Impact of patient education on chronic heart failure in primary care (ETIC): a cluster randomised trial

Clinical Heart fAilure Management Program: Changing the practice by partnering primary care and specialists (CHAMP-HF)

Background

While significant gains were made in the management of heart failure (HF), most patients are still diagnosed when they are acutely ill in hospital, often with advanced disease. Earlier diagnosis in the community could lead to improved outcomes. Whether a partnership and an educational program for primary care providers (PCP) increase HF awareness and management is unknown.

Methods

We conducted an observational study between March 2019 and June 2020 during which HF specialists gave monthly HF conferences to PCP. Using a pre-post design, medical charts and administrative databases were reviewed and a questionnaire was completed by participating PCP. Primary and secondary endpoints included: 1) the number of patients diagnosed with HF, 2) implementation of GDMT for patients with HFrEF; 3) PCPs' experience and confidence.

Results

Six PCP agreed to participate. Amongst the 11,909 patients of the clinic, 70 (0.59 %) patients met the criteria for HF. This number increased by 28.6 % (n = 90) after intervention. Increased use of GDMT for HFrEF patients at baseline (n = 35) was observed for all class of agents, with doubling of patients on triple therapies, from 8 (22.9 %) to 16 (45.7 %), p = 0.0047. Self-confidence on HF management was low (1, 16.7 %) but increased after the educational intervention of physicians (3, 50 %).

Conclusion

An educational and collaborative approach between HF specialists and community PCP increased the number of new HF cases diagnosed, enhanced implementation of GDMT in patients with HFrEF and increase PCPs' confidence in treating HF, despite being conducted during the COVID-19 pandemic.

How to Evaluate Online Education for General Practitioners: Development of a Tailored Questionnaire for Heart Failure Education

Physician-oriented online education could be a pathway to improve care for patients with heart failure, however, it is difficult to measure the impact of such education. Self-efficacy is a potential outcome measure. In this article, we develop a methodology for analyzing an educational intervention for general practitioners (GPs) using self-efficacy as a concept. This study was partly conducted within the setting of an observational study, IMPACT-B, where we developed online education for GPs. We designed and refined a 24-item questionnaire using item analysis, and exploratory and confirmatory factor analysis. Ninety-one GPs completed the questionnaire before and after the online education. Follow-up data after 6 months was available for 13 GPs. Item analysis revealed a high degree of internal consistency (coefficient alpha 0.95) and validity. Each additional year of experience was associated with an average baseline self-efficacy score of 0.50 points (95% CI [0.21-0.80]), and each additional patient in HF follow-up with an average score of 2.0 points (95% CI [0.48-3.5]). Items that differentiated most between GPs with high and low self-efficacy were the treatment of congestion as well as titrating medication and MRA in heart failure with reduced ejection fraction. Factor analysis reduced the number of questions to 14, mapping to three factors (diagnosis, treatment, and follow-up), and improved the model fit as measured by the goodness-of-fit indicator comparative-fit-index (from 0.83 to 0.91). We demonstrated a method to assess the impact of online education on general practitioners. This led to a questionnaire that was reliable, valid, and convenient to use in an implementation context.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions

BACKGROUND

Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.

METHODS

Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.

ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).

INFORMATION SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020.

OUTCOME MEASURES

Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate.

DATA SYNTHESIS

We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.

RESULTS

We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%).

CONCLUSIONS

KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

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

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

A Pilot Study on Standardized In-hospital Education About Heart Failure Conducted During the First Days After Decompensation

INTRODUCTION

Education addressed to heart failure (HF) patients constitutes an important element of modern comprehensive treatment programs. The present article demonstrates a novel method of standardized in-hospital education addressed to patients admitted due to decompensation in HF.

METHODS

This pilot study was conducted among 20 patients [19 men, age 63 ± 16 years, NYHA (Classification according to New York Heart Association) on admission (II/III/IV): 5/25/70%]. Five-day education was based on individual sessions conducted using colorful boards demonstrating selected, highly practical elements of the knowledge about HF management, prepared by experts in HF management (medical doctors, a psychologist, and a dietician). The level of knowledge about HF was measured before and after education, based on a questionnaire prepared by the authors of the boards.

RESULTS

All patients experienced an improvement of their clinical status (confirmed by reduced New York Heart Association class and body mass, both P < 0.05). Mini Mental State Exam (MMSE) confirmed that no one demonstrated cognitive impairment. The score reflecting the level of knowledge about HF improved significantly after 5 days of in-hospital treatment accompanied by education (P = 0.0001).

CONCLUSIONS

We showed that the proposed model of education addressed to patients with decompensated HF, conducted using colorful boards demonstrating selected, highly practical elements of the knowledge about HF management, prepared by experts in HF management lead to significant increase of HF-related knowledge.

Alignment of Doctors' Understanding of Treatment Burden Priorities and Chronic Heart Failure Patients' Experiences: A Nominal Group Technique Consultation

PURPOSE

To identify and rank areas of treatment burden in chronic heart failure (CHF), including solutions, that should be discussed during the clinical encounter from a patient, and doctors' perspective.

PATIENTS AND METHODS

Patients with CHF and clinicians managing heart failure were invited. Nominal group technique sessions held either face to face or online in 2021-2022, with individual identification of priorities and voting on ranking.

RESULTS

Four patient groups (N=22) and one doctor group (N=5) were held. For patients with heart failure, in descending order of priority Doctor-patient communication, Inefficiencies of the healthcare system, Healthcare access issues, Cost implications of treatment, Psychosocial impacts on patients and their families, and Impact of treatment work were the most important treatment burdens. Priorities independently identified by the doctors aligned with the patients' but ranking differed. Patient solutions ranged from involvement of nurses or pharmacists to enhance understanding of discharge planning, through to linkage between health information systems, and maintaining strong family or social support networks. Doctors' solutions covered timing medicines with activities of daily living, patient education on the importance of compliance, medication reviews to overcome clinical inertia, and routine clinical audits.

CONCLUSION

The top treatment burden priorities for CHF patients were related to interaction with clinicians and health system inefficiencies, whereas doctors were generally aware of patients' treatment burden but tended to focus on the complexity of the direct treatment work. Addressing the priority issues identified here can commence with clinicians becoming aware of the issues that matter to patients and proactively discussing feasible immediate and longer-term solutions during clinical encounters.

Mixed‐methods evaluation of a multifaceted heart failure intervention in general practice: the OSCAR‐HF pilot study

AIMS

Heart failure (HF) is an important health problem for which multidisciplinary care is recommended, yet few studies involve primary care practitioners in the multidisciplinary management of HF. We set up a multifaceted prospective observational trial, OSCAR-HF, piloting audit and feedback, natriuretic peptide testing at the point of care, and the assistance of a specialist HF nurse in primary care. The aim was to optimize HF care in general practice.

METHODS AND RESULTS

This is an analysis at 6 month follow-up of the study interventions of the OSCAR-HF pilot study, a nonrandomized, noncontrolled prospective observational trial conducted in eight Belgian general practices [51 general practitioners (GPs)]. Patients who were assessed by their GP to have HF constituted the OSCAR-HF study population. We used descriptive statistics and mixed-effects modelling for the quantitative analysis and thematic analysis of the focus group interviews. There was a 10.2% increase in the registered HF population after 6 months of follow-up (n = 593) compared with baseline (n = 538) and a 27% increase in objectified HF diagnoses (baseline n = 359 to 456 at T6 M). Natriuretic peptide testing (with or without referral) accounted for 54% (n = 60/111) of the newly registered HF diagnoses. There was no difference in the proportion of patients with HF with reduced ejection fraction who received their target dosage of renin-angiotensin-aldosterone system inhibitors or beta-blockers at 6 months compared with baseline (P = 0.9). Patients who received an HF nurse intervention (n = 53) had significantly worse quality of life at baseline [difference in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score 9.2 points; 95% confidence interval (CI) 4.0, 14] and had a significantly greater improvement in quality-of-life scores at the 6 month follow-up [change in MLHFQ score -9.8 points; 95% CI -15, -4.5] than patients without an HF nurse intervention. GPs found audit and feedback valuable but time intensive. Natriuretic peptides were useful, but the point-of-care test was impractical, and the assistance of an HF nurse was a useful addition to routine HF care.

CONCLUSIONS

The use of audit and feedback combined with natriuretic peptide testing was a successful strategy to increase the number of registered and objectified HF diagnoses at 6 months. GPs and HF nurses selected patients with worse quality-of-life scores at baseline for the HF nurse intervention, which led to a significantly greater improvement in quality-of-life scores at the 6 month follow-up compared with patients without an HF nurse intervention. The interventions were deemed feasible and useful by the participating GPs with some specific remarks that can be used for optimization.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02905786), registered on 14 September 2016 at https://clinicaltrials.gov/.

Investigating the effect of multimedia education in combination with teach-back method on quality of life and cardiac anxiety in patients with heart failure: a randomized clinical trial

BACKGROUND

Education can contribute to promotion of the quality of life and reduction of heart anxiety in patients with heart failure, so it is important to find a suitable educational method for these patients. Therefore, the present study was an attempt to determine the effect of multimedia education using teach-back method on the life quality and cardiac anxiety in patients with heart failure.

METHODS

The present study was a randomized clinical trial. 120 patients with heart failure class I to III and aged less than 60 years old were selected using sequential sampling; then, they were assigned randomly into two intervention groups and one control group. Group A (multimedia education), group B (education using multimedia together with teach-back method), and group C (control). The quality of life and cardiac anxiety were evaluated in the participants of the three groups before, after, 1 month, and 3 months after the intervention. Data were analyzed using descriptive tests, Pearson correlation, Kolmogorov-Smirnov, chi square and ANOVA test in SPSS 22. The significance level was set at P < 0.05.

RESULTS

No significant differences were found in the mean scores of the quality of life and cardiac anxiety in the control and two intervention groups before the educational intervention. However, immediately after, 1 month and 3 months after the educational intervention, a significant difference was observed between the mean scores of the quality of life and cardiac anxiety in the intervention groups (P < 0.05).

CONCLUSION

Multimedia education together with Teach-Back method is effective in promoting the quality of life and reducing cardiac anxiety in patients with heart failure. Therefore, it is recommended that health policymakers should use this educational method in providing treatment programs.

IRANIAN REGISTRY OF CLINICAL TRIALS

20190917044802N1. Registration date: 5/2/2020.

Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review

BACKGROUND

Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management.

AIM

To present an updated review undertaken from September 2013 to August 2018.

DESIGN & SETTING

A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol.

METHOD

Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018.

RESULTS

The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up.

CONCLUSION

More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.

Effectiveness of motivational interviewing on health-service use and mortality: a secondary outcome analysis of the MOTIVATE-HF trial

Aims

Intense health‐care service use and high mortality are common in heart failure (HF) patients. This secondary analysis of the MOTIVATE‐HF trial investigates the effectiveness of motivational interviewing (MI) in reducing health‐care service use (e.g. emergency service use and hospitalizations) and all‐cause mortality.

Methods and results

This study used a randomized controlled trial. Patients and caregivers were randomized to Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), or Arm 3 (control group). Data were collected at baseline and at 3, 6, 9, and 12 months. Face‐to‐face MI plus three telephone calls were performed in Arms 1 and 2. The sample consisted of 510 patient (median age 74 years, 58% male patients) and caregiver dyads (median age 55 years, 75% female patients). At 12 months, 16.1%, 17%, and 11.2% of patients used health‐care services at least once in Arms 1, 2, and 3, respectively, without significant difference. At 3 months, 1.9%, 0.6%, and 5.1% of patients died in Arms 1, 2, and 3, respectively. Mortality was lower in Arm 2 vs. Arm 3 at 3 months [hazard ratio (HR) = 0.112, 95% CI: 0.014–0.882, P = 0.04]; no difference was found at subsequent follow‐ups. Mortality was lower in Arm 1 vs. Arm 3 at 3 months but did not reach statistical significance (HR = 0.38, 95% CI: 0.104–1.414, P = 0.15).

Conclusion

This study suggests that MI reduces mortality in patients with HF if caregivers are included in the intervention. Further studies with a stronger intervention and longer follow‐up are needed to clarify the benefits of MI on health‐care service use and mortality.

Epidemiological profile, cardiopulmonary fitness and health-related quality of life of patients with heart failure: a longitudinal study

BACKGROUND

Heart failure (HF) is a severe and self-limiting syndrome. Its signs and symptoms are believed to predict poorer health-related quality of life scores, which are mainly influenced by deterioration in physical capacity. In the present study we try to analyze the influence of clinical and socioeconomic characteristics and physical capacity on the quality of life of people with HF diagnosis.

METHODS

A longitudinal study was conducted over 2 years with patients diagnosed with HF. To evaluate the patients the method of face-to-face visit and telephone monitoring was used. In the evaluations were applied: the Clinical and Socioeconomic Characterization Questionnaire, the Minnesota Living With Heart Failure Questionnaire (MLHFQ) for quality of life evaluation and the Veterans Specific Activity Questionnaire (VSAQ) for cardiopulmonary fitness analysis. Measures of central tendency, proportion, normality test, confidence intervals, comparison of data through paired Student t test and Wilcoxon or Mann Whitney test were performed and correlations were verified through Spearman coefficient.

RESULTS

The study included 108 patients, most of them female (50.90%) and mean age of 66.62 ± 11.33 years. The median time of HF diagnosis was 5 ± 6 years, being Chagas' disease the main etiologic cause for the disease (57.40%). As for the clinical condition, functional classes II (44.40%) and III (48.10%) of the New York Heart Association (NYHA) were the most frequent. There was a low cardiopulmonary fitness, with loss of capacity to perform daily activities (3 ± 1 to 3 ± 3) over the time of clinical follow-up. There was an increase in the MLHFQ instrument scores, from 50.98 ± 15.52 to 61.76 ± 19.95, over the analysis time. The analysis of correlations demonstrated that variables such as schooling, NYHA class, echocardiographic alterations and the drug profile have a significant relationship with the constructs of quality of life and physical fitness.

CONCLUSION

Individuals in HF have significant impairment of cardiorespiratory capacity and tend to present worsening of QL along the evolution of the disease.

Motivational Interviewing as a Strategy to Impact Outcomes in Heart Failure Patients: A Systematic Review

BACKGROUND

Heart failure (HF) hospitalization is an expensive healthcare utilization event. Motivational interviewing (MI) has been studied for effects on HF self-management behaviors.

OBJECTIVE

The objective of this systematic review was to conduct an exploration and report of evidence and gaps in the literature regarding the impact of MI on HF outcomes.

DATA SOURCES

A modified Cochrane systematic review was conducted via a literature search in the MEDLINE, CINAHL, Cochrane Collaborative Systematic Reviews, PsycINFO, Health Source: Nursing/Academic Edition, and Google Scholar databases.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized controlled trials (RCTs) or controlled experimental studies published in English from January 1990 to February 2019 that included adults (18 years and older) diagnosed with HF New York Heart Association (NYHA) class I, II, II, or IV were eligible for inclusion. Interventions evaluated were an MI-based face-to-face communication or telephone-based conversation provided by any healthcare provider type.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Cochrane method for assessing risk of bias was used to analyze the methodological quality of retained studies.

RESULTS

Of 167 initial articles, nine were retained, describing eight unique studies (758 total patients, range 30-241; age range 58-79 years; attrition range 13-36%). The impact of MI was examined for general self-care behaviors (SCBs) (physical activity specifically), quality of life (QoL), and/or hospital readmission prevention. Eight of nine articles reported a positive impact of MI over advice-giving, seven being statistically significant. MI interventions used an initial face-to-face encounter with three to five follow-up telephone encounters.

LIMITATIONS

This systematic review had the following limitations: most retained studies included intervention activities conducted in hospital/clinic settings, which limits generalizability of the intervention in other care settings; intervention fidelity, blinding, selection, interventionist training, and random assignment were not clear in all studies; retained studies did not include potential covariates such as health literacy, patient age, and perception of disease/health risks; and some retained studies relied on patient self-report of outcomes, which may introduce recall or social desirability bias.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

MI demonstrated a positive effect on the SCB hospital readmission prevention factor and on QoL. MI delivered with greater frequency and over a longer duration may improve the immediate risk of hospital readmission as well as long-term outcomes through better medication adherence and SCBs. However, heterogeneity in the methods, design, intervention type, and structure challenged comparisons across studies and further research is warranted.

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study

Aims

Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care.

Methods and results

This study describes the baseline results of the OSCAR‐HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N‐terminal pro‐B‐type natriuretic peptide point‐of‐care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR‐HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ≥ 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin–angiotensin–aldosterone system blockers (84%, n = 92) and beta‐blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively).

Conclusions

This study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease‐modifying drugs in HFrEF patients.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Optimisation of diagnosis and treatment of heart failure in a primary care setting

BACKGROUND

Heart failure (HF) is one of the leading causes of emergency department visits and hospital admissions in the USA. We identified a gap in the diagnosis and the use of guideline-directed medical therapy in patients with HF at the internal medicine clinic.

AIM

To improve the diagnosis and treatment of HF, as well as to reduce emergency department visits and hospitalisation over 12 months in patients aged 40-75 years.

METHODS

The multidisciplinary quality improvement (QI) team performed a root cause analysis and identified barriers to optimal guideline-directed medical therapy. Rates of patients on guideline-directed medical therapy with systolic HF diagnosis, emergency department visits and hospital admissions were the outcome measures. The process measures included echocardiogram order and completion rates, and rates of accurate classification of HF from the baseline rate of less than 10%. We used the focus, analyse, develop, execute and evaluate (FADE) model with five improvement cycles. The major components of interventions included (1) leveraging health information technology; (2) optimising teamwork; and (3) providing education to patients, physicians and internal medicine clinic staff. Data were analysed using statistical process control and run charts.

RESULTS

We observed a reduction in the total number of emergency department visits (160 vs 108), hospital admissions (117 vs 114) and observation visits (22 vs 16) comparing the 1-year preproject and 1-year postproject periods. An increase in the use of ACE inhibitors or angiotensin receptor blockers occurred from the baseline rate of 20%-37% during the second half of the project and was sustained at 71.4% (median) during 6 months of the postproject period.

CONCLUSIONS

We achieved a sustainable increase in the accurate diagnosis of HF and achieved 80% diagnosis during the 6-month poststudy period.

Optimising standards of care of heart failure in general practice the OSCAR-HF pilot study protocol

Background: Heart failure (HF) imposes a burden for patients and health economics. General practitioners (GPs) are confronted with the broadest range of HF management. Although guidelines exist, they are not fully implemented in the Belgian health care system. Methods: We will conduct a non-randomised, non-controlled prospective observational trial (six months follow-up) to implement a multifaceted intervention in Belgian general practice to support GPs in the implementation of evidence-based HF guidelines. The multifaceted intervention consists of an audit and feedback method to detect previously unrecognised patients with HF and to increase awareness for proactive HF management, an NT-proBNP point-of-care test to improve detection and adequate diagnosis of patients with HF and a specialist HF nurse to assist GPs in the education of patients, optimisation of treatment and follow-up after hospitalisation. All patients aged 40 years and older with a confirmed diagnosis of HF by their GP based on the clinical audit are eligible for participation. The main objective of this pilot study is to evaluate the feasibility of this multifaceted intervention and the evolution of predefined quality indicators. We will measure the impact on HF diagnosis, medication optimisation, multidisciplinary follow-up and patients' quality of life after six months. Additionally, the experiences of GPs and investigators will be studied. Conclusions: Heart failure is an important health problem in which GPs play a key role. Therefore, we will evaluate the feasibility of a multifaceted intervention to optimise diagnosis as well as implement the guideline recommended therapies in patients with HF in general practice.

Haemodynamic Monitoring Devices in Heart Failure: Maximising Benefit with Digitally Enabled Patient Centric Care

ICDs and resynchronisation devices are routinely implanted in patients with heart failure for primary prevention of sudden cardiac death or to treat the condition. The addition of device features and algorithms that directly or indirectly monitor cardiac haemodynamics to assess heart failure status can provide additional benefit by treating heart failure more continuously. Established and emerging devices and sensors aimed at treating or measuring cardiac haemodynamics represent the next era of heart failure disease management. Digitally enabled models of heart failure care, based on frequent haemodynamic measurements, will increasingly involve patients in their own disease management. Software tools and services tailored to provide patients with personalised information to guide diet, activity, medications and haemodynamic management offer an unprecedented opportunity to improve patient outcomes. This will enable physicians to care for larger populations because management will be exception based, automated and no longer depend on one-to-one patient and physician interactions.

Registry-Based Pragmatic Trials in Heart Failure: Current Experience and Future Directions

PURPOSE OF REVIEW

Randomized controlled trials (RCTs) in heart failure (HF) are becoming increasingly complex and expensive to conduct and if positive deliver expensive therapy tested only in selected populations.

RECENT FINDINGS

Electronic health records and clinical cardiovascular quality registries are providing opportunities for pragmatic and registry-based prospective randomized clinical trials (RRCTs). Simplified regulatory, ethics, and consent procedures; recruitment integrated into real-world care; and simplified or automated baseline and outcome collection allow assessment of study power and feasibility, fast and efficient recruitment, delivery of generalizable findings at low cost, and potentially evidence-based and novel use of generic drugs with low costs to society. There have been no RRCTs in HF to date. Major challenges include generating funding, international collaboration, and the monitoring of safety and adherence for chronic HF treatments. Here, we use the Spironolactone Initiation Registry Randomized Interventional Trial in Heart Failure with Preserved Ejection Fraction (SPIRRIT-HFpEF), to be conducted in the Swedish Heart Failure Registry, to exemplify the advantages and challenges of HF RRCTs.