Heart Failure Disease Management Research Articles

Haemodynamic Monitoring Devices in Heart Failure: Maximising Benefit with Digitally Enabled Patient Centric Care.

ICDs and resynchronisation devices are routinely implanted in patients with heart failure for primary prevention of sudden cardiac death or to treat the condition. The addition of device features and algorithms that directly or indirectly monitor cardiac haemodynamics to assess heart failure status can provide additional benefit by treating heart failure more continuously. Established and emerging devices and sensors aimed at treating or measuring cardiac haemodynamics represent the next era of heart failure disease management. Digitally enabled models of heart failure care, based on frequent haemodynamic measurements, will increasingly involve patients in their own disease management. Software tools and services tailored to provide patients with personalised information to guide diet, activity, medications and haemodynamic management offer an unprecedented opportunity to improve patient outcomes. This will enable physicians to care for larger populations because management will be exception based, automated and no longer depend on one-to-one patient and physician interactions.

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.

Use of Electronic Patient Reported Outcomes and Automated Devices for Heart Failure Disease Management

Background: Congestive heart failure (CHF) is a major public health issue. Today, CHF affects 6.5 million people in the U.S. and the incidence rate is projected to rise by 46% to more than 8 million cases by 2030. Current reimbursement policies use readmission rates and length of hospital stays as indicators of quality of care, and incentivize providers to meet these quality measures as the cost of hospitalization alone significantly contributes to the overall burden of CHF on patients and health systems. Symptoms of CHF can be unpredictable and presently there are no reliable solutions to track disease control for discharged patients.

From laboratory to bedside: a case report of a concise and pragmatic approach on heart failure

Heart failure is one of the most common and intensely studied diseases in the world. Nevertheless, it is considered a difficult condition to diagnose and manage.This case report, starting from the description of a brief clinical case, aims to directly and concisely explain the most important steps, from laboratory to bedside, in the diagnosis and management of heart failure disease. Physicians can rely on some laboratory tests (e.g., natriuretic peptides) and instrumental exams to diagnose and manage the patients in everyday medical practice. Finally, this article highlights that a multidisciplinary team management can improve the clinical status and the quality of life, thus preventing hospital admission and reducing mortality in patients with heart failure.

Protocol-driven remote monitoring of cardiac resynchronization therapy as part of a heart failure disease management strategy

Background: Cardiac resynchronisation therapy (CRT) is an established treatment for heart failure (HF) with reduced ejection fraction. CRT devices are equipped with remote monitoring functions, which are pivotal in the detection of device problems, but may also facilitate disease management. The aim of this study was to provide a comprehensive overview of the clinical interventions taken based on remote monitoring.Methods: This is a single centre observational study of consecutive CRT patients (n = 192) participating in protocol-driven remote follow-up. Incoming technical- and disease-related alerts were analysed together with subsequently triggered interventions.Results: During 34 ± 13 months of follow-up, 1372 alert-containing notifications were received (2.53 per patient-year of follow-up), comprising 1696 unique alerts (3.12 per patient-year of follow-up). In 60%, notifications resulted in a phone contact. Technical alerts constituted 8% of incoming alerts (0.23 per patient-year of follow-up). Rhythm (1.43 per patient-year of follow-up) and bioimpedance alerts (0.98 per patient-year of follow-up) were the most frequent disease-related alerts. Notifications included a rhythm alert in 39%, which triggered referral to the emergency room (4%), outpatient cardiology clinic (36%) or general practitioner (7%), or resulted in medication changes (13%). Sole bioimpedance notifications resulted in a telephone contact in 91%, which triggered outpatient evaluation in 8% versus medication changes in 10%. Clinical outcome was excellent with 97% 1-year survival.Conclusions: Remote CRT follow-up resulted in 0.23 technical- versus 2.64 disease-related alerts annually. Rhythm and bioimpedance notifications constituted the majority of incoming notifications which triggered an actual intervention in 22% and 15% of cases, respectively.

When Returning Home Is Not a Good Option

When Returning Home Is Not a Good Option

2. Anemia in heart failure – The underdog of risk predictors?

Abstract type Clinical Research. Presentation type Poster Presentation. Introduction Anemia is frequent in chronic heart failure and has shown to reduce survival in heart failure, particularly in patients with reduced ejection fraction. However, there is paucity of such data in a Saudi heart failure population. Methodology We studied patients enrolled in a dedicated Heart Failure Disease Management Programme (n = 2727, 72% male). Clinical characteristics and mortality data were analysed for the entire cohort and categorized using WHO Classification of anaemia. Categorical variables were presented as percentages, compared by chi-square test and expressed as odds ratio and 95% confidence intervals. Continuous data were summarized as mean ± SD. Relationship between parameters was analysed using regression analysis. Survival analysis was performed using Kaplan Meir curves. Data was analysed using JMP(SAS for Windows and p Results Some 35% patients had anemia, of which 10% was severe. Some 20% had Hb >15 g/dl. Patients with anemia were older, more likely to be NYHA Class II–III, have renal impairment and reduced ejection fraction (all p Conclusion Anemia is quite prevalent in a Saudi heart failure population with a significant preponderance in older patients with significant comorbidities. It is also associated with poor survival compared with those with normal haemoglobin levels.

Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities

BackgroundIndividuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied. ObjectivesTo describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization. Design, setting, and participantsRetrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016. MeasurementsValidity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission. ResultsOf 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation (“No CPR”), 58% selected “Full Treatment,” 17% chose “Selective Treatment,” and 23% chose “Comfort-Focused Treatment.” Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing “No CPR.” Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose “Comfort-Focused Treatment” and were hospitalized for more than symptom management. ConclusionSeventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. Clinicaltrials.gov # NCT01822912.

Heart Failure Disease Management Program and the Six Months Readmission Rate

Heart Failure Disease Management Program and the Six Months Readmission Rate

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.

A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned.

Conducting clinical trials in skilled nursing facilities is particularly challenging. This manuscript describes facility and patient recruitment challenges and solutions for clinical research in skilled nursing facilities. Lessons learned from the SNF Connect Trial, a randomized trial of a heart failure disease management versus usual care for patients with heart failure receiving post-acute care in skilled nursing facilities, are discussed. Description of the trial design and barriers to facility and patient recruitment along with regulatory issues are presented. The recruitment of Denver-metro skilled nursing facilities was facilitated by key stakeholders of the skilled nursing facilities community. However, there were still a number of barriers to facility recruitment including leadership turnover, varying policies regarding research, fear of litigation and of an increased workload. Engagement of facilities was facilitated by their strong interest in reducing hospital readmissions, marketing potential to hospitals, and heart failure management education for their staff. Recruitment of patients proved difficult and there were few facilitators. Identified patient recruitment challenges included patients being unaware of their heart failure diagnosis, patients overwhelmed with their illness and care, and frequently there was no available proxy for cognitively impaired patients. Flexibility in changing the recruitment approach and targeting skilled nursing facilities with higher rates of admissions helped to overcome some barriers. Recruitment of skilled nursing facilities and patients in skilled nursing facilities for clinical trials is challenging. Strategies to attract both facilities and patients are warranted. These include aligning study goals with facility incentives and flexible recruitment protocols to work with patients in "transition crisis."

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.

A comparison of HFrEF vs HFpEF's clinical workload and cost in the first year following hospitalization and enrollment in a disease management program

BackgroundAdmission with heart failure (HF) is a milestone in the progression of the disease, often resulting in higher intensity medical care and ensuing readmissions. Whilst there is evidence supporting enrolling patients in a heart failure disease management program (HF-DMP), not all reported HF-DMPs have systematically enrolled patients with HF with preserved ejection fraction (HFpEF) and there is a scarcity of literature differentiating costs based on HF-phenotype. Methods1292 consenting, consecutive patients admitted with a primary diagnosis of HF were enrolled in a hospital based HF-DMP and categorized as HFpEF (EF≥45%) or HFrEF (EF<45%). Hospitalizations, primary care, medications, and DMP workload with associated costs were evaluated assessing DMP clinic-visits, telephonic contact, medication changes over 1year using a mixture of casemix and micro-costing techniques. ResultsThe total average annual cost per patient was marginally higher in patients with HFrEF €13,011 (12,011, 14,078) than HFpEF, €12,206 (11,009, 13,518). However, emergency non-cardiovascular admission rates and average cost per patient were higher in the HFpEF vs HFrEF group (0.46 vs 0.31 per patient/12months) & €655 (318, 1073) vs €584 (396, 812). In the first 3months of the outpatient HF-DMP the HFrEF population cost more on average €791 (764, 819) vs €693 (660, 728). ConclusionThere are greater short-term (3-month) costs of HFrEF versus HFpEF as part of a HF-DMP following an admission. However, long-term (3–12month) costs of HFpEF are greater because of higher non-cardiovascular rehospitalisations. As HFpEF becomes the dominant form of HF, more work is required in HF-DMPs to address prevention of non-cardiovascular rehospitalisations and to integrate hospital based HF-DMPs into primary healthcare structures.

Bendopnea and risk of adverse clinical outcomes in ambulatory patients with systolic heart failure

Recently, the symptom of bendopnea, that is, shortness of breath when bending forwards such as when putting on shoes, has been described in heart failure patients and found to be associated with higher ventricular filling pressures, particularly in the setting of low cardiac index. However, it is not known whether bendopnea is associated with clinical outcomes. In a prospective convenience sample of 179 patients followed in our heart failure disease management clinic, we determined the presence of bendopnea at the time of enrollment and ascertained clinical outcomes through 1 year of follow-up. We performed univariate and stepwise multivariable modeling to test the association of bendopnea with clinical outcomes. Bendopnea was present in 32 of 179 (18%) subjects. At 1 year, those with versus without bendopnea were at increased risk of the composite endpoint of death, heart failure admission, inotrope initiation, left ventricular assist device implantation, or cardiac transplantation in univariate (hazard ratio [HR] 1.9, P < .05) but not multivariable (HR 1.9, P = .11) analysis. Bendopnea was more strongly associated with short-term outcomes including heart failure admission at 3 months in both univariate (HR 3.1, P < .004) and multivariable (HR 2.5, P = .04) analysis. Bendopnea was associated with an increased risk of adverse outcomes in ambulatory patients with heart failure, particularly heart failure admission at 3 months.

Improving medication titration in heart failure by embedding a structured medication titration plan

BackgroundTo improve up-titration of medications to target dose in heart failure patients by improving communication from hospital to primary care. MethodsThis quality improvement project was undertaken within three heart failure disease management (HFDM) services in Queensland, Australia. A structured medication plan was collaboratively designed and implemented in an iterative manner, using methods including awareness raising and education, audit and feedback, integration into existing work practice, and incentive payments. Evaluation was undertaken using sequential audits, and included process measures (use of the titration plan, assignment of responsibility) and outcome measures (proportion of patients achieving target dose) in HFDM service patients with reduced left ventricular ejection fraction. ResultsComparison of the three patient cohorts (pre-intervention cohort A n=96, intervention cohort B n=95, intervention cohort C n=89) showed increase use of the titration plan, a shift to greater primary care responsibility for titration, and an increase in the proportion of patients achieving target doses of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (A 37% vs B 48% vs C 55%, p=0.051) and beta-blockers (A 38% vs B 33% vs C 51%, p=0.045). Combining all three cohorts, patients not on target doses when discharged from hospital were more likely to achieve target doses of ACEI/ARB (p<0.0001) and beta blockers (p<0.0001) within six months if they received a medication titration plan. ConclusionsA medication titration plan was successfully implemented in three HFDM services and improved transitional communication and achievement of target doses of evidence-based therapies within six months of hospital discharge.

Effectiveness of a multidisciplinary heart failure disease management programme on 1-year mortality: Prospective cohort study.

We performed a multicenter prospective observational cohort study (Epidémiologie et Pronostic de l'Insuffisance Cardiaque Aiguë en Lorraine, Epidemiology and Prognosis of Acute Heart Failure in Lorraine [EPICAL2]) to evaluate the effectiveness on mortality of a community-based multidisciplinary disease management programme (DMP) for heart failure (HF) patients.Between October 2011 and October 2012, 1816 patients, who were hospitalized for acute HF or who developed acute HF during a hospitalization, were included from 21 hospitals in a northeast region of France. At hospital admission, their mean age was 77.3 (standard deviation [SD] 11.6) years and mean left ventricular ejection fraction was 45.0 (SD 16.0)%. A subset of patients were enrolled in a multidimensional DMP for HF (n = 312, 17.2%), based on structured patient education, home monitoring visits by HF-trained nurses, and automatic alerts triggered by significant clinical and biological changes to the patient. The DMP involved general practitioners, nurses, and cardiologists collaborating via an individual web-based medical electronic record. The outcome was all-cause mortality from the 3rd to the 12th month after discharge. During the follow-up, a total of 377 (20.8%) patients died: 321 (21.3%) in the control group and 56 (17.9%) in the DMP group. In a propensity score analysis, DMP was associated with lower 1-year all-cause mortality (hazard ratio 0.65, 95% CI 0.46-0.92). Instrumental variable analysis gave similar results (hazard ratio 0.56, 0.27-1.16).In a real world setting, a multidimensional DMP for HF with structured patient education, home nurse monitoring, and appropriate physician alerts may improve survival when implemented after discharge from hospitalization due to worsening HF.

Patient, Caregiver, and Physician Work in Heart Failure Disease Management: A Qualitative Study of Issues That Undermine Wellness

ObjectiveTo identify factors underlying heart failure hospitalization. MethodsBetween January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory–informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review. ResultsPatient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients. ConclusionTo improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis.

175 - Ten Years Too Early? Failure of Smart Phone Technology for Disease Management in Heart Failure

175 - Ten Years Too Early? Failure of Smart Phone Technology for Disease Management in Heart Failure

383 - Implementation of an Inpatient Heart Failure Disease Management (HFDM) Service with a Focus on Identifying Advanced Heart Failure and Focused Education Decreases 30 Day Re-Admission Rate

383 - Implementation of an Inpatient Heart Failure Disease Management (HFDM) Service with a Focus on Identifying Advanced Heart Failure and Focused Education Decreases 30 Day Re-Admission Rate

260 - Prevalence of Cognitive Impairment (CI) in Hospitalized Heart Failure (HF) Patients Utilizing the Mini-Cog Assessment Tool

Background: HF and CI are common medical conditions resulting in high hospital admissions and readmission rates. Both diagnoses are major healthcare problems leading to longer hospital length of stay, higher costs, and frequent readmissions. Objective: We present the prevalence of CI for patients admitted to the hospital with acute decompensated heart failure (ADHF) from a performance improvement project at our institution. Method: Three cardiology nurse practitioners (NP) formed the heart failure disease management (HFDM) service and provided a tailored assessment and intervention to patients admitted with HF including CI assessment in order to provide education with family for those with CI. The NP performed a 3-minute mini-cog assessment utilizing the standard mini-cog clock draw test (CDT) and 3-item recall test. Each word recalled was worth 1 point and the CDT was worth 2 points if completed correctly. A cutoff of < 3 points on the mini-cog assessment has been validated as a positive dementia screen and was used a positive CI score. Results: The HFDM NP saw 144 patients from December 2015 to February 2016. 136 patients had a completed mini-cog assessment documented. Nine patients seen refused to have a mini-cog assessment performed. 58% were male, 43% black with a mean age of 69 years old and an age range of 25 to 94 years. A positive cognitive deficit score of <3 points resulted in 32.4% of assessed patients evaluated. The 136 patients accounted for 347 total inpatient admissions within the hospital system within the past 4 years prior to the mini-cog assessment tool being utilized. Out of the 136 patients, 92 have a risk adjusted readmission rate of 13.64% (n = 6). Conclusion: The HFDM NP quality initiative validates that cognitive impairment with HF patients is a major contributor in hospital admissions with readmissions. 32.4% of the assessed patients has a score of < 3 points, indicating a CI. There is a continued need to assess the cognitive status of patients admitted to the hospital with HF. Further protocol care is instrumental in effective treatment of the underlying disease process for patients with a cognitive impairment. (Table 1, Table 2)Table 1Mini-Cog ScoreMini-Cog Score (0–5)N = 136 (CI %)0N = 22 (16.2%)1N = 9 (6.6%)2N = 13 (9.6%)3N = 14 (10.3%)4N = 7 (5.1%)5N = 71 (52.2%) Open table in a new tab Table 2Mini-Cog Score Divided into 4 QuartilesMini-Cog Score (0–5)1st QuartileMedian3rd Quartile4th QuartileGrand TotalAge (0–57)Age (58–69)Age (70–80)Age (81–95)033412221001892523313312741441222752223151171Grand Total3232324013625%16%25%58%32% Open table in a new tab