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

[The risks of re-hospitalization of patients with heart failure with prolonged follow-up in a specialized center for the treatment of heart failure and in real clinical practice.]

Relevance The number of patients with functional class III-IV chronic heart failure (CHF) characterized by frequent rehospitalization for acute decompensated HF (ADHF) has increased. Rehospitalizations significantly increase the cost of patient management and the burden on health care system.Objective To determine the effect of long-term follow-up at a specialized center for treatment of HF (Center for Treatment of Chronic Heart Failure, CTCHF) on the risk of rehospitalization for patients after ADHF.Materials and Methods The study successively included 942 patients with CHF after ADHF. Group 1 consisted of 510 patients who continued the outpatient follows-up at the CTCHF, and group 2 included 432 patients who refused of the follow-up at the CTCHF and were managed at outpatient clinics at their place of residence. CHF patient compliance with recommendations and frequency of rehospitalization for ADHF were determined by outpatient medical records and structured telephone calls. A rehospitalization for ADHF was recorded if the patient stayed for more than one day in the hospital and required intravenous loop diuretics. The follow-up period was two years. Statistical analyses were performed using a Statistica 7.0 software for Windows, SPSS, and a R statistical package.Results Patients of group 2 were significantly older, more frequently had FC III CHF and less frequently had FC I CHF than patients of group 1. Both groups contained more women and HF patients with preserved ejection fraction. Using the method of binary multifactorial logit-regression a mathematical model was created, which showed that risk of rehospitalization during the entire follow-up period did not depend on age and sex but was significantly increased 2.4 times for patients with FC III-IV CHF and 3.4 times for patients of group 2. Multinomial multifactorial logit-regression showed that the risk of one, two, three or more rehospitalizations within two years was significantly higher in group 2 than in group 1 (2.9-4.5 times depending on the number of rehospitalizations) and for patients with FC III-IV CHF compared to patients with FC I-II CHF (2-3.2 times depending on the number of rehospitalizations). Proportion of readmitted patients during the first year of follow-up was significantly greater in group 2 than in group 1 (55.3 % vs. 39.8 % of patients [odd ratio (OR) =1.9; 95% confidence interval (CI), 1.4-2.4; р<0.001]; during the second year, the proportion was 67.4 % vs. 28.2 % (OR=5.3; 95 % CI, 3.9-7.1; р<0.001). Patients of group 1 were readmitted more frequently during the first year than during the second year (р<0,001) whereas patients of group 2 were readmitted more frequently during the second than the first year of follow-up (р<0.001). Total proportion of readmitted patients for two years of follow-up was significantly greater in group 2 (78.0 % vs. 50.6 %) (OR=3.5; 95 % CI, 2.6-4.6; р<0.001). Reasons for rehospitalizations were identified in 88.7 % and 45.9 % of the total number of readmitted patients in groups 1 and 2, respectively. The main cause for ADHF was non-compliance with recommendations in 47.4 % and 66.7 % of patients of groups 1 and 2, respectively (р<0.001).Conclusion Follow-up in the system of specialized health care significantly decreases the risk of rehospitalization during the first and second years of follow-up and during two years in total for both patients with FC I-II CHF and FC III-IV CHF. Despite education of patients, personal contacts with medical personnel, and telephone support, main reasons for rehospitalization were avoidable.

[The prognosis of patients with chronic heart failure, depending on adherence to observation in a specialized heart failure treatment center]

Actuality. The risk of death of patients with chronic heart failure (CHF) after acute decompensation of heart failure (ADHF) is directly related to the quality of the treatment of CHF after discharge from the hospital. In order to achieve the maximum effect of therapy in patients with CHF, experts in Europe and the USA recommend the creation of centers of specialized medical care for patients with CHF. Objective: to determine the risks of general, cardiovascular mortality and death from ADHF in patients with CHF during two years of observation, depending on their adherence to observation in a specialized center for the treatment of chronic heart failure (center CHF). Materials and methods. The study consistently included 942 patients with CHF after ADHF. The adherence of patients to follow up in center CHF was analyzed and 4 groups were distinguished: group 1 (n = 313) included patients who were observed continuously for two years; group 2 (n = 382) included patients who, after discharge, had never been observed in the center CHF; group 3 (n = 197) consisted of patients who were monitored at center CHF during the first year and then discontinued, and group 4 (n = 49) united patients who, when included in the study, abandoned observation, but after a year began to be constantly observed during the second year center CHF. Results. Statistically significant differences in age were registered only between groups 1 and 2 (69.6+9.9 and 71.8+11 years, respectively, р1/2=0.006). The overall mortality over the 2 years of follow-up was significantly higher in group 2 (32.4%) versus group 1 (1.2%, OR=3.8, 95% CI 2.5-5.7; p1/2<0.001 ); compared with group 3 (9.1%, OR=4.8, 95% CI 2.8-8.1; p2/3<0.001) and group 4 (8,2%, OR = 5.4, 95% CI 1.9-15.3; p2/4=0.0005). Cardiovascular mortality (CVM) for 2 years of follow-up was significantly higher in group 2 versus group 1 (8.1% and 1.3% of cases, OR=6.8, 95% CI 2.4-19.5; p1/2<0.001), as well as in comparison with group 3 (CVM 3% for 2 years, OR=2.8, 95% CI 1.1-6.8; p2/3=0.02). CVM in group 4 (6.1%) was 5 times higher in comparison with group 1 (OR=5.0, 95% CI 1.1-23.2; p1/4=0.02). The risks of death from ADHF over the 2 years of follow-up were significantly higher in group 2 (16.4%) compared with all groups: with group 1 (6.4%) OR=2.9, 95% CI 1.7-4, 9, p1/2<0.001; with group 3 (5.1%) OR=3.7, 95% CI 1.8-7.3, p2/3<0.001; and with group 4 (2%) OR=9.5, 95% CI 1.3-69.7, p2/4= 0.008. The combined endpoint (CVM and death from ADHF in 2 years of follow-up) was also significantly higher in group 2 (24.5%) compared with all compared groups: group 1 (7.7%), OR=3.9, 95% CI 2.4-6.3, p1/2<0.001; group 3 (8.1%), OR=3.7, 95% CI 2.1-6.5, p2/3<0.001; and group 4 (8.2%), OR=3.7, 95% CI 1.3-10.4; p2/4=0.01. Conclusion. Surveillance of patients with CHF after an episode of ADHF in a specialized center CHF, both for a long time (two years) and partially during the first year of observation, reduces the risk of all-cause death, CVM and death from ADHF.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.

High impact of depression in heart failure: Early diagnosis and treatment options

Depressive syndromes in chronic heart failure (CHF) are common and are associated with a poorer prognosis, particularly with increased morbidity and mortality. CHF as a severe physical disorder may increase the risk of developing depressive syndromes or vice-versa as an interaction of possible common psycho-organic etiological aspects. Depression in CHF is associated with impaired NYHA status and daily activities, resulting in enhanced hospitalisation rates and medical costs with a great impact on long-term health. Only a fraction of comorbid patients receives antidepressants. Therefore, identification of risk factors and prevention by optimizing cardiological and psychiatric therapeutic strategies appear essential for these patients. Early diagnosis and treatment of both CHF and depression may prevent further pathophysiological effects on the heart and brain. This review gives a comprehensive overview of the occurrence, risk factors and shared pathophysiology of depression in CHF, and focuses on improving insufficient diagnosis and therapy of depression. Special attention is given on the cardiac effects of psychopharmacological and alternate non-pharmacological antidepressant therapy in CHF. Recommendations are made for treating depression in CHF patients for a better prevention of this disabling physical and psychosocial condition.

Heart failure disease management: implementation and outcomes

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

Management of heart failure patients using telemedicine communication systems

Heart failure (HF) continues to place significant demands on health care resources because of the large number of hospital admissions for HF, the growth of the elderly population with HF, and the improved survival of patients with chronic heart disease who develop HF that requires continuous care. Because HF is best managed using a disease management approach, frequent communication is an important component of care. A variety of studies using the telephone to maintain communication have demonstrated reduced hospital admissions and improved morbidity rate. Hardware monitoring systems that can record vital signs and transmit information from the home to a data center have also demonstrated their value in HF care, but such systems become expensive when considered for large populations of HF patients. Most HF patients can transmit their vital signs, weight, and symptoms to a practice data center using the Internet with no specialized hardware other than a sphygmomanometer and a scale. We have used such a system to monitor HF patients and have provided care instructions using the same system. With use of an Internet communication system, it is possible to reduce hospitalizations and maintain a stable HF status without frequent office visits.

Uncovering a hidden epidemic: a study of the current burden of heart failure in Australia

BACKGROUND

Australia, like other countries, is experiencing an epidemic of heart failure (HF). However, given the lack of national and population-based datasets collating detailed cardiovascular-specific morbidity and mortality outcomes, quantifying the specific burden imposed by HF has been difficult.

METHODS

Australian Bureau of Statistics (ABS data) for the year 2000 were used in combination with contemporary, well-validated population-based epidemiologic data to estimate the number of individuals with symptomatic and asymptomatic HF related to both preserved (diastolic dysfunction) and impaired left ventricular systolic (dys)function (LVSD) and rates of HF-related hospitalisation.

RESULTS

In 2000, we estimate that around 325,000 Australians (58% male) had symptomatic HF associated with both LVSD and diastolic dysfunction and an additional 214,000 with asymptomatic LVSD. 140,000 (26%) live in rural and remote regions, distal to specialist health care services. There was an estimated 22,000 incidents of admissions for congestive heart failure and approximately 100,000 admissions associated with this syndrome overall.

CONCLUSION

Australia is in the midst of a HF epidemic that continues to grow. Overall, it probably contributes to over 1.4 million days of hospitalization at a cost of more than 1 billion dollars. A national response to further quantify and address this enormous health problem is required.

The cost and cost-effectiveness of nursing services in health care

This article examines the literature on cost-effectiveness in nursing, and considers the relationship between this literature and decision-making in health care systems. Researchers have attempted to examine costs and benefits of nurse staffing and nursing interventions for decades. There are strong literatures for some topics, such as advanced practice nursing, clinical practices, occupational health nursing, and workplace training. However, there are gaps in the literature on the cost-effectiveness of nurse staffing patterns, the use of agency personnel, and changes in organizational structure. A review of 6 major health care management textbooks finds few references to cost-effectiveness analysis, suggesting that health care leaders have little education regarding how to conduct or evaluate economic studies. The agenda for nursing research on cost-effectiveness is daunting. Research must be based on large, representative samples; provide clear, compelling results; discuss the importance of both costs and benefits in decision-making; and be published in highly-visible journals.

Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis

BACKGROUND

Disease management programmes (DMP) have been advocated to improve long term outcomes of heart failure (HF) patients.

AIMS

To summarise the evidence supporting DMP effectiveness in improving HF clinical outcomes.

METHODS

Eligible studies were located through a systematic literature search. Only randomised controlled trials (RCTs), enrolling HF patients, and allocating them to DMP or usual care (UC), were included. Information on study setting and design, participants' characteristics and interventions tested were collected. A study quality assessment was performed. Main clinical outcomes assessed were: all-cause mortality and (re)hospitalisations, HF-related (re)hospitalisations and mortality. Meta-analysis was performed according to both Yusuf-Peto method and random effects model.

RESULTS

Thirty-three RCTs were included. Mortality was significantly reduced by DMP compared to UC: OR = 0.80 (CI 0.69-0.93, p = 0.003). All-cause and HF-related hospitalisation rates were also significantly reduced: OR = 0.76 (CI 0.69-0.94, p < 0.00001) and OR = 0.58 (CI 0.50-0.67, p < 0.00001), respectively. Different DMP approaches appeared to be equally effective (sensitivity analyses).

CONCLUSION

DMP reduce mortality and hospitalisations in HF patients. Because various types of DMP appear to be similarly effective, the choice of a specific programme depends on local health services characteristics, patient population, and resources available.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Economic evaluation: what does a nurse manager need to know?

This paper considers how health economists can assist nurse managers, using the concepts and tools of economic evaluation. We aim to clarify these and also explode some of the myths about economic evaluation and its role in health care decision-making. Economic evaluation techniques compare alternative courses of action in terms of their costs and consequences. There are four principal methods; cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis, all of which synthesize costs and outcomes, at different levels of outcome. Economic evaluation is an intrinsic part of national decision-making about the efficient provision of effective treatments and services, and increasingly, organizational matters. In the UK, such technology evaluation is disseminated in guidelines from the National Institute for Clinical Effectiveness (NICE), having a top-down impact on the nurse manager. But economic evaluation is increasingly relevant to the nurse manager at local level, through newer techniques such as Programme Budgeting Marginal Analysis (PBMA), which facilitates explicit, transparent decisions, from the bottom-up. Nurse managers need to weigh up competing demands on resources and decide in ways which maximize health gain. Economic evaluation can help here because it presents evidence to challenge or support existing allocations, and provides a systematic framework to analyse health care decisions. In the current context of competition for scarce resources, we suggest that nurse managers need to embrace these techniques, or be marginalized from the resource allocation process.

Advances in the non-drug, non-surgical, non-device management of chronic heart failure

There have been many articles, reviews and editorials about the recent advances in pharmaceutical and device management of chronic heart failure in this and other journals over the last few years. What has been less praised are the significant advances we have made in understanding the best management of heart failure using other non-drug, non-surgical, non-device approaches. Approaches as diverse as nutrition, education, exercise, physiotherapy, psychotherapy and therapies for sleep-disordered breathing have shown considerable promise in improving the lot of our chronic heart failure (CHF) patients. Chronic heart failure is a common condition with a poor prognosis. It generates many debilitating symptoms for the sufferer. Non-pharmacologic treatment modalities play an important role alongside effective modern pharmaceutical, surgical and device therapies in relieving symptoms and improving prognosis. These treatments include those lifestyle measures that reduce the risk of underlying diseases such as coronary artery disease, diabetes, and hypertension lifestyle interventions of benefit in established CHF. Recent advances are reviewed including specialist nursing care, multi-disciplinary heart failure clinics, exercise rehabilitation, the treatment of sleep-disordered breathing, depression, obesity and cachexia. The day of the multi-disciplinary patient-centred CHF clinic has arrived and all sufferers deserve experienced management using all these approaches.

State of the science: posthospitalization nursing interventions in congestive heart failure

Nursing's role as key healthcare providers who give emotional support and teach self-care to patients with congestive heart failure has evolved substantially in recent years. The purpose of this article is to provide a systematic evaluation of the impact of posthospital nursing interventions in the management of heart failure. Four models of nursing interventions emerged: home-based nursing interventions, multidisciplinary interventions, heart failure clinics, and telephone- or technology-based nursing interventions. On the basis of currently available data, posthospital nursing interventions in congestive heart failure can improve clinical outcomes and decrease healthcare costs and resource use.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Financial aspects of heart failure programs of care

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

Treatment for heart failure: good news and bad

Heart failure is a common disorder associated with significant morbidity, mortality and financial burden to health services. The pharmacotherapy of heart failure, including new treatments, will be discussed.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.