groningen and University Medical Centre Groningen; Groningen The Netherlands
| | - Helen V. Evsyukova
- Department of Hospital Therapy; Medical Faculty; St Petersburg State University; St. Petersburg Russia
| | - Te-Chao Fang
- Division of Nephrology; Department of Internal Medicine; Buddhist Tzu Chi General Hospital; Hualien Taiwan
| | - Nandu Goswami
- Institute of Physiology; Medical University of Graz; Austria
| | | | - Yi-Lwun Ho
- Department of Internal Medicine; National Taiwan University Hospital and National Taiwan University College of Medicine; Taipei Taiwan
| | - Clemens Hoebaus
- Department of Medicine II; Angiology, Medical University and General Hospital of Vienna; Vienna Austria
| | - Martin Hülsmann
- Division of Cardiology; Department of Internal Medicine II; Medical University of Vienna; Vienna Austria
| | - Olafur S. Indridason
- Internal Medicine Services; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland
| | - Ivana Kholová
- Pathology; Fimlab Laboratories; Tampere University Hospital; Tampere Finland
| | - Yen-Hung Lin
- Department of Internal Medicine; National Taiwan University Hospital and National Taiwan University College of Medicine; Taipei Taiwan
| | - Mauro Maniscalco
- Section of Respiratory Diseases; Hospital “S. Maria della Pietà”; Casoria Naples Italy
| | - Patrick Mathieu
- Department of Surgery; Laboratoire d'Études Moléculaires des Valvulopathies (LEMV); Institut Universitaire de Cardiologie et de Pneumologie de Québec/Research Center; Laval University; Québec Canada
| | - Hiroki Mizukami
- Department of Pathology and Molecular Medicine; Hirosaki University Graduate School of Medicine; Hirosaki Japan
| | - Gjin Ndrepepa
- Herz- und Kreislauferkrankungen; Deutsches Herzzentrum München; Technische Universität; Munich Germany
| | | | | | - Francesca Santamaria
- Department of Translational Medical Sciences; Federico II University; Naples Italy
| | | | | | | | - Gudrun V. Skuladottir
- Department of Physiology; Faculty of Medicine; School of Health Sciences; University of Iceland; Reykjavik Iceland
| | - Olivier Steichen
- Internal Medicine Department; Assistance Publique-Hôpitaux de Paris; Tenon Hospital; Paris France
- Faculty of Medicine; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum; Department of Clinical Science; Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Marta Tejera-Alhambra
- Laboratory of Neuroimmunology; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Gianluca Testa
- Dipartimento di Medicina e Scienze della Salute; Università del Molise; Campobasso Italy
| | - Frank L.J. Visseren
- Department of Vascular Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Anna Witasp
- Divisions of Renal Medicine and Baxter Novum; Department of Clinical Science; Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Soroku Yagihashi
- Department of Pathology and Molecular Medicine; Hirosaki University Graduate School of Medicine; Hirosaki Japan
| | - Seppo Ylä-Herttuala
- A.I.Virtanen Institute for Molecular Sciences; University of Eastern Finland; Kuopio Finland
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Fox AA, Nascimben L, Body SC, Collard CD, Mitani AA, Liu KY, Muehlschlegel JD, Shernan SK, Marcantonio ER. Increased perioperative b-type natriuretic peptide associates with heart failure hospitalization or heart failure death after coronary artery bypass graft surgery. Anesthesiology 2013; 119:284-94. [PMID: 23695172 PMCID: PMC3840806 DOI: 10.1097/aln.0b013e318299969c] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF) is a leading cause of hospitalization and mortality. Plasma B-type natriuretic peptide (BNP) is an established diagnostic and prognostic ambulatory HF biomarker. We hypothesized that increased perioperative BNP independently associates with HF hospitalization or HF death up to 5 yr after coronary artery bypass graft surgery. METHODS The authors conducted a two-institution, prospective, observational study of 1,025 subjects (mean age = 64 ± 10 yr SD) undergoing isolated primary coronary artery bypass graft surgery with cardiopulmonary bypass. Plasma BNP was measured preoperatively and on postoperative days 1-5. The study outcome was hospitalization or death from HF, with HF events confirmed by reviewing hospital and death records. Cox proportional hazards analyses were performed with multivariable adjustments for clinical risk factors. Preoperative and peak postoperative BNP were added to the multivariable clinical model in order to assess additional predictive benefit. RESULTS One hundred five subjects experienced an HF event (median time to first event = 1.1 yr). Median follow-up for subjects who did not have an HF event = 4.2 yr. When individually added to the multivariable clinical model, higher preoperative and peak postoperative BNP concentrations each, independently associated with the HF outcome (log10 preoperative BNP hazard ratio = 1.93; 95% CI, 1.30-2.88; P = 0.001; log10 peak postoperative BNP hazard ratio = 3.38; 95% CI, 1.45-7.65; P = 0.003). CONCLUSIONS Increased perioperative BNP concentrations independently associate with HF hospitalization or HF death during the 5 yr after primary coronary artery bypass graft surgery. Clinical trials may be warranted to assess whether medical management focused on reducing preoperative and longitudinal postoperative BNP concentrations associates with decreased HF after coronary artery bypass graft surgery.
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Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Curiati MNC, Silvestre OM, Pires LJT, Mangini S, Pires PV, Gaiotto FA, Laurino AM, Pêgo-Fernandes PM, Ferreira CEDS, Bacal F. Agreement of BNP and NT-proBNP and the influence of clinical and laboratory variables. EINSTEIN-SAO PAULO 2013; 11:273-7. [PMID: 24136751 PMCID: PMC4878583 DOI: 10.1590/s1679-45082013000300003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 08/24/2013] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To correlate the serum levels of B type natriuretic peptide and the N-terminal fraction of the pro-B type natriuretic peptide, as well as to analyze the influence of age, obesity, renal failure, left ventricle ejection fraction, diastolic dysfunction, and anemia on serum levels of both markers. METHODS An observational study in which the agreement was compared between these markers in consecutive samples of 138 patients. For the correlation, Pearson's test was used, and p<0.05 was considered statistically significant. RESULTS A linear association was observed between the B type natriuretic peptide and N-terminal fraction of the pro-B type natriuretic peptide (r=0.907; p<0.001). When evaluating the categorized measurements as normal and altered, there was good agreement, with 90.6% of agreement classifications (p<0.001) in which altered values of the N-terminal fraction of the pro-B type natriuretic peptide and normal values of the B type natriuretic peptide represented 8.7% of the total; the opposite situation represented 1% of the total. Assessment of the influence of the clinical and laboratorial factors on the levels of natriuretic peptides showed that they rise according to age, but that they fall as the ejection fraction increases. Patients with anemia (p<0.001) or with renal failure (p=0.007) had higher values of both markers. There was no association between obesity and the B type natriuretic peptide. CONCLUSION There was satisfactory agreement between the B type natriuretic peptide and the N-terminal fraction of the pro-B type natriuretic peptide. Age, creatinine levels, and hemoglobin, as well as ventricular function, influence the serum levels of both natriuretic peptides.
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Affiliation(s)
| | - Odilson Marcos Silvestre
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | | | | | | | - Fernando Bacal
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Abstract
Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.
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Affiliation(s)
- Luis E Rohde
- Postgraduate Program in Cardiovascular Science, Universidade Federal do Rio Grande do Sul, National Institute for Health Technology Assessment (IATS), CNPq, Av. Bento Gonçalves 9500, Porto Alegre, RS, Brazil
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Adlbrecht C, Hülsmann M, Neuhold S, Strunk G, Pacher R. Prognostic utility of the Seattle Heart Failure Score and amino terminal pro B-type natriuretic peptide in varying stages of systolic heart failure. J Heart Lung Transplant 2013; 32:533-8. [PMID: 23453573 DOI: 10.1016/j.healun.2013.01.1048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/08/2013] [Accepted: 01/25/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Cardiac transplantation represents the best procedure to improve long-term clinical outcome in advanced chronic heart failure (CHF), if pre-selection criteria are sufficient to outweigh the risk of the failing heart over the risk of transplantation. Although the cornerstone of success, risk assessment in heart transplant candidates is still under-investigated. Amino terminal pro B-type natriuretic peptide (NT-proBNP) is regarded as the best predictor of outcome in CHF, and the Seattle Heart Failure Score (SHFS), including clinical markers, is widely used if NT-proBNP is unavailable. METHODS The present study assessed the predictive value for all-cause death of the SHFS in CHF patients and compared it with NT-proBNP in a multivariate model including established baseline parameters known to predict survival. RESULTS A total of 429 patients receiving stable HF-specific pharmacotherapy were included and monitored for 53.4 ± 20.6 months. Of these, 133 patients (31%) died during follow-up. Several established predictors of death on univariate analysis proved significant for the total study cohort. Systolic pulmonary arterial pressure (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.02-1.05); p < 0.001, Wald 15.1), logNT-proBNP (HR, 1.51; 95% CI, 1.22-1.86; p < 0.001, Wald 14.9), and the SHFS (HR, 0.99; 95% CI, 0.99-1.00; p < 0.001, Wald 12.6) remained within the stepwise multivariate Cox regression model as independent predictors of all-cause death. Receiver operating characteristic curve analysis revealed an area under the curve of 0.802 for logNT-proBNP and 0.762 for the SHFS. CONCLUSIONS NT-proBNP is a more potent marker to identify patients at the highest risk. If the NT-proBNP measurement is unavailable, the SHFS may serve as an adequate clinical surrogate to predict all-cause death.
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Affiliation(s)
- Christopher Adlbrecht
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Cost-effectiveness of N-terminal pro-B-type natriuretic-guided therapy in elderly heart failure patients: results from TIME-CHF (Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure). JACC-HEART FAILURE 2013; 1:64-71. [PMID: 24621800 DOI: 10.1016/j.jchf.2012.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/16/2012] [Accepted: 08/22/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study aimed to assess cost-effectiveness of N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided versus symptom-guided therapy in heart failure (HF) patients ≥60 years old. BACKGROUND Cost-effectiveness of NT-proBNP guidance in HF patients is unclear. It may create additional costs with uncertain benefits. METHODS In the TIME-CHF (Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure), patients with left ventricular ejection fraction (LVEF) of ≤45% were randomized to receive intensified NT-proBNP-guided therapy or standard, symptom-guided therapy. For cost-effectiveness analysis, 467 (94%) patients (age 76 ± 7 years, 66% male) were eligible. Incremental cost-effectiveness was calculated as incremental costs per gained life-year and quality-adjusted life-year (QALY) within the 18-month trial period, as defined per protocol. RESULTS NT-proBNP-guided therapy was dominant (i.e., more effective and less costly) over symptom-guided therapy, saving $2,979 USD (2.5 to 97.5% confidence interval [CI]: $8,758 to $3,265) per patient, with incremental effectiveness of +0.07 life-years and +0.05 QALYs. The probability of NT-proBNP-guided therapy being dominant was 80%, and the probability of saving 1 life-year or QALY at a cost of $50,000 was 97% and 93%, respectively. Exclusion of residence costs resulted in an incremental cost-effectiveness ratio (ICER) of $5,870 per life-year gained. Cost-effectiveness of NT-proBNP-guided therapy was most pronounced in patients <75 years old and in those with <2 significant comorbidities, being dominant in all sensitivity analyses. In the worst-case scenario (excluding residence costs in those with ≥2 comorbidities), the ICER was $11,935 per life-year gained. CONCLUSIONS NT-proBNP-guided therapy has a high probability of being cost effective in HF patients with reduced LVEF, particularly in patients age 60 to 75 years or with less than 2 comorbidities. (Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure [TIME-CHF]; ISRCTN43596477).
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COST-UTILITY ANALYSIS OF NT-PROBNP-GUIDED MULTIDISCIPLINARY CARE IN CHRONIC HEART FAILURE. Int J Technol Assess Health Care 2012; 29:3-11. [DOI: 10.1017/s0266462312000712] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives: A recent randomized, controlled trial in chronic heart failure patients showed that NT-proBNP-guided, intensive patient management (BMC) on top of multidisciplinary care reduced all-cause mortality and heart failure hospitalizations compared with multidisciplinary care (MC) or usual care (UC). We now performed a cost-utility analysis of these interventions from a payer's perspective.Methods: Costs related to hospitalizations, ambulatory physician and nurse visits, and NT-proBNP testing for the three management strategies were acquired for both Austria (€) and Canada ($) and combined with the survival and quality of life data from the clinical trial for cost-effectiveness analysis. Data on long-term survival, costs, and quality-adjusted life-years (QALY) were extrapolated for a 20-year time horizon using a Markov model, which simulated the progression of disease through beta-blocker use, hospitalizations, and mortality.Results: BMC was the most cost-effective strategy as it was dominant (cost-saving with improved health outcome) over both MC and UC based on both Austrian and Canadian costs. Incremental cost-effectiveness ratios for MC relative to UC were €3,746 and $5,554 per QALY gained for Austrian and Canadian costs, respectively. The probabilities for BMC being the most cost-effective strategy were 92 percent at a threshold value of Austrian €40,000 and 93 percent at a threshold value of Canadian $50,000.Conclusions: NT-proBNP-guided, intensive HF patient management in addition to multidisciplinary care not only reduces death and hospitalization but also proves to be cost-effective.
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Pastural-Thaunat M, Ecochard R, Boumendjel N, Abdullah E, Cardozo C, Lenz A, M'pio I, Szelag JC, Fouque D, Walid A, Laville M. Relative Change in NT-proBNP Level: An Important Risk Predictor of Cardiovascular Congestion in Haemodialysis Patients. NEPHRON EXTRA 2012; 2:311-8. [PMID: 23341833 PMCID: PMC3551398 DOI: 10.1159/000343897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background Cross-sectional studies have shown that B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) are predictive of cardiovascular death in haemodialysis (HD) patients. In the present study, we tested the hypothesis that monitoring NT-proBNP measurements adds further prognostic information, i.e. predicts congestive heart failure (CHF) events. Methods In a prospective cohort of 236 HD patients, NT-proBNP levels were measured monthly during 18 months. Patients were divided according to the occurrence of CHF events. In a nested case-control study, we assessed the evolution of NT-proBNP levels. Results On average, the 236 HD patients were followed up for 12.5 months, a period during which 44 patients developed a CHF event (half requiring hospitalisation). At baseline, patients who developed a CHF event had significantly more dilated cardiomyopathy and/or altered left ventricular ejection fraction and higher NT-proBNP levels compared with patients who did not develop a CHF event. During follow-up, we observed a significant increase in NT-proBNP levels preceding the CHF event. At a 20% relative increase of NT-proBNP, the sensitivity of NT-proBNP as a predictor of CHF events was 0.57 and the specificity 0.77. Conclusion The relative change in NT-proBNP levels is a significant risk predictor of a CHF event.
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Kalogeropoulos AP, Georgiopoulou VV, Butler J. Clinical adoption of prognostic biomarkers: the case for heart failure. Prog Cardiovasc Dis 2012; 55:3-13. [PMID: 22824105 DOI: 10.1016/j.pcad.2012.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The recent explosion of scientific knowledge and technological progress has led to the discovery of a large array of circulating molecules commonly referred to as biomarkers. Biomarkers in heart failure (HF) research have been used to provide pathophysiologic insights, aid in establishing the diagnosis, refine prognosis, guide management, and target treatment. However, beyond diagnostic applications of natriuretic peptides, there are currently few widely recognized applications for biomarkers in HF. This represents a remarkable discordance considering the number of molecules that have been shown to correlate with outcomes, refine risk prediction, or track disease severity in HF in the past decade. In this article, we use a broad framework proposed for cardiovascular risk markers to summarize the current state of biomarker development for patients with HF. We use this framework to identify the challenges of biomarker adoption for risk prediction, disease management, and treatment selection for HF and suggest considerations for future research.
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