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Seckin M, Johnston B, Petrie MC, Stewart S, Chan YK. Characteristics of symptoms and symptom change across different heart failure subtypes: a sex-stratified analysis. Eur J Cardiovasc Nurs 2023; 22:690-700. [PMID: 36288919 DOI: 10.1093/eurjcn/zvac099] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 10/12/2023]
Abstract
AIMS To examine sex-stratified differences in the association of left ventricular ejection fraction-based heart failure (HF) subtypes and the characteristics and correlates of self-reported changes in HF symptoms. METHODS AND RESULTS We report a secondary data analysis from 528 hospitalized individuals diagnosed with HF characterised by a reduced, mildly reduced, or preserved ejection fraction [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] who completed 12-month follow-up within a multicentre disease management trial. There were 302 men (71.1 ± 11.9 years, 58% with HFrEF) and 226 women (77.1 ± 10.6 years, 49% with HFpEF). The characteristics of self-reported symptoms measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12-month were analysed. At baseline, shortness of breath and fatigue predominated; with key differences according to HF subtypes in bilateral ankle oedema (both sexes), walking problems (women) and depressive symptoms (men). At 12-month follow-up, most KCCQ scores had not significantly changed. However, 25% of individuals reported worse symptom. In women, those with HFpEF had worse symptoms than those with HFmrEF/HFrEF (P = 0.025). On an adjusted basis, women [odds ratios (OR): 1.78, 95% confidence interval (CI): 1.00-3.16 vs. men], those with coronary artery disease (OR: 2.01, 95% CI: 1.21-3.31) and baseline acute pulmonary oedema (OR: 1.67, 95% CI: 1.02-2.75) were most likely to report worsening symptoms. Among men, worsening symptoms correlated with a history of hypertension (OR: 2.16, 95% CI: 1.07-4.35) and a non-English-speaking background (OR: 2.30, 95% CI: 1.02-5.20). CONCLUSION We found significant heterogeneity (with potential clinical implications) in the symptomatic characteristics and subsequent symptom trajectory according to the sex and HF subtype of those hospitalized with the syndrome. TRIAL REGISTRATION ANZCTR12613000921785.
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Affiliation(s)
- Muzeyyen Seckin
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
| | - Bridget Johnston
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
- NHS Greater Glasgow and Clyde, 1055 Great Western Rd, Glasgow, G12 0XH, UK
| | - Mark C Petrie
- NHS Greater Glasgow and Clyde, 1055 Great Western Rd, Glasgow, G12 0XH, UK
- School of Cardiovascular & Metabolic Health, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Simon Stewart
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
- Institute of Health Research, Notre Dame University of Australia, 32 Mouat St, Fremantle, WA 6160, Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australia Catholic University, 215 Spring Street, Melbourne, VIC 3000, Australia
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Cope AL, Bannister C, Karki A, Harper P, Allen M, Jones R, Peddle S, Walters B, Chestnutt IG. The development and application of a chairside oral health risk and need stratification tool in general dental services. J Dent 2022; 123:104206. [PMID: 35752369 DOI: 10.1016/j.jdent.2022.104206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the development and application of the Assessment of Clinical Oral Risks and Needs (ACORN) stratification tool based on a traffic light system in National Health Service (NHS) general dental services (GDS) Wales, UK. MATERIALS AND METHODS This was a secondary analysis of routinely-collected dental care data. All courses of treatment provided in dental practices participating in NHS GDS Reform Programme between July 2018 and September 2019, in which an ACORN assessment and age were recorded were included in the analysis. RESULTS A total of 236,490 subjects contributed 339,933 courses of treatment during the study period. 'Amber' and 'red' ACORN outcomes were associated with more courses of treatment per annum than 'green' outcomes. Outcomes indicating an increased risk of decay or other dental problems were associated with a greater likelihood of several operative treatment items. Patients at greater risk of poor periodontal health were more likely to receive extractions and dentures than low-risk patients. Patients were most likely to either remain in the same ACORN outcome categories or move to a healthier state between assessments. CONCLUSION More research is required to understand the utility of the ACORN tool in risk communication and behaviour change.
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Affiliation(s)
| | | | | | - Paul Harper
- School of Mathematics, Cardiff University, Wales, UK
| | - Michael Allen
- Cardiff and Vale University Health Board, Cardiff, Wales, UK
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Yiallourou SR, Carrington MJ. Improved sleep efficiency is associated with reduced cardio-metabolic risk: Findings from the MODERN trial. J Sleep Res 2021; 30:e13389. [PMID: 34080247 DOI: 10.1111/jsr.13389] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 11/27/2022]
Abstract
Poor sleep increases cardio-metabolic risk, but limited information on the impact of sleep for the improvement of cardio-metabolic health exists. This analysis examined the impact of sleep on a health and lifestyle modification programme to reduce cardio-metabolic disease risk factors. Secondary analysis of the MODERN randomised controlled trial to reduce cardio-metabolic risk was undertaken at baseline and 24-month follow-up. Participants aged 40-70 years (n = 121) with three or more cardio-metabolic risk factors were randomised to a health and lifestyle modification intervention (n = 59) or usual care (n = 62), and underwent 7 day/night actigraphy to assess total sleep time, sleep efficiency (%), number of awakenings/night and physical activity levels. Blood pressure, blood lipid and glycaemic levels, anthropometric and diet measures were collected. The mean age was 59 ± 7 years and 37% were male. Baseline sleep measures were not different between groups. At the 24-month follow-up, both groups showed improvements in cardio-metabolic risk factors, albeit the change in blood pressure was greater in the intervention compared with the usual care group (systolic blood pressure: -11 versus -4 mmHg, p = .014). There were no differences between groups for diet, physical activity or sleep parameters. An increase in sleep efficiency was independently associated with lower systolic blood pressure (β = -2.117, p = .002) and higher high-density lipoprotein levels (β = 0.040, p = .033); an increase in total sleep time was associated with lower low-density lipoprotein levels (β = -0.003, p = .038) at 24 months. Overall, improvement in sleep quality over time was beneficial to reduce blood pressure and lipid levels. These findings highlight sleep as a potential target to reduce cardio-metabolic risk.
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Affiliation(s)
- Stephanie R Yiallourou
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Melinda J Carrington
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
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Carrington MJ, Zimmet PZ. Nurse co-ordinated health and lifestyle modification for reducing multiple cardio-metabolic risk factors in regional adults: outcomes from the MODERN randomized controlled trial. Eur J Cardiovasc Nurs 2021; 21:26-35. [PMID: 33899090 DOI: 10.1093/eurjcn/zvab042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/16/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Nurse-led health and lifestyle modification programmes can prevent cardio-metabolic diseases and be advantageous where health disparities exist. AIMS To assess the effectiveness of a nurse-driven health and lifestyle modification programme in improving cardio-metabolic risk parameters for higher-risk regional residing adults. METHODS We conducted an open, parallel-group randomized controlled trial in two sites. Participants were aged 40-70 years with no prior cardiovascular disease who had any three or more of; central obesity, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure (BP) and dysglycaemia. Intervention participants received individual face-to-face and telephone coaching for improving cardio-metabolic risk. Control group participants received standard care and general information about risk factor management. The primary endpoint was the percentage of participants who achieved the target risk factor thresholds or clinically significant minimum changes for any three or more cardio-metabolic risk factors during 24 months of follow-up. RESULTS Participant average age was 57.6 (SD 7.6) years, 61% were female and 71% were employed. The primary endpoint was achieved by 76% intervention (97 of 127) and 71% usual care (92 of 129) participants [adjusted risk ratio (RR): 1.08; 95% CI 0.94, 1.24; P = 0.298]. Improved BP in the intervention group was more likely than in the control group (84% vs. 65%) (adj. RR: 1.28; 95% CI 1.11, 1.48; P = 0.001) but no other cardio-metabolic component. CONCLUSION Nurse intervention to modify cardio-metabolic risk parameters had no enhanced effectiveness compared with usual care. However, participation was associated with improvements in cardio-metabolic abnormalities, with particular emphasis on BP. TRIAL REGISTRATION Registered with the Australian New Zealand Clinical Trial Registry (ACTRN12616000229471).
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Affiliation(s)
- Melinda J Carrington
- Pre-Clinical Disease and Prevention Unit, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne VIC 3004, Australia
| | - Paul Z Zimmet
- Department of Diabetes, Faculty of Medicine, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne VIC 3004, Australia
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Garrido MV, Prada M, Simão C, Semin GR. The Impact of Stimuli Color in Lexical Decision and Semantic Word Categorization Tasks. Cogn Sci 2019; 43:e12781. [DOI: 10.1111/cogs.12781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/14/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Marília Prada
- Instituto Universitário de Lisboa (ISCTE‐IUL) CIS – IUL
| | - Cláudia Simão
- Católica Lisbon School of Business and Economics Universidade Católica Portuguesa
| | - Gün R. Semin
- William James Center for Research ISPA‐Instituto Universitário
- Faculty of Social and Behavioral Sciences Utrecht University
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Stewart S. Have Traditional Heart Failure Management Programs Reached Their "Use by" Date? Time to Apply More Nuanced Care. Curr Heart Fail Rep 2019; 16:75-80. [PMID: 30891675 DOI: 10.1007/s11897-019-00426-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW To determine the current evidence supporting the otherwise proven heart failure management programs (HFMPs) in the setting of an increasingly older and more complex patient population. RECENT FINDINGS Attempts to replace proven face-to-face, multidisciplinary management of HF with remote management techniques (including telemedicine and implantable remote monitoring devices) have yielded mixed results. This may well reflect the clinical cascade effect of greater surveillance paradoxically leading to worse health outcomes as well as a narrow focus on HF alone in patients with clinically significant multimorbidity. Concurrently, there is preliminary evidence that the increasing phenomenon of HF and multimorbidity in older patients is undermining the otherwise positive impact of "traditional" HFMPs. A more nuanced approach to determining who would benefit from what form of HF management, including the integration of remote surveillance techniques, is required.
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Affiliation(s)
- Simon Stewart
- Hatter Institute, University of Cape Town, Cape Town, 8001, South Africa.
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Scuffham PA, Ball J, Horowitz JD, Wong C, Newton PJ, Macdonald P, McVeigh J, Rischbieth A, Emanuele N, Carrington MJ, Reid CM, Chan YK, Stewart S. Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial. Eur Heart J 2018; 38:2340-2348. [PMID: 28531281 PMCID: PMC5843128 DOI: 10.1093/eurheartj/ehx259] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/27/2017] [Indexed: 12/28/2022] Open
Abstract
Aims To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint). Methods and results A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively. Conclusion During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.
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Affiliation(s)
- P A Scuffham
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, N78_2.42 The Circuit, Nathan, Queensland 4111, Australia
| | - J Ball
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia
| | - J D Horowitz
- Department of Cardiology, Queen Elizabeth Hospital, University of Adelaide, North Terrace, Adelaide, South Australia 5000, Australia
| | - C Wong
- Department of Cardiology, Western Health (Footscray Hospital), Melbourne Medical School, The University of Melbourne, Grattan St, Parkville, Victoria 3010, Australia
| | - P J Newton
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, New South Wales 2007, Australia
| | - P Macdonald
- Heart Failure and Transplant Unit, St Vincent's Hospital, 390 Victoria St, Darlinghurst, Sydney, NSW 2010, Australia
| | - J McVeigh
- Department of Cardiology, Prince of Wales Hospital, Barker St, Randwick, NSW 2031, Australia
| | - A Rischbieth
- National Heart Foundation of Australia, 500 Collins St Melbourne, Victoria 3000, Australia.,Faculty of Health Sciences, University of Adelaide, North Terrace, Adelaide, South Australia 5000, Australia
| | - N Emanuele
- National Heart Foundation of Australia, 500 Collins St Melbourne, Victoria 3000, Australia
| | - M J Carrington
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Mary MacKillop Institute for Health Research, NHMRC of Australia Centre of Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Level 5, 215 Spring St, Melbourne, Victoria 3000, Australia
| | - C M Reid
- NHMRC Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Kent St, Bentley, Western Australia 6102, Australia
| | - Y K Chan
- Mary MacKillop Institute for Health Research, NHMRC of Australia Centre of Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Level 5, 215 Spring St, Melbourne, Victoria 3000, Australia
| | - S Stewart
- Mary MacKillop Institute for Health Research, NHMRC of Australia Centre of Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Level 5, 215 Spring St, Melbourne, Victoria 3000, Australia
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Carrington MJ, Zimmet P. Nurse health and lifestyle modification versus standard care in 40 to 70 year old regional adults: study protocol of the Management to Optimise Diabetes and mEtabolic syndrome Risk reduction via Nurse-led intervention (MODERN) randomized controlled trial. BMC Health Serv Res 2017; 17:813. [PMID: 29212477 PMCID: PMC5719565 DOI: 10.1186/s12913-017-2769-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/27/2017] [Indexed: 11/10/2022] Open
Abstract
Background Metabolic syndrome (MetS), the clustering of multiple leading risk factors, predisposes individuals to increased risk for developing type 2 diabetes and/or cardiovascular disease (CVD). Cardio-metabolic disease risk increases with greater remoteness where specialist services are scarce. Nurse-led interventions are effective for the management of chronic disease. The aim of this clinical trial is to determine whether a nurse-implemented health and lifestyle modification program is more beneficial than standard care to reduce cardio-metabolic abnormalities and future risk of CVD and diabetes in individuals with MetS. Methods MODERN is a multi-centre, open, parallel group randomized controlled trial in regional Victoria, Australia. Participants were self-selected and individuals aged 40 to 70 years with MetS who had no evidence of CVD or other chronic disease were recruited. Those attending a screening visit with any 3 or more risk factors of central obesity, dyslipidemia (high triglycerides or low high density lipoprotein cholesterol) elevated blood pressure and dysglycemia were randomized to either nurse-led health and lifestyle modification (intervention) or standard care (control). The intervention included risk factor management, health education, care planning and scheduled follow-up commensurate with level of risk. The primary cardio-metabolic end-point was achievement of risk factor thresholds to eliminate MetS or minimal clinically meaningful changes for at least 3 risk factors that characterise MetS over 2 year follow-up. Pre-specified secondary endpoints to evaluate between group variations in cardio-metabolic risk, general health and lifestyle behaviours and new onset CVD and type 2 diabetes will be evaluated. Key outcomes will be measured at baseline, 12 and 24 months via questionnaires, physical examinations, pathology and other diagnostic tests. Health economic analyses will be undertaken to establish the cost-effectiveness of the intervention. Discussion The MODERN trial will provide evidence for the potential benefit of independent nurse-run clinics in the community and their cost-effectiveness in adults with MetS. Findings will enable more nurse-led clinics to be adopted outside of major cities and encompassing other chronic diseases as a key primary preventative initiative. Trial registration MODERN is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000229471) on 19 February 2016 (retrospectively registered). Secondary identifiers: MODERN is an investigator-initiated trial funded by the National Health and Medical Research Council of Australia from 2014 to 2017 via a Project Grant (ID No. APP1069043) and was approved by the Australian Catholic University Human Research Ethics Committee (Project No: 2014 244 V) and the Department of Health Human Research Ethics Committee (Project No:38/2014) for the release of Medicare claims information.
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Affiliation(s)
- Melinda J Carrington
- Pre-Clinical Disease and Prevention Unit, Baker Heart and Diabetes Institute, PO Box 6492, Melbourne, Victoria, 3004, Australia. .,Centre for Primary Care and Prevention, MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.
| | - Paul Zimmet
- Department of Diabetes, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Desai AS, Pfeffer MA. Beyond the P-value and the sound bite: learning from ‘negative’ clinical trials. Eur Heart J 2017; 38:2349-2351. [DOI: 10.1093/eurheartj/ehx395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chan YK, David AM, Mainland C, Chen L, Stewart S. Applying Heart Failure Management to Improve Health Outcomes: But WHICH One? Card Fail Rev 2017; 3:113-115. [PMID: 29387463 DOI: 10.15420/cfr.2017:11:1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report on our learning from many years of research testing the value of nurse-led, multidisciplinary, home-based management of heart failure. We discuss and highlight the key challenges we have experienced in testing this model of care relative to alternatives and evolving patient population. Accordingly, we propose a pragmatic approach to adapt current models of care to meet the needs of increasingly complex (and costly) patients with multimorbidity.
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Affiliation(s)
- Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University,Melbourne, Australia
| | - Alice M David
- Mary MacKillop Institute for Health Research, Australian Catholic University,Melbourne, Australia
| | - Caitlyn Mainland
- Mary MacKillop Institute for Health Research, Australian Catholic University,Melbourne, Australia
| | - Lei Chen
- Mary MacKillop Institute for Health Research, Australian Catholic University,Melbourne, Australia
| | - Simon Stewart
- Mary MacKillop Institute for Health Research, Australian Catholic University,Melbourne, Australia
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Stewart S, Wiley JF, Ball J, Chan YK, Ahamed Y, Thompson DR, Carrington MJ. Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials. Circulation 2016; 133:1867-77. [PMID: 27083509 PMCID: PMC4857795 DOI: 10.1161/circulationaha.116.020730] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/11/2016] [Indexed: 12/19/2022]
Abstract
Background— We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types. Methods and Results— Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112–1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2–92.0] versus 87.2% [95% confidence interval, 85.1–89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50–0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0–1.3] versus 0.36 [0–2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%–65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%–61%). Conclusions— These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.
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Affiliation(s)
- Simon Stewart
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.
| | - Joshua F Wiley
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Jocasta Ball
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Yih-Kai Chan
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Yasmin Ahamed
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - David R Thompson
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Melinda J Carrington
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
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Cost-Effectiveness of a Home Based Intervention for Secondary Prevention of Readmission with Chronic Heart Disease. PLoS One 2015; 10:e0144545. [PMID: 26657844 PMCID: PMC4684189 DOI: 10.1371/journal.pone.0144545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 11/19/2015] [Indexed: 12/22/2022] Open
Abstract
The aim of this study is to consider the cost-effectiveness of a nurse-led, home-based intervention (HBI) in cardiac patients with private health insurance compared to usual post-discharge care. A within trial analysis of the Young @ Heart multicentre, randomized controlled trial along with a micro-simulation decision analytical model was conducted to estimate the incremental costs and quality adjusted life years associated with the home based intervention compared to usual care. For the micro-simulation model, future costs, from the perspective of the funder, and effects are estimated over a twenty-year time horizon. An Incremental Cost-Effectiveness Ratio, along with Incremental Net Monetary Benefit, is evaluated using a willingness to pay threshold of $50,000 per quality adjusted life year. Sub-group analyses are conducted for men and women across three age groups separately. Costs and benefits that arise in the future are discounted at five percent per annum. Overall, home based intervention for secondary prevention in patients with chronic heart disease identified in the Australian private health care sector is not cost-effective. The estimated within trial incremental net monetary benefit is -$3,116 [95% CI: -11,145, $4,914]; indicating that the costs outweigh the benefits. However, for males and in particular males aged 75 years and above, home based intervention indicated a potential to reduce health care costs when compared to usual care (within trial: -$10,416 [95% CI: -$26,745, $5,913]; modelled analysis: -$1,980 [95% CI: -$22,843, $14,863]). This work provides a crucial impetus for future research to understand for whom disease management programs are likely to benefit most.
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Tuttle CSL, Carrington MJ, Stewart S, Brown A. Overcoming the tyranny of distance: An analysis of outreach visits to optimise secondary prevention of cardiovascular disease in high-risk individuals living in Central Australia. Aust J Rural Health 2015; 24:99-105. [PMID: 27087389 DOI: 10.1111/ajr.12222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES We examined the logistical challenges of conducting an outreach, secondary prevention program for adults discharged from Alice Springs Hospital following an acute presentation of cardiovascular disease. DESIGN AND SETTING This represents a sub-study of the Central Australian Heart Protection Study (CAHPS). Clinical, logistic and demographic data were used to examine the characteristics of outreach visits in the intervention arm of the study. PARTICIPANTS Fifty subjects initially allocated to the intervention arm of the trial were studied. MAIN OUTCOME MEASURES Completion of scheduled, plus additional outreach visits according to the intervention protocol. RESULTS The majority of subjects presented with an acute coronary syndrome (44/50 (88%)) and 31 (62%) were of Indigenous ethnicity. However, Indigenous subjects being younger (53.1 ± 11.1 versus 58.0 ± 11.0 years non-Indigenous) had a more complex risk factor and co-morbid profile, with significantly more diabetes (77% versus 26% P < 0.001), hypertension (81% versus 53% P = 0.04) and renal failure (52% versus 21% P = 0.03). Community of origin of Indigenous subjects was 230 ± 208 km from the hospital versus 61 ± 150 km for non-Indigenous subjects (P = 0.004). Indigenous subjects missed a significantly higher number of scheduled visits at six months (1.39 ± 2.14 versus 0.16 ± 0.50 visits; P = 0.02). However, multivariate analyses suggested that distance did not influence successful completion of visits. CONCLUSIONS These early findings from CAHPS are invaluable to understanding and improving the feasibility of secondary prevention programs for Indigenous adults living with heart disease in remote communities.
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Affiliation(s)
- Camilla S L Tuttle
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Melinda J Carrington
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Simon Stewart
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Alex Brown
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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Stewart S, Chan YK, Wong C, Jennings G, Scuffham P, Esterman A, Carrington M. Impact of a nurse-led home and clinic-based secondary prevention programme to prevent progressive cardiac dysfunction in high-risk individuals: the Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) randomized controlled study. Eur J Heart Fail 2015; 17:620-30. [DOI: 10.1002/ejhf.272] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 01/22/2023] Open
Affiliation(s)
- Simon Stewart
- Mary MacKillop Institute for Health Research; Australian Catholic University; Melbourne Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research; Australian Catholic University; Melbourne Australia
| | - Chiew Wong
- Non-intervention Cardiology; Western Health; Melbourne Australia
| | - Garry Jennings
- Baker IDI Heart and Diabetes Institute; Melbourne Australia
| | - Paul Scuffham
- Centre for Applied Health Economics & Menzies Health Institute Queensland; Griffith University; Brisbane Australia
| | - Adrian Esterman
- University of South Australia, Adelaide, Australia and Centre for Research Excellence in Chronic Disease Prevention; James Cook University; Cairns Australia
| | - Melinda Carrington
- Mary MacKillop Institute for Health Research; Australian Catholic University; Melbourne Australia
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15
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Affiliation(s)
| | - Holli A DeVon
- University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
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16
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Stewart S, Ball J, Horowitz JD, Marwick TH, Mahadevan G, Wong C, Abhayaratna WP, Chan YK, Esterman A, Thompson DR, Scuffham PA, Carrington MJ. Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: pragmatic, multicentre, randomised controlled trial. Lancet 2015; 385:775-84. [PMID: 25467562 DOI: 10.1016/s0140-6736(14)61992-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients are increasingly being admitted with chronic atrial fibrillation, and disease-specific management might reduce recurrent admissions and prolong survival. However, evidence is scant to support the application of this therapeutic approach. We aimed to assess SAFETY--a management strategy that is specific to atrial fibrillation. METHODS We did a pragmatic, multicentre, randomised controlled trial in patients admitted with chronic, non-valvular atrial fibrillation (but not heart failure). Patients were recruited from three tertiary referral hospitals in Australia. 335 participants were randomly assigned by computer-generated schedule (stratified for rhythm or rate control) to either standard management (n=167) or the SAFETY intervention (n=168). Standard management consisted of routine primary care and hospital outpatient follow-up. The SAFETY intervention comprised a home visit and Holter monitoring 7-14 days after discharge by a cardiac nurse with prolonged follow-up and multidisciplinary support as needed. Clinical reviews were undertaken at 12 and 24 months (minimum follow-up). Coprimary outcomes were death or unplanned readmission (both all-cause), measured as event-free survival and the proportion of actual versus maximum days alive and out of hospital. Analyses were done on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTRN 12610000221055). FINDINGS During median follow-up of 905 days (IQR 773-1050), 49 people died and 987 unplanned admissions were recorded (totalling 5530 days in hospital). 127 (76%) patients assigned to the SAFETY intervention died or had an unplanned readmission (median event-free survival 183 days [IQR 116-409]) and 137 (82%) people allocated standard management achieved a coprimary outcome (199 days [116-249]; hazard ratio 0·97, 95% CI 0·76-1·23; p=0·851). Patients assigned to the SAFETY intervention had 99·5% maximum event-free days (95% CI 99·3-99·7), equating to a median of 900 (IQR 767-1025) of 937 maximum days alive and out of hospital. By comparison, those allocated to standard management had 99·2% (95% CI 98·8-99·4) maximum event-free days, equating to a median of 860 (IQR 752-1047) of 937 maximum days alive and out of hospital (effect size 0·22, 95% CI 0·21-0·23; p=0·039). INTERPRETATION A post-discharge management programme specific to atrial fibrillation was associated with proportionately more days alive and out of hospital (but not prolonged event-free survival) relative to standard management. Disease-specific management is a possible strategy to improve poor health outcomes in patients admitted with chronic atrial fibrillation. FUNDING National Health and Medical Research Council of Australia.
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Affiliation(s)
- Simon Stewart
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia.
| | - Jocasta Ball
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - John D Horowitz
- The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | | | - Gnanadevan Mahadevan
- The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Chiew Wong
- Department of Cardiology, Footscray Hospital, Melbourne, VIC, Australia
| | - Walter P Abhayaratna
- Division of Medicine, Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Yih K Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Adrian Esterman
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - David R Thompson
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
| | - Melinda J Carrington
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
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17
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Carrington MJ, Stewart S. Cardiovascular disease prevention via a nurse-facilitated intervention clinic in a regional setting: The Protecting Healthy Hearts Program. Eur J Cardiovasc Nurs 2014; 14:352-61. [DOI: 10.1177/1474515114537022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 04/29/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Melinda J Carrington
- Centre for Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
| | - Simon Stewart
- Centre for Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Australia
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19
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Cameron J, Ski CF, McLennan SN, Rendell PG, Whitbourn RJ, Thompson DR. Development of the Heart Failure Screening Tool (Heart-FaST) to measure barriers that impede engagement in self-care. Eur J Cardiovasc Nurs 2013; 13:408-17. [PMID: 23969781 DOI: 10.1177/1474515113502461] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Screening for self-care capacity is advocated before applying educational strategies. No screening tool has been specifically developed to assess barriers that impede engagement in self-care in people with heart failure. Earlier conceptual work (InCOGNITO) identified NYHA class, mild cognitive impairment and depressive symptoms as barriers that impede engagement in HF self-care. AIMS Study aims were: 1) to develop the Heart Failure Screening Tool (Heart-FaST) as a means of assessing three critical barriers to self-care; 2) to assess the content validity of the Heart-FaST; and 3) to test the feasibility of implementing the Heart-FaST in clinical practice. METHODS The Heart-FaST was developed from barriers identified in previous research (InCOGNITO) and from expert panel consensus. Content validity was assessed by examining the proportion of experts who scored each item as relevant. RESULTS The InCOGNITO study indicated that four cognitive tasks, seven emotional questions and NYHA functional class were significantly correlated with the self-care scales: maintenance, management and confidence. These factors were used to create the Heart-FaST items. Consensus on wording and items to be included in the Heart-FaST was reached after two rounds of panel discussion. All items had an item-level content validity index ≥ 0.78. High scores on each barrier (physical, cognitive and emotional functioning) suggest poor self-care and the need for more intensive disease management efforts. CONCLUSION The Heart-FaST measures three critical barriers that impede engagement in self-care. In clinical practice this tool may assist in individually tailoring educational and support strategies to promote effective heart failure self-care.
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Affiliation(s)
- Jan Cameron
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - Chantal F Ski
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - Skye N McLennan
- School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Peter G Rendell
- School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Robert J Whitbourn
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - David R Thompson
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
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