Abstract
BackgroundMany older people in long-term care do not receive evidence-based diagnosis or management for heart failure; it is not known whether this can be achieved for this population. We initiated an onsite heart failure service, compared with ‘usual care’ with the aim of establishing the feasibility of accurate diagnosis and appropriate management.MethodsA pilot randomised controlled trial which randomised residents from 33 care facilities in North-East England with left ventricular systolic dysfunction (LVSD) to usual care or an onsite heart failure service. The primary outcome was the optimum prescription of angiotensin-converting enzyme inhibitors and beta-adrenergic antagonists at 6 months.ResultsOf 399 echocardiographically-screened residents aged 65–100 years, 30 subjects with LVSD were eligible; 28 (93%) consented and were randomised (HF service: 16; routine care: 12). Groups were similar at baseline; six month follow-up was completed for 25 patients (89%); 3 (11%) patients died. Results for the primary outcome were not statistically significant but there was a consistent pattern of increased drug use and titration to optimum dose in the intervention group (21% compared to 0% receiving routine care, p=0.250). Hospitalisation rates, quality of life and mortality at 6 months were similar between groups.ConclusionsThis study demonstrated the feasibility of an on-site heart failure service for older long-term care populations. Optimisation of medication appeared possible without adversely affecting quality of life; this questions clinicians’ concerns about adverse effects in this group. This has international implications for managing such patients. These methods should be replicated in a large-scale study to quantify the scale of benefit.Trial registrationISRCTN19781227 http://www.controlled-trials.com/ISRCTN19781227
Highlights
Many older people in long-term care do not receive evidence-based diagnosis or management for heart failure; it is not known whether this can be achieved for this population
The use of angiotensin-converting enzyme inhibitors (ACEi) and β-blockers to treat heart failure (HF) in older people living in their own homes or in long term care are associated with reduced hospitalisation and mortality rates [16,17,18,19]
Difficulties in differential diagnoses, knowledge about the benefits of ACEi compared to diuretics, and the inconvenience of monitoring and adverse effects are identified as key challenges [25,26]
Summary
Many older people in long-term care do not receive evidence-based diagnosis or management for heart failure; it is not known whether this can be achieved for this population. Research indicates the challenges of HF management in primary care, little is known about the most appropriate organisation of care to improve care delivery for residents in care homes This pilot trial evaluates the implementation of a HF team delivering onsite assessment and management, comparing outcomes with routine GP care. A nested qualitative element (This paper is under consideration by BMC Geriatrics) evaluated patients’ and clinicians’ experiences of the model Findings suggest this as an acceptable solution to variations in the management of heart failure for this group
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