One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

 

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model.

This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings.

A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000).

The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

Funding Acknowledgement

Type of funding sources: None.

Alternative methods for assessing bronchodilator reversibility in chronic obstructive pulmonary disease

BACKGROUND

Bronchodilator reversibility testing is recommended in all patients with chronic obstructive pulmonary disease (COPD) but does not predict improvements in breathlessness or exercise performance. Two alternative ways of assessing lung mechanics-measurement of end expiratory lung volume (EELV) using the inspiratory capacity manoeuvre and application of negative expiratory pressure (NEP) during tidal breathing to detect tidal airflow limitation-do relate to the degree of breathlessness in COPD. Their usefulness as end points in bronchodilator reversibility testing has not been examined.

METHODS

We studied 20 patients with clinically stable COPD (mean age 69.9 (1.5) years, 15 men, forced expiratory volume in one second (FEV(1)) 29.5 (1.6)% predicted) with tidal flow limitation as assessed by their maximum flow-volume loop. Spirometric parameters, slow vital capacity (SVC), inspiratory capacity (IC), and NEP were measured seated, before and after nebulised saline, and at intervals after 5 mg nebulised salbutamol and 500 microg nebulised ipratropium bromide. The patients attended twice and the treatment order was randomised.

RESULTS

Mean FEV(1), FVC, SVC, and IC were unchanged after saline but the degree of tidal flow limitation varied. FEV(1) improved significantly after salbutamol and ipratropium (0.11 (0.02) l and 0.09 (0.02) l, respectively) as did the other lung volumes with further significant increases after the combination. Tidal volume and mean expiratory flow increased significantly after all bronchodilators but breathlessness fell significantly only after the combination treatment. The initial NEP score was unrelated to subsequent changes in lung volume.

CONCLUSIONS

NEP is not an appropriate measurement of acute bronchodilator responsiveness. Changes in IC were significantly larger than those in FEV(1) and may be more easily detected. However, our data showed no evidence for separation of "reversible" and "irreversible" groups whatever outcome measure was adopted.

Alternative methods for assessing bronchodilator reversibility in chronic obstructive pulmonary disease

BACKGROUND

Bronchodilator reversibility testing is recommended in all patients with chronic obstructive pulmonary disease (COPD) but does not predict improvements in breathlessness or exercise performance. Two alternative ways of assessing lung mechanics—measurement of end expiratory lung volume (EELV) using the inspiratory capacity manoeuvre and application of negative expiratory pressure (NEP) during tidal breathing to detect tidal airflow limitation—do relate to the degree of breathlessness in COPD. Their usefulness as end points in bronchodilator reversibility testing has not been examined.

METHODS

We studied 20 patients with clinically stable COPD (mean age 69.9 (1.5) years, 15 men, forced expiratory volume in one second (FEV1) 29.5 (1.6)% predicted) with tidal flow limitation as assessed by their maximum flow-volume loop. Spirometric parameters, slow vital capacity (SVC), inspiratory capacity (IC), and NEP were measured seated, before and after nebulised saline, and at intervals after 5 mg nebulised salbutamol and 500 μg nebulised ipratropium bromide. The patients attended twice and the treatment order was randomised.

RESULTS

Mean FEV1, FVC, SVC, and IC were unchanged after saline but the degree of tidal flow limitation varied. FEV1 improved significantly after salbutamol and ipratropium (0.11 (0.02) l and 0.09 (0.02) l, respectively) as did the other lung volumes with further significant increases after the combination. Tidal volume and mean expiratory flow increased significantly after all bronchodilators but breathlessness fell significantly only after the combination treatment. The initial NEP score was unrelated to subsequent changes in lung volume.

CONCLUSIONS

NEP is not an appropriate measurement of acute bronchodilator responsiveness. Changes in IC were significantly larger than those in FEV1and may be more easily detected. However, our data showed no evidence for separation of “reversible” and “irreversible” groups whatever outcome measure was adopted.

Antimicrobial management of acute exacerbation of chronic airflow limitation

Antibiotics are frequently administered for exacerbations of chronic obstructive pulmonary disease and asthma, yet their role remains unclear. We prospectively audited the antimicrobial management of 167 patients aged >50 years hospitalized for exacerbations of chronic airflow limitation. Antibiotics were commenced on admission for 151 (90%) patients (oral 52%, intravenous 38%), including 17/23 (74%) with no evidence of fever, purulent sputum, leucocytosis or inflammatory chest X-ray changes. The mean number of different antibiotics prescribed was 1.8 (range 0-6); a wide range of antibiotics and antibiotic combinations were used. Sputum samples were sent for microbiological examination in 101 (61%) patients. Sputum culture was positive in 34, but only 11 (7% of the total) had amoxycillin-resistant organisms in their sputum. Seventeen patients (10%) developed diarrhoea while in hospital. Under logistic regression analysis, total number of antibiotics prescribed (p<0.0001) and age (p=0.0062) were the two factors associated with hospital-acquired diarrhoea. Only 34% of patients had received an influenza vaccination in the winter of the study, and 10% a pneumococcal vaccination within the last 5 years. In routine clinical practice, aggressive antibiotic therapy was frequently administered to patients admitted with chronic airflow limitation, despite limited clinical, radiological and microbial indications. Excessive use of antibiotics has important implications, including morbidity (antibiotic-associated diarrhoea), cost and the potential for increased microbial antibiotic resistance. A minority of patients with chronic airflow limitation are being vaccinated against influenza and Pneumococcus.