Chronic Heart Failure Care Research Articles

Is B-type natriuretic peptide-guided heart failure management cost-effective?

Background: Chronic heart failure (CHF) is a common medical problem and B-type natriuretic peptide (BNP)-guided heart failure management for outpatients with symptomatic CHF was found to reduce the readmission rate and mortality, but the costs of treatment may provoke concern in the current cost-conscious clinical setting. Methods: We conducted a cost-effectiveness analysis using a Markov model of regular BNP measurement in the outpatient setting. The target population was symptomatic CHF patients aged 35–85 years recently discharged from the hospital. Intervention was BNP measurement once every 3 months (BNP group) or no BNP measurement (clinical group). Clinical and utility data were retrieved from published studies. Costs were based on published data in the US. Cost-effectiveness was measured by $ per quality-adjusted life year (QALY). Results: The baseline analysis during the 9-month period after hospitalization showed the QALY to be longer for the BNP group (0.57 for the BNP group and 0.55 for the clinical group) and the costs were also lower for the BNP group ($9577 and 10,131). The dominance of the BNP group continued during the 1-year follow-up. The incremental costs would be $3491–7787 per QALY. In sensitivity analyses, two parameters with strong effects on the cost-effectiveness were the probability of the first readmission for CHF in the clinical group and the costs for inpatient CHF care. When these two parameters were simultaneously put on the simulation model, the incremental costs of the BNP group may exceed $50,000. Conclusions: Introduction of BNP measurement in heart failure management may be cost-effective.

Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care

ObjectivesThis study compared the effectiveness and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care in chronic heart failure (CHF) outpatients. BackgroundPrevious studies showed that about 50% of readmissions for CHF can be prevented by a multidisciplinary approach However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management related to evidence-based medicine have not been considered. MethodsA total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared. ResultsAfter 12 ± 3 months of follow-up, the individual rate access in DH was 5.5 ± 3.8 days. The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13 vs. 78, p < 0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed a cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 (CI $13,904 to $34,048). ConclusionsA heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients. This management strategy is cost-effective and has an equitable value from a societal point of view.

Do general practice patients with heart failure understand its nature and seriousness, and want improved information?

This study describes the extent to which patients with heart failure in general practice understand the nature and seriousness of their condition, and want more or better information about it than they currently get. The study involved a random sample of 62 patients receiving care for chronic heart failure in 30 central Auckland, New Zealand, practices. The narrative texts of personal, semi-structured interviews in late 1999 were edited (explicitly and systematically reduced and reassembled) until their interpretation was complete. Approximately 40% of the patients interviewed appeared not to understand the nature and seriousness of their heart failure condition. Two patients had accidentally discovered the diagnosis from inappropriate sources. Eleven patients (18%) expressed wanting improved information about their condition. However, to avoid harm, we did not ask patients about wants for information relating to the seriousness of their heart failure. Through patient education and counselling, providers could help patients to produce an advance written directive of wants for information.

Thinking of Heart Failure As a Medical Emergency

Sometimes overlooked in all our conversations about the societal and economic impact heart failure patients make upon our resources is the role of the Emergency Department (ED). Clearly an important portal for up to 80% of our heart failure admissions, the ED stands as a critical link in the chain of chronic heart failure care. That link, as many of us may attest, while potentially strong, is often in reality one of the weakest; and as the saying goes, the weak link in the chain frequently dictates the outcome. What, then, are the issues to consider in strengthening the ED link in heart failure care? First of all is the awareness, by heart failure teams, of the critical role the ED and its prehospital care programs play in the team efforts to provide care for heart failure patients. Another issue surrounds standardized evaluation and care of these patients—an area in which we have clearly lagged behind. Only ongoing measurement and objective study will delineate best practices that will be applicable to a broad range of ED styles and operations. Another is the education of ED staff, doctors, and nurses about how heart failure care can and should be performed in noncritical settings, such as offices and heart failure centers. Coupling the longer-term, chronic care approaches with aggressive short-term therapies will ultimately coordinate the care and outcome for many patients and their families. In this issue of Congestive Heart Failure is a manuscript that begins to address some, but certainly not all, of these questions. In reading the paper, one may certainly not agree with all of the statements (I do not) or suggested protocols (although I am struck by how much our own standard order set for the ED resembles the suggested protocol in Table IV), but at least the dialogue has begun (“Evaluation and Management of Acutely Decompensated Chronic Heart Failure in the Emergency Department,” page 124). What will be needed is an ongoing dialogue and cross-fertilization of our own little heart failure world with that of the ED doctors and nurses. As this progresses, we will build consensus and understanding and, most importantly, we will improve patient care and outcomes. So from this point forward, let us move ahead with the goal of incorporating the ED in our heart failure teams and ultimately of making the ED an equally strong link in the heart failure continuum chain of excellence!