Chronic Heart Failure Disease Management Research Articles

EE458 Benefits, Costs and Cost Effectiveness of a Chronic Heart Failure Disease Management Program for Austria – a Decision-Analytic Modeling Study

EE458 Benefits, Costs and Cost Effectiveness of a Chronic Heart Failure Disease Management Program for Austria – a Decision-Analytic Modeling Study

State-of-the-art Structural Interventions in Heart Failure.

Heart failure (HF) is a leading cause of hospitalisation and healthcare costs worldwide. Acute decompensated heart failure accounts for more than 1 million hospitalisations in the US. Despite advances in the quality of acute and chronic HF disease management, gaps in knowledge about effective interventions to support the transition of care for patients with HF remain. Despite multiple trials of promising therapies, standard care consists of decongestion with IV diuretics and haemodynamic support with vasodilators and inotropes and this has remained largely unchanged during the past 45 years. Newer advances in medical innovations and structural heart disease interventions have now given promise to improved survival, outcomes and quality of life for patients with advanced HF of multiple aetiologies. In this article, we focus on structural interventions in the treatment of patients with HF.

Current status of readmission rate and related factors in chronic heart failure

Chronic heart failure (CHF) has the characteristics of high morbidity, high mortality and high rehospitalization rate, especially high rehospitalization rate. Now it has become a serious social public problems. Factors influencing the rate of CHF rehospitalization include age and gender, etiology, lifestyle, medication compliance, etc. According to the above factors, clinical doctors can make all kinds of CHF disease management program, thus reducing the CHF rehospitalization rates and the patient's family and social burden. Key words: Heart failure; Patient readmission; Risk factors; Review

TRIMETAZIDINE INFLUENCE ON FILTRATION AND TUBULOINTERSTITIAL FUNCTION OF KIDNEYS IN ISCHEMIC HEART DISEASE PATIENTS WITH CHRONIC HEART FAILURE AND RENAL DYSFUNCTION

Aim. Evaluation of trimetazidine influence on the parameters of filtration and tubulo-interstinal function of kidneys in angina patients of II-III functional class (FC) and stable chronic heart failure (CHF) of II-III FC with chronic kidney disease (CKD) stage 3. Material and methods. Totally, 288 stable angina (II-III FC) patients included, among them a cohort selected of 162 (56,3%) CHF II-III FC. In 62 (38,3%) CKD of stage 3 was diagnosed. All CHF and stage 3 CKD patients were randomized to equal 2 groups depending on the kind of treatment. First group patients, together with standard CHF and coronary heart disease (CHD) management, were taking trimetazidine (Preductal МR®, Servier, France) 35 mg in the morning, and the second group patients did not receive trimetazidine. Treatment duration lasted 6 months. For renal function assessment, glomerular filtration rate (GFR) was implemented (CKD-EPIcre), calculated via serum creatinine and cystatin C in the blood (CKD-EPIcys), albumincreatinine ratio in single urine portion (UACR), molecules of tubules damage (KIM-1) in urea, tissue inhibitor of matrix proteases type 1 in the blood (ТIMP-1). Results. Introduction of trimetazidine to the standard therapy of CHD with CHF and CKD stage 3 makes it to not only improve clinical course of the disease, but increases exercise tolerance and demonstrates regression of disorder of kidney function by the dynamics of cystatin C (p=0,005), GFR increase, calculated by cystatin С (p=0,012), decrease of UACR (p=0,002), KIM-1 (p<0,001), restores positive collagenolysis in renal interstitium by dynamics of TIMP-1 decline (p<0,001). Conclusion. Trimetazidine shows nephroprotective effect if added to the treatment of CHD and CHF patients comorbid with CKD stage 3. The effect is characterized by improved filtration function, decrease of albumin secretion with urine, decrease of tubular disorder by suppression of collagen formation in renal interstitium.

Understanding how a palliative-specific patient-reported outcome intervention works to facilitate patient-centred care in advanced heart failure: A qualitative study

Background: Palliative care needs of patients with chronic heart failure are poorly recognised. Policy makers advise a patient-centred approach to holistically assess patients’ needs and care goals. Patient-reported outcome measures are proposed to facilitate patient-centred care. Aim: To explore whether and how a palliative care–specific patient-reported outcome intervention involving the Integrated Palliative care Outcome Scale influences patients’ experience of patient-centred care in nurse-led chronic heart failure disease management clinics. Design: A feasibility study using a parallel mixed-methods embedded design was undertaken. The qualitative component which examined patients and nurses experience of the intervention is reported here. Semi-structured interviews were conducted and analysed using framework analysis. Setting/participants: Eligible patients attended nurse-led chronic heart failure disease management clinics in two tertiary referral centres in Ireland with New York Heart Association functional class II–IV. Nurses who led these clinics were eligible for inclusion. Results: In all, 18 patients and all 4 nurses involved in the nurse-led clinics were interviewed. Three key themes were identified: identification of unmet needs, holistic assessment and patient empowerment. The intervention impacted on processes of care by enabling a shared understanding of patients’ symptoms and concerns, facilitating patient–nurse communication by focusing on these unmet needs and empowering patients to become more involved in clinical discussions. Conclusion: This Integrated Palliative care Outcome Scale–based intervention empowered patients to become more engaged in the clinical consultation and to highlight their unmet needs. This study adds to the evidence for the mechanism of action of patient-reported outcome measures to improve patient-centred care and will help inform outcome selection for future patient-reported outcome measure research.

Strategies to address the shortcomings of commonly used advanced chronic heart failure descriptors to improve recruitment in palliative care research: A parallel mixed-methods feasibility study

Background: Recruitment challenges contribute to the paucity of palliative care research with advanced chronic heart failure patients. Aim: To describe the challenges and outline strategies of recruiting advanced chronic heart failure patients. Design: A feasibility study using a pre–post uncontrolled design. Setting: Advanced chronic heart failure patients were recruited at two nurse-led chronic heart failure disease management clinics in Ireland Results: Of 372 patients screened, 81 were approached, 38 were recruited (46.9% conversion to consent) and 25 completed the intervention. To identify the desired population, a modified version of the European Society of Cardiology definition was used together with modified New York Heart Association inclusion criteria to address inter-study site New York Heart Association classification subjectivity. These modifications substantially increased median monthly numbers of eligible patients approached (from 8 to 20) and median monthly numbers recruited (from 4 to 9). Analysis using a mortality risk calculator demonstrated that recruited patients had a median 1-year mortality risk of 22.7 and confirmed that the modified eligibility criteria successfully identified the population of interest. A statistically significant difference in New York Heart Association classification was found in recruited patients between study sites, but no statistically significant difference was found in selected clinical parameters between these patients. Conclusion: Clinically relevant modifications to the European Society of Cardiology definition and strategies to address New York Heart Association subjectivity may help to improve advanced chronic heart failure patient recruitment in clinical settings, thereby helping to address the paucity of palliative care research this population.

Integrating Care: Developing a Primary Care Chronic Heart Failure Disease Management Program - a Tertiary Hospital/General Practice Partnership

Background: Patients with chronic heart failure (CHF) require regular assessment, monitoring and self-care support. Clinical care is predominantly delivered by general practitioners (GP), cardiologists, and hospital and community based CHF disease management programs (DMP) which although effective, reach only 20% of patients discharged from hospital. To improve accessibility, there have been calls for the development of primary care based CHF DMP. In support of this proposal, there is evidence to suggest primary care practice nurses (PN) are well placed to contribute to the clinical management of stable chronic disease. Aim: To develop a primary care based CHF DMP through a joint partnership between hospital and general practice clinicians. Method: GPs and PNs from six (6) general practices partnered with tertiary hospital based specialist CHF clinicians over a 12-month period to develop a primary care based CHF DMP. Results: Opportunities and barriers were identified and solutions implemented to inform a primary care based CHF DMP. Barriers included identification of CHF patients, limited resources to support self-care and limited scope of practice and professional support for practice nurses. Opportunities and solutions included standardising disease coding, incorporating an assessment and monitoring template within electronic patient management systems, identifying opportunities to expand the role of the practice nurse, development of self-care support resources and improved communication with hospital based CHF DMPs. Conclusion: Partnerships between hospital and primary care based clinicians can inform the development of a practice nurse supported primary care based CHF CDM to improve clinical management and support care integration.

Quality of life in patients receiving telemedicine enhanced chronic heart failure disease management: A meta-analysis

Background Previous reviews have investigated the effectiveness of telemedicine in the treatment of heart failure (HF). Dependent variables have included hospitalisations, mortality rates, disease knowledge and health costs. Few reviews, however, have examined the variable of health-related quality of life (QoL). Methods Randomised controlled trials comparing the delivery methods of any form of telemedicine with usual care for the provision of HF disease-management were identified via searches of all relevant databases and reference lists. Studies had to report a quantitative measure for mental, physical or overall QoL in order to be included. Results A total of 33 studies were identified. However, poor reporting of data resulted in the exclusion of seven, leaving 26 studies with 7066 participants. Three separate, random effects meta-analyses were conducted for mental, physical and overall QoL. Telemedicine was not significantly more effective than usual care on mental and physical QoL (standardised mean difference (SMD) 0.03, (95% confidence interval (CI) −0.05–0.12), p = 0.45 and SMD 0.24, (95% CI −0.08–0.56), p = 0.14, respectively). However, when compared to usual care, telemedicine was associated with a small significant increase in overall QoL (SMD 0.23, (95% CI 0.09–0.37), p = 0.001). Moderator analyses indicated that telemedicine delivered over a long-duration (≥52 weeks) and via telemonitoring was most beneficial. Conclusion Compared to usual care, telemedicine significantly increases overall QoL in patients receiving HF disease management. Statistically non-significant but nonetheless positive trends were also observed for physical QoL. These findings provide preliminary support for the use of telemedicine in the management of heart failure without jeopardising patient well-being.

Cardiovascular Nursing: From Florence to Melbourne

This paper, based on the 2015 CSANZ Cardiovascular Nursing Lecture, takes its title from the invitation to give this lecture in Melbourne being received when the author was visiting Florence, after whom Florence Nightingale, the founder of modern nursing, is named. Her work has indirectly shaped and influenced cardiovascular nursing, which has developed over the past 50 years. Despite its relatively short history, cardiovascular nursing has made a major contribution to improving the cardiovascular health and well-being of patients and families through health promotion, risk reduction and disease prevention. Examples include cardiac rehabilitation and secondary prevention and chronic heart failure disease management. Challenges, however, remain, including nurses practising to the full extent of their education and training, working as full partners with physicians and other health professionals in redesigning healthcare, ensuring better data collection and being more active in advocacy and policy initiatives. Cardiovascular nursing has a strong record of innovation but should always remember that it is there to serve the public and, bearing in mind the risk of potential harm versus benefit, be mindful of Florence Nightingale's wise counsel, "First, do no harm".

DI-052 Chronic heart failure patients’ knowledge of their medicines; a system for post-discharge pharmacist-led educational interventions

BackgroundPatients with chronic heart failure (CHF) have complex medicines regimens which can frequently be difficult to remember/understand, especially for elderly patients. This fact can be responsible for non-adherence and drug...

Importance of Predictors of Rehospitalisation in Heart Failure: A Survey of Heart Failure Experts

We investigated the opinion of clinical experts and researchers involved in chronic heart failure disease management regarding the ranking of patient, provider and system factors that predict the risk of rehospitalisation. Item generation for the online survey was informed by a literature review and current risk prediction models. Consultation with experts was undertaken via a secure online survey platform. Invitations to participate in the 10 question online survey were sent through Listserves of professional nursing and medical associations within Australia and New Zealand. Data were collected in August 2011. A total of 119 respondents completed the survey. Respondents ranged from researchers, registered nurses, cardiologists and allied health personnel. A mean importance score was used to rank risk factors for rehospitalisation. Risk factors that scored high for predicting the risk for rehospitalisation included poor adherence to medications (9.04) and prior hospitalisation for heart failure (8.33). Having private health insurance (4.8) and being female (4.9) scored lower in influencing rehospitalisation for adults with heart failure. No new risk factors were identified from the experts in predicting the risk of rehospitalisation. The survey results will contribute to the development of a nomogram to convey prognostic information related to adults with heart failure that will guide clinicians in management decisions.

Pharmacist educational interventions program for outpatients with chronic heart failure

BackgroundPatients with chronic heart failure (CHF) take several medicines and frequently manage their medicines inappropriately. In our hospital, a postdischarge pharmacist educational interventions program (PEIP) has been introduced as a...

Targeting a Hard to Access Population—Heart Failure and Homelessness in Sydney

Homeless people find accessing health services difficult due to their living situation and complex physical and mental health issues. Homelessness affects a large number of people with 310 rough sleepers and 451 occupying hostel beds in the City of Sydney Area 2012 Homeless Count. Chronic heart failure disease management programs (CHF-MP) are effective in reducing hospitalisations but require that the service is accessed after discharge. This under serviced group of people are likely to have numerous risk factors for the development of cardiovascular disease and heart failure (HF) such as smoking and high alcohol intake and many also live with undiagnosed or untreated hypertension and diabetes. The St Vincent's CHF-MP was referred to 13 homeless patients for follow-up in 2011, 12 of these patients were lost to follow-up. In order to improve the management of this group, the CHF-MP worked in collaboration with a local homeless hostel to establish an outreach clinic providing multidisciplinary HF care to complex patients with multi-morbidity. To date, seven patients have been regularly presenting for the past five months. In this time initiation and uptitration of HF medications have been achieved, HF symptoms have improved; referrals have been made to other health professionals. None of these patients have had a HF related admission during this time. The collaborative approach between these services can improve outcomes for this complex group of people. This presentation will discuss the strategies used to access and manage this group and the lessons we have learnt so far.

Prevalence of Depression Is High among Low-Income, Uninsured Hispanic Patients with Chronic Heart Failure

Introduction: The association between chronic heart failure (CHF) and depression are well documented and is associated with poor prognosis and poor quality of life. However, little is known about this relationship in the Hispanic population, especially those who are uninsured with low-income levels. The purpose of this study was to determine the prevalence of depression in uninsured, Hispanic patients with CHF. Methods: A total sample of 94 patients (51% Hispanic, 74% male, mean age±SD was 52.8±11.4, mean ejection fraction 24±9%, 68% non-ischemic cardiomyopathy, 88% with NYHA class II-III, 72% unemployed) were enrolled from a CHF Disease Management Program at a Los Angeles County facility.

Reduced Health Care Costs Associated With Disease Management for Chronic Heart Failure: A Study Using Three Methods to Examine the Financial Impact of a Heart Failure Disease Management Program Among Medicare Advantage Enrollees

Background Disease management (DM) for chronic heart failure (CHF) has been examined in several randomized clinical trials. Most have shown improvements in quality and cost reductions. However, there is only limited information about the financial impact of CHF DM outside of research settings. Methods and Results Three commonly employed observational study methods (pre-post comparison, comparison of intervention patients to a convenience cohort and comparison of intervention patients to a propensity matched cohort) were used to assess the financial impact of DM for CHF for Medicare Advantage enrollees over different 1-year periods between 2001 and 2004. DM was associated with savings ranging from $318 to $708 per patient per month. Most savings appeared to be associated with reduced expense for hospitalizations and exceeded the cost of providing DM. Conclusion CHF DM savings repeatedly demonstrated in randomized clinical trials are achievable in commercial insurance settings and exceed the cost of the intervention. Given the widespread interest in addressing the rising cost of health care, CHF DM remains an important consideration for Medicare beneficiaries.

Isolation of Health Services Research from Practice and Policy: The Example of Chronic Heart Failure Management

This study examined how health services research connects with practice and policy, first by investigating whether successful research projects continued in their test settings and engendered replication and then by examining whether a coherent body of research helped shape public policy. Chronic heart failure (CHF) was studied because randomized, controlled trials of posthospital CHF disease management have repeatedly demonstrated patient benefits and reduced costs, yet this practice has not become standard in the United States. Literature review produced 30 randomized, controlled trials of multidisciplinary outpatient CHF management, generally yielding improved patient outcomes. An e-mail survey of first authors (97% response rate) showed that practices proven to be effective in U.S. studies generally did not continue or expand (13 of 15 studies), mostly attributed to financial constraints (11 of 13), whereas similar projects in other countries often became permanent (7 of 13). U.S. respondents generally rated current quality of clinical care as good, whereas those elsewhere mostly rated it as excellent. Recent Medicare reforms implemented a model of CHF management substantially different from those studied in health services research. The Congressional hearings leading to these Medicare reforms, and the statute itself, mostly evidence the model used by commercial disease-management firms. Policy-makers, health service researchers, and funding agencies could develop more-effective methods for translating proven models of healthcare delivery into routine practice. Reforms that might improve the effectiveness of the linkages between research, policy, and practice are suggested.

Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction

To determine the prevalence and predictors of anxiety and depression in patients with heart failure due to Left Ventricular Systolic Dysfunction (LVSD). Psychological adjustment to Chronic Heart Failure (CHF) can be poor, with the prevalence of depression in out-patients ranging from 13% to 48%. The prevalence of anxiety disorders in this population is unknown and the factors that predict anxiety and depression are not well understood. 100 out-patients from a community heart failure programme completed a clinical diagnostic interview--the Structured Clinical Interview (SCID-I), to evaluate anxiety and depression. Mean age was 67+/-11 years, 17% were women and 91% were NYHA Class II or III. Other standardised measures were of cognition, biomedical status, social support and previous physical and mental health history. The prevalence rates of anxiety and depression (all subtypes) were 18.4% and 28.6%, respectively. Predictors of depression included a reported history of mental ill-health and NYHA class. Predictors of anxiety included a reported history of mental ill-health, co-morbid physical illness (diabetes and angina) and NYHA class. Severity of LVSD did not predict either anxiety or depression. Both anxiety and depression are common in CHF patients. The data on the predictors of poor psychological adjustment might assist in targeting bio-psychosocial intervention for patients who are at most at risk of anxiety and depression, within community CHF disease management programmes.

Human Centred Design Considerations for Multidisciplinary Chronic Heart Failure Disease Management Technology

Chronic Heart Failure (CHF) is a multi-faceted syndrome associated with high mortality and morbidity, as well as high health care costs from both patient and healthcare system perspectives. Optimal CHF disease management involves a high degree of information management and processing, for patients and providers, as well as timely and appropriate information sharing between them. Nurses have long been important conductors of information between patients and the healthcare system, and can provide a valuable perspective on the design of interactive information technology (IIT) to support multidisciplinary sharing of health information. The complimentary perspectives of holistic nursing and human-centred engineering design are discussed in evaluating multidisciplinary information needs and information management needs regarding CHF disease management of home-based CHF patients in Iceland, the author's home country.