Chronic Heart Failure In Primary Care Research Articles

Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study

Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management.Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland.Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected.Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ <0.001) and in women than in men (62% versus 71%, P <0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared.Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.

Chronic Heart Failure Care Model for home Monitoring of Patients

Chronic heart failure (CHF), often life-threatening, affects over 95,000 Australian and over 23 million people worldwide. Despite advances in modern medicine, patients with CHF are dismally impacted by poor five-year survival rates, poor health related quality of life, and high 30-day readmission rates. To improve the CHF management, an innovative telemonitoring enhanced home care model has been developed. In this enhanced model of care, patients are provided with a wireless (Bluetooth) weight scale and tablet computer to perform daily weight monitoring at home. Measured weight entries are automatically transferred from the scale to the tablet, and subsequently uploaded to a clinical portal. An application monitors uploaded entries in real time to detect missing weight-monitoring events, and abnormal weight changes according to the guidelines, such as rapid weight gains and unintentional weight loss. The detected events are then classified to generate different types of alerts for interventions needed in usual care. To minimise clinical workload, some alerts automatically trigger questionnaires preloaded in the tablet to assist nurses to triage patients. Finally, the generated alerts are distributed to project nurses and/or the MEPACS call centre, integrated in the care model. Nurses and call operators respectively monitor their alerts on a daily basis to provide three levels of interventions: 1) reminder calls to help patients monitor body weight daily, 2) clinical support on the CHF action plan, including emergency calls, and 3) nurse follow-ups to help identify symptoms of acute decompensated heart failure and other health issues for early intervention. Nurses also regularly review risks of alert and patients’ health conditions and engage with the patients and their care teams. To evaluate this care model, a multicentre RCT is being conducted. The trial started in Jan 2015, and is expected to be completed in Dec 2017. Patients with CHF (n=300) will be recruited from Victoria and Western Australia. Patients consented will be randomized to receive either the enhanced care (n=150) or usual care (n=150) for a minimum of 6 months. All the patients will be assessed at baseline, 6-month, and 12-month (if available) points. The aim of the enhanced model of care is to improve adherence (compliance) to the CHF management including daily weight monitoring, as well as health outcomes (health related quality of life, risk factors, functional capacity, frailty, and psychological states), and economic outcomes (risks of hospital readmissions, GP/ED visits, and cost benefits). Effective management of CHF in primary care remains a clinical challenge globally. This project will evaluate the effectiveness of an innovative telemonitoring enhanced home care model to assist patients in managing CHF. The evaluation will provide clinical evidence to integrate telemonitoring innovations to business as usual healthcare services for improvement of CHF care. At present over 80 patients have been recruited for the RCT form a large group of screened patients. Recruitment will continue until mid-2017 to capture close as possible to the trial target of 300 patients. Early results from the trial will be presented including clinical trial protocol, trial design, recruitment, challenges and compliance.

Impact of patient education on chronic heart failure in primary care (ETIC): a cluster randomised trial.

BackgroundThe Education Thérapeutique des patients Insuffisants Cardiaques (ETIC; Therapeutic Education for Patients with Cardiac Failure) trial aimed to determine whether a pragmatic education intervention in general practice could improve the quality of life of patients with chronic heart failure (CHF) compared with routine care.ResultsThis cluster randomised controlled clinical trial included 241 patients with CHF attending 54 general practitioners (GPs) in France and involved 19 months of follow-up. The GPs in the Intervention Group were trained during a 2-day interactive workshop to provide a patient education programme. The mean age of the patients was 74 years (±10.5), 62 % were men and their mean left-ventricular ejection fraction was 49.3 % (± 14.3). At the end of the follow-up period, the mean Minnesota Living with Heart Failure Questionnaire scores in the Intervention and Control Groups were 33.4 (± 22.1) versus 27.2 (± 23.3; P = 0.74, intra-cluster coefficient [ICC] = 0.11). At the end of the follow-up period, the 36-Item Short Form Health Survey (mental health and physical health) scores in the Intervention and Control Groups were 58 (± 22.1) versus 58.7 (± 23.9; P = 0.58, ICC = 0.01) and 52.8 (± 23.8) versus 51.6 (± 25.5; P = 0.57, ICC = 0.01), respectively.ConclusionsPatient education delivered by GPs to elderly patients with stable heart failure in the ETIC programme did not achieve an improvement in their quality of life compared with routine care. Further research on improving the quality of life and clinical outcomes of elderly patients with CHF in primary care is necessary.Trial registrationThe Education Thérapeutique des patients Insuffisants Cardiaques (ETIC; Therapeutic Education for Patients with Cardiac Failure) trial is a cluster randomised controlled trial registered with ClinicalTrials.gov (Registration Number: NCT01065142) and the French Drug Agency (Agence Nationale de Sécurité du Médicament et des Produits de Santé; Registration Number: 2009-A01142-55).Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0473-4) contains supplementary material, which is available to authorized users.

Improvement of primary care for patients with chronic heart failure: A study protocol for a cluster randomised trial comparing two strategies

BackgroundMany patients with chronic heart failure (CHF), a common condition with high morbidity and mortality rates, receive treatment in primary care. To improve the management of CHF in primary care, we developed an implementation programme comprised of educational and organisational components, with support by a practice visitor and focus both on drug treatment and lifestyle advice, and on organisation of care within the practice and collaboration with other healthcare providers. Tailoring has been shown to improve the success of implementation programmes, but little is known about what would be best methods for tailoring, specifically with respect to CHF in primary care.Methods/designWe describe the study protocol of a cluster randomised controlled trial to examine the effectiveness of tailoring a CHF implementation programme to general practices compared to a standardised way of delivering a programme. The study population will consist of 60 general practitioners (GPs) and the CHF patients they include. GPs are randomised in blocks of four, stratified according to practice size. With a tailored implementation programme GPs prioritise the issues that will form the bases of the support for the practice visits. These may comprise several issues, both educational and organizational.The primary outcome measures are patient's experience of receiving structured primary care for CHF (PACIC, a questionnaire related to the Chronic Care Model), patients' health-related utilities (EQ-5D), and drugs prescriptions using the guideline adherence index. Patients being clustered in practices, multilevel regression analyses will be used to explore the effect of practice size and type of intervention programme. In addition we will examine both changes within groups and differences at follow-up between groups with respect to drug dosages and advice on lifestyle issues. Furthermore, in interviews the feasibility of the programme and goal attainment, organisational changes in CHF care, and formalised cooperation with other disciplines will be assessed.DiscussionIn the tailoring of the programme we will present the GPs a list with barriers; GPs will assess relevance and possibility to solve these barriers. The list is rigorously developed and tested in various projects. The factors for ordering the barriers are related to the innovation, the healthcare professional, the patient, and the context.CHF patients do not form a homogeneous group. Subgroup analyses will be performed based on the distinction between systolic CHF and CHF with preserved left ventricular function (diastolic CHF).Trial registrationISRCTN: ISRCTN18812755

Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT‐proBNP Guided Management of Heart Failure – SIGNAL‐HF (Swedish Intervention study – Guidelines and NT‐proBNP AnaLysis in Heart Failure)

Treatment of chronic heart failure (CHF) guided by natriuretic peptides has been studied in clinical trials with conflicting results. The aim of this study was to investigate if N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided therapy in symptomatic heart failure patients in primary care would improve clinical outcomes over and above treatment according to guidelines. SIGNAL-HF was a 9 month, randomized, single-blind, parallel group study in patients with CHF in NYHA class II-IV, ejection fraction (EF)<50% and elevated NT-proBNP levels (males>800, females>1000 ng/L). All investigators underwent a pre-study educational programme about current CHF guidelines. A control group managed by non-trained investigators was considered not possible for ethical and practical reasons. Patients were randomized to structured treatment of CHF according to guidelines with or without NT-proBNP monitoring. The choice and dose of therapy for CHF was at the investigator's discretion. The primary outcome variable was the composite endpoint of days alive, days out of hospital, and symptom score from the Kansas City Cardiomyopathy Questionnaire. In all, 252 patients were randomized. The allocation groups were well balanced with regards to age, NT-proBNP, and EF. Treatment doses of beta-blockers and blockers of the renin-angiotensin-aldosterone system were markedly increased towards target doses and to a similar degree in both groups. There were no differences between the groups concerning either the primary endpoint (P=0.28) or its components [cardiovascular (CV) death, P=0.93; CV hospitalization, P=0.88; or symptom score, P=0.28]. NT-proBNP-guided CHF treatment did not result in important improvements in clinical outcomes in patients with CHF in primary care above and beyond what could be achieved by education and structured CHF treatment according to guidelines.

Current treatment of chronic heart failure in primary care; still room for improvement

RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care. In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires. Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice. Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.

Depression Is a Major Determinant of Quality of Life in Patients With Chronic Systolic Heart Failure in General Practice

Background Quality of life (QoL) is severely restricted in patients with chronic heart failure (CHF). Patients frequently suffer from depressive comorbidity. It is not clear, to what extent sociodemographic variables, heart failure severity, somatic comorbidities and depression determine QoL of patients with CHF in primary care. Methods and Results In a cross-sectional analysis, 167 patients, 68.2 ± 10.1 years old, 68.9% male, New York Heart Association (NYHA) functional class II-IV, Left ventricular ejection fraction (LVEF) ≤40%, were recruited in their general practitioner's practices. Heart failure severity was assessed with echocardiography and N-terminal brain natriuretic peptide (NT-proBNP); multimorbidity was assessed with the Cumulative Illness Rating Scale (CIRS-G). QoL was measured with the Short Form 36 Health Survey (SF-36) and depression with the depression module of the Patient Health Questionnaire (PHQ-9). Significant correlations with all SF-36 subscales were only found for the CIRS-G ( r = −0.18 to −0.36; P < .05) and the PHQ-9 ( r = −0.26 to −0.75; P < .01). In multivariate forward regression analyses, the PHQ-9 summary score explained the most part of QoL variance in all of the SF-36 subscales ( r 2 = 0.17–0.56). LVEF and NT-proBNP did not have significant influence on QoL. Conclusions Depression is a major determinant of quality of life in patients with chronic systolic heart failure, whereas somatic measures of heart failure severity such as NT-proBNP and LVEF do not contribute to quality of life. Correct diagnosis and treatment of depressive comorbidity in heart failure patients is essential.

Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES

Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC. Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables. Eight hundred forty seven (847) patients were included (age 73.0 +/- 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers. AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC.

Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial

Aims:To evaluate the effect of a disease management programme for patients with coronary heart disease (CHD) and chronic heart failure (CHF) in primary care.Methods:A cluster randomised controlled trial of 1316...

Gender Makes a Difference in the Description of Dyspnoea in Patients with Chronic Heart Failure

Dyspnoea is a common symptom of chronic heart failure (CHF). In the community setting, patients with CHF are most often women. To examine the impact of gender on the description of dyspnoea and to explore which clinical variables support a diagnosis of CHF. From four primary health care centres, 158 patients with CHF were included. Patients were examined with echocardiography and a cardiologist assessed the diagnosis of CHF. The patients filled in a questionnaire containing 11 descriptors of dyspnoea. A diagnosis of CHF was confirmed in 87 (55%) patients (47 males and 40 females). One descriptor, I feel that I am suffocating, was significantly scored higher in CHF patients (p=0.014) as compared to non-CHF patients. Three descriptors, My breath does not go in all the way (p=0.006), I feel that I am suffocating (p=0.040), and I cannot get enough air (p=0.0327) were significantly scored higher among men with CHF, compared to no descriptor among women with CHF. Being male (OR=2.7; CI: 1.3-5.6, p=0.008), having diabetes (OR=5.6; CI: 1.7-18.2, p=0.004), IHD (OR=3.3; CI: 1.3-8.5, p=0.014), and a borderline significance for age (OR=1.04; CI: 0.99-1.08, p=0.058) predicted a confirmed diagnosis of CHF. Three descriptors of dyspnoea were associated with CHF among men, whereas no such association was found among women. Our results suggest that gender is an important factor and should-together with age, underlying heart disease, and diabetes-be taken into account when symptoms are evaluated in the diagnosis of CHF in primary care.