Multidisciplinary Disease Management Program Research Articles

HerzMobil Tirol – A telemedical, integrated disease management program for patients with heart failure

Heart failure (HF) is a global health problem with an increasing an increasing incidence and prevalence and thus a major impact on healthcare systems. The 1-year mortality is 23.6% in patients with acute HF. Hospitalization for acute HF is associated with higher mortality and recurrent hospitalization. The majority of readmissions occurs early after hospital discharge: about 25% of patients are readmitted within the first month with a 50% proportion of HF-related causes of readmissions.
 Therefore, in 2012 the Austrian province of Tyrol launched the HerzMobil Tirol (HMT) program, which is a multidisciplinary post-discharge disease management program for HF patients. It is supported by a telemedical monitoring system and embedded in a network of specialized nurses, resident physicians, and secondary/tertiary referral centers. After initial project phases, HMT reached its adolescence in 2017 and was adopted as regular service. This ensures reimbursement of the program by the social security system. 
 HMT is based on: (1) patient education to improve patient empowerment, (2) nurse-led care for early detection of imminent decompensation, (3) patient-held mobile phone for daily data acquisition and transmission of blood pressure, heart rate, body weight, well-being and drug intake, including nurse and physician-controlled telemonitoring, (4) continuous optimization of guideline-based HF therapy for long-term stabilization, and (5) network communication to assure comprehensive HF management across venues;
 Patients enter HMT at the end of hospitalization for acute HF. Patient education is delivered by specialized HF nurses. On discharge, each patient is assigned to a resident network physician near his/her home. Network physicians supervise the management of the patient and optimize individualized guideline-directed medical therapy. Discharge information including a detailed treatment plan from the hospital is communicated to the HMT network. Within HMT, patients are supervised for 3 months. Telemedically transmitted patient data are reviewed daily by HF nurses and weekly by network physicians. Out-of-limit data are automatically signaled so that interventions, for example, adjustment of diuretics, can follow immediately. Face-to-face visits of the patient with the network physician are scheduled 1, 4, and 12 weeks after discharge. HF nurses monitor patients’ compliance with medication, maintain telephone contact with patients if necessary and adjust HF medication according to the network physicians’ instructions. Additionally, a home visit by the HF nurse is scheduled immediately after discharge to complete disease- and equipment-related education and to ensure that prescribed medication is available. At the end of the managed care program, structured transfer of patients to regular care is organized. Regular HF network meetings of physicians and nurses are scheduled every 3 months.
 A recently publication demonstrated the effectiveness of the program as indicated by a significant reduction of HF readmission and all-cause mortality within 6 months for patients in the HMT program compared to usual-care patients. 
 HerzMobil was adopted in other provinces of Austria following the Tyrolean model. It is continuously further developed. In a next step, the coronary heart disease will be included in the HMT model. An extension of the program with physical activity aspects is planned.

Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score-Matched Study.

The beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance-reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF. This was a retrospective propensity score-matched cohort study using the Taiwan National Health Insurance Research Database. In total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis. All patients were followed up after discharge for all-cause mortality, emergency visits within 30days, and length of stay and medical expenses for readmission within 180days after discharge. After propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio= 0.520, 95% CI= 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank= 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180days post discharge (all P < .001). HF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.

Impact of primary care involvement and setting on multidisciplinary heart failure management: a systematic review and meta-analysis.

Multidisciplinary disease management programmes (DMPs) are a cornerstone of modern guideline‐recommended care for heart failure (HF). Few programmes are community initiated or involve primary care professionals, despite the importance of home‐based care for HF. We compared the outcomes of different multidisciplinary HF DMPs in relation to their recruitment setting and involvement of primary care health professionals. We conducted a systematic review and meta‐analysis of randomized controlled trials published in MEDLINE, Embase, and Cochrane between 2000 and 2020 using Cochrane Collaboration methodology. Our meta‐analysis included 19 randomized controlled trials (7577 patients), classified according to recruitment setting and involvement of primary care professionals. Thirteen studies recruited in the hospital (n = 5243 patients) and six in the community (n = 2334 patients). Only six studies involved primary care professionals (n = 3427 patients), with two of these recruited in the community (n = 225 patients). Multidisciplinary HF DMPs that recruited in the community had no significant effect on all‐cause and HF readmissions nor on mortality, irrespective of primary care involvement. Studies that recruited in the hospital demonstrated a significant reduction in mortality (relative risk 0.87, 95% confidence interval [CI] [0.76, 0.98]), HF readmissions (0.70, 95% CI [0.54, 0.89]), and all‐cause readmissions (0.72, 95% CI [0.60, 0.87]). However, the difference in effect size between recruitment setting and involvement of primary care was not significant in a meta‐regression analysis. Multidisciplinary HF DMPs that recruit in the community have no significant effect on mortality or hospital readmissions, unlike DMPs that recruit in the hospital, although the difference in effect size was not significant in a meta‐regression analysis. Only six multidisciplinary studies involved primary care professionals. Given demographic evolutions and the importance of integrated home‐based care for patients with HF, future multidisciplinary HF DMPs should consider integrating primary care professionals and evaluating the effectiveness of this model.

Implementation of a Disease Management Program in Adult Patients With Heart Failure.

Approximately 5.7 million people in the United States are diagnosed and living with heart failure (HF), with projected prevalence rates to increase 46% by 2030. Heart failure leads hospital admissions in the United States for individuals 65 years or older, with many acute exacerbation admissions resulting from a lack of medication management, poor patient treatment plan adherence, and lack of appropriate follow-up within the health care system. In 2017, the 30-day HF readmission rate at the facility of implementation was 27%, 3% higher than the national average and, more specifically, 18.5% for the cardiac care unit (CCU). The aim of this study was to develop an HF disease management program to reduce 30-day readmission rates for HF patients through the implementation of a structured program including self-care education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. The implementation of the disease management program took place at a major military treatment facility in the continental United States. The facility is a teaching facility housing a 272-bed multispecialty hospital and an ambulatory complex. The implementation took place on the CCU, the primary unit for cardiac admissions, with approximately 30 admissions a month for a primary diagnosis of HF. In August 2018, a multidisciplinary disease management program was implemented to include patient education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. Data were collected and analyzed for 90 days and compared with retrospective data from 2017. Participants in the disease management program had a statistically significant improvement (p < .001) in the hospital readmission rate. The overall 30-day readmission rate decreased from 27% to 10.2% during the implementation period, a decrease of 38%. Ninety-three percent of the patients completed the self-care education, and telephone follow-up was successfully achieved with 96% of these patients. Only 4 patients in the HF disease management program experienced readmission within 30 days. Patients and caregivers reported increased satisfaction with their care due to the disease management program and increased follow-up with care. The findings of this innovation suggest that a multidisciplinary disease management program can reduce avoidable 30-day readmissions. The program improved patient follow-up and decreased follow-up appointment no-shows. Multiple participants expressed increased patient satisfaction. The program supports the need for coordinated, interdisciplinary disease management to improve the quality of life of those affected by HF and improve the use of resources to reduce the overall health care burden. Case management is critical to the organized care of HF patients due to the complex, individualized care to achieve optimum patient outcomes.

Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana.

The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.

Rola edukacji zdrowotnej u chorych z niewydolnością serca

According to European Society of Cardiology guidelines, the goal of heart failure (HF) management is to provide an effective system of care through the whole patient’s journey including hospital and ambulatory pathway. Strategies based on patients’ education, psychosocial support and monitoring should be considered as a fundamental part of multidisciplinary disease management programs and may lead to a reduction in mortality and morbidity and improvement in the quality of life. In this article, we focus on patient’s education strategies by describing different models: “one-to-one” strategies, multidisciplinary care management programs, activation of the family members, pharmaceutical care, and end-stage HF advance care planning. Furthermore, we explain the problem of health literacy among HF patients and describe actionable advice on how medical professionals can effectively improve patients’ comprehension and knowledge on disease management and the ability for self-care. Lastly, we review the latest evidence on outcomes obtained by HF education.

2019 Focused Update of the Guidelines of the Taiwan Society of Cardiology for the Diagnosis and Treatment of Heart Failure.

Heart failure is a growing epidemic, especially in Taiwan because of the aging population. The 2016 Taiwan Society of Cardiology - Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed that the guideline-recommended therapies were prescribed suboptimally both at the time of hospital discharge and during follow-up. We, therefore, conducted this 2019 focused update of the guidelines of the Taiwan Society of Cardiology for the diagnosis and treatment of heart failure to reinforce the importance of new diagnostic and therapeutic modalities of heart failure. The 2019 focused update discusses new diagnostic criteria, pharmacotherapy, non-pharmacological management, and certain co-morbidities of heart failure. Angiotensin receptor neprilysin inhibitor and If channel inhibitor is introduced as new and recommended medical therapies. Latest criteria of cardiac resynchronization therapy, implantable cardioverter-defibrillator, heart transplantation, and ventricular assist device therapy are reviewed in the non-pharmacological management chapter. Co-morbidities in heart failure are discussed including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and sleep-disordered breathing. We also explain the adequate use of oxygen therapy and non-invasive ventilation in heart failure management. A particular chapter for chemotherapy-induced cardiac toxicity is incorporated in the focused update to emphasize the importance of its recognition and management. Lastly, implications from the TSOC-HFrEF registry and post-acute care of heart failure are discussed to highlight the importance of guideline-directed medical therapy and the benefits of multidisciplinary disease management programs. With guideline recommendations, we hope that the management of heart failure can be improved in our society.

Role and efficacy of cardiac rehabilitation in patients with heart failure.

Despite improvements in treatments, the prognosis of heart failure remains poor. Elderly patients with heart failure are burdened with multiple co-morbidities and polypharmacy. Multidisciplinary disease-management programs are recommended as standard care for patients at high risk of hospitalization. Cardiac rehabilitation is defined a coordinated multidimensional intervention that integrates the basic elements in multidisciplinary management programs with a continuing program of physical activity and exercise training. Cardiac rehabilitation services can be provided on an inpatient or outpatient basis according to the clinical characteristics and severity of the disease. Data support the usefulness of inpatient cardiac rehabilitation interventions soon after hospitalization for acute decompensated heart failure as a "transition care service" to overcome the particularly high risk "vulnerable" phase. Although in the elderly, physical activity is conditioned by the general clinical conditions, the presence of comorbidities and frailty, several data underscore the importance of improving exercise capacity in the elderly vulnerable patient.

High-Intensity Interval Training is Associated with Improved Long-Term Survival in Heart Failure Patients.

This matched-control cohort study explored the effects of high-intensity interval training (HIIT) on left ventricle (LV) dimensions and survival in heart failure (HF) patients between 2009 and 2016. HF patients who underwent the multidisciplinary disease management program (MDP) were enrolled. Non-exercising participants, aged (mean (95% confidence interval)) 62.8 (60.1–65.5) years, were categorized as the MDP group (n = 101). Participants aged 61.5 (58.7–64.2) years who had completed 36 sessions of HIIT were treated as the HIIT group (n = 101). Peak oxygen consumption (VO2peak) and LV geometry were assessed during the 8-year follow-up period. The 5-year all-cause mortality risk factors and overall survival rates were determined in the longitudinal observation. An increased VO2peak of 14–20% was observed in the HIIT group after exercise training. Each 1-mL/kg/min increase in VO2peak conferred a 58% improvement in 5-year mortality. Increased LV end-systolic diameter (LVESD) was significantly (p = 0.0198) associated with increased mortality. The 8-month survival rate was significantly improved (p = 0.044) in HIIT participants compared to non-exercise participants. HF patients with VO2peak ≥14.0 mL/kg/min and LVESD <44 mm had a significantly better 5-year survival rate (98.2%) than those (57.3%) with lower VO2peak and greater LVESD. Both HIIT-induced increased VO2peak and decreased LVESD are associated with improved survival in HF patients.

P1826Predictors of disease progression in heart failure patients managed in a multidisciplinary disease management program

P1826Predictors of disease progression in heart failure patients managed in a multidisciplinary disease management program

Effects of a multidisciplinary disease management programme with or without exercise training for heart failure patients: Secondary analysis of a randomized controlled trial

BackgroundHeart failure is a complex syndrome that causes substantial functional impairment and poor outcomes. Although multidisciplinary disease management programmes are effective, the role of additional outpatient-based exercise training and the effects of multidisciplinary disease management programmes for patients with contraindications to exercise training are unclear. ObjectivesTo compare the effects of the multidisciplinary disease management programme with and without exercise training on heart failure-related rehospitalization, disease knowledge, and functional capacity. DesignSecondary analysis of a randomized controlled trial. Participants and SettingData for 212 patients hospitalized for heart failure at a local teaching hospital in Taiwan were analysed. MethodsPatients’ data were assigned to three groups: control (n = 71), multidisciplinary disease management programme without exercise training (n = 70) or multidisciplinary disease management programme with exercise training (n = 71). The multidisciplinary disease management programme included comprehensive assessments, individualized education, optimizing medications, pre-scheduled clinic visits, and encouraging regular physical activity at home. Outpatient-based exercise training was performed only in the multidisciplinary disease management programme with exercise training group. The control and the multidisciplinary disease management programme without exercise training groups were further divided into subgroups with and without contraindications to exercise training. Patients were followed up monthly for heart failure-related rehospitalizations for 1 year. Cox proportional hazard models and Kaplan-Meier analyses were used to identify the significant predictors of heart failure-related rehospitalizations. A generalized estimation equation model was used to analyse the secondary outcomes, including disease knowledge and 6-min walking distance at baseline and 6 and 12 months after discharge. ResultsAt 12 months after discharge, the multidisciplinary disease management programme with and without exercise training groups had significantly lower heart failure-related rehospitalization rates and better disease knowledge compared with the control group (p < 0.01). Only the multidisciplinary disease management programme with exercise training group had a significant improvement in 6-min walking distance (p < 0.05). For patients with contraindications to exercise, the multidisciplinary disease management programme significantly reduced heart failure-related rehospitalization rates at 12 months after discharge (p < 0.05). For those without contraindications, the event-lowering effect was only noted for the multidisciplinary disease management programme with exercise training group (p < 0.05). ConclusionsOutpatient-based exercise training is recommended to be incorporated into multidisciplinary disease management programmes for patients without exercise contraindications to improve disease outcomes and functional capacity. For patients with contraindications to exercise, a multidisciplinary disease management programme is recommended to improve patient outcomes.

HerzMobil, an Integrated and Collaborative Telemonitoring-Based Disease Management Program for Patients With Heart Failure: A Feasibility Study Paving the Way to Routine Care.

BackgroundHeart failure is a major health problem associated with frequent hospital admissions. HerzMobil Tirol is a multidisciplinary postdischarge disease management program for heart failure patients to improve quality of life, prevent readmission, and reduce mortality and health care costs. It uses a telemonitoring system that is incorporated into a network of specialized heart failure nurses, physicians, and hospitals. Patients are equipped with a mobile phone, a weighing scale, and a blood pressure and heart rate monitor for daily acquisition and transmission of data on blood pressure, heart rate, weight, well-being, and drug intake. These data are transmitted daily and regularly reviewed by the network team. In addition, patients are scheduled for 3 visits with the network physician and 2 visits with the heart failure nurse within 3 months after hospitalization for acute heart failure.ObjectiveThe objectives of this study were to evaluate the feasibility of HerzMobil Tirol by analyzing changes in health status as well as patients’ self-care behavior and satisfaction and to derive recommendations for implementing a telemonitoring-based interdisciplinary disease management program for heart failure in everyday clinical practice.MethodsIn this prospective, pilot, single-arm study including 35 elderly patients, the feasibility of HerzMobil Tirol was assessed by analyzing changes in health status (via Kansas City Cardiomyopathy Questionnaire, KCCQ), patients’ self-care behavior (via European Heart Failure Self-Care Behavior Scale, revised into a 9-item scale, EHFScB-9), and user satisfaction (via Delone and McLean System Success Model).ResultsA total of 43 patients joined the HerzMobil Tirol program, and of these, 35 patients completed it. The mean age of participants was 67 years (range: 43-86 years). Health status (KCCQ, range: 0-100) improved from 46.2 to 69.8 after 3 months. Self-care behavior (EHFScB-9, possible range: 9-22) after 3 months was 13.2. Patient satisfaction in all dimensions was 86% or higher. Lessons learned for the rollout of HerzMobil Tirol comprise a definite time schedule for interventions, solid network structures with clear process definition, a network coordinator, and specially trained heart failure nurses.ConclusionsOn the basis of the positive evaluation results, HerzMobil Tirol has been officially introduced in the province of Tyrol in July 2017. It is, therefore, the first regular financed telehealth care program in Austria.

Outcomes and Factors Influencing Response to an Individualized Multidisciplinary Chronic Disease Management Program for Hip and Knee Osteoarthritis

BackgroundThe objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA). MethodsOver a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index. ResultsAt mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001). ConclusionsPatients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

Effectiveness of a multidisciplinary disease management program on outcomes in patients with heart failure in China: A randomized controlled single center study

BackgroundMultidisciplinary disease management programs (MDMP) for patients with heart failure (HF) have been delivered, but evidence of their effectiveness in China is limited. ObjectiveTo determine if a MDMP improves quality of life (QoL), physical performance, depressive symptoms, self-care behaviors and mortality or rehospitalization in patients with HF in China. MethodsThis is a randomized controlled single center trial in which patients with HF received either MDMP with discharge education, physical training, follow-up visits and telephone calls for 180 days (n = 31) or standard care (SC, n = 31). ResultsCompared with SC, QoL, depressive symptoms, and self-care behaviors were significantly improved by MDMP from baseline to 180 days (37% vs 66%, 20% vs 61%, and 8% vs 33%, respectively, all p < 0.001). There were no differences in physical performance and mortality or rehospitalization during follow-up. ConclusionsA HF MDMP can improve QoL, depressive symptoms and self-care behaviors in China.

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.

Team Medicine for CHF Treatment.

The mortality associated with end stage heart failure (HF) is high, despite the development of new and increasingly effective drugs and non-pharmacological therapies. Repetitive hospitalizations predict fatal outcomes, and each hospitalization should prompt individual conversations with the patient, the family and the caregivers. A multidisciplinary disease management program promotes the education of patients and their families, and modifies their behaviour, with a view to ultimately improving the prognosis and quality of life. Beginning with the earliest stages of HF, on through the late stages, a multidisciplinary disease management program should be implemented.

Factors Associated With Inadequate Effectiveness of a Multidisciplinary Disease Management Program in Heart Failure Patients Stratified by Galectin 3 Level.

This study investigated whether multidisciplinary disease management programs (MDPs) exert the same effects in heart failure (HF) patients across risk levels stratified by galectin-3 (Gal-3) level and what factors are associated with inadequate effectiveness of MDP. We used a longitudinal follow-up design based on a previous randomized trial. A total of 355 stabilized hospitalized HF patients were enrolled. The effects of MDP on death and HF-related rehospitalization were analyzed according to Gal-3 levels. During the 4-year follow-up, Gal-3 levels predicted mortality and composite events ( p < .001). Multivariable analysis demonstrated the event-lowering effect of MDP (hazard ratio [HR] = 0.49, p = .001 for death and HR = 0.50, p < .001 for composite events). However, the effect of MDP was inadequate for those with high Gal-3 levels (≥17.9 ng/ml), whose 4-year composite event rate was 43% in the MDP arm. Further analysis showed that, in patients with Gal-3 ≥ 17.9 ng/ml, the independent factors associated with a high composite event rate were no MDP, older age, worse New York Heart Association functional class, no angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, higher predischarge natriuretic peptide levels, and wider QRS complexes. The effectiveness of MDP for HF patients at high risk was inadequate. Our findings identified the characteristics of these MDP nonresponders. Better integration of advanced care plans based on strategies guided by Gal-3 level is needed to improve care quality.

Congestive heart failure disease management program: 1-Year population experience from a tertiary center heart failure registry in Saudi Arabia

AimsWe aimed to evaluate congestive heart failure (CHF) multidisciplinary disease management program (DMProg) impact on mortality, readmission rates, length of stay (LOS), and gender health characteristics. Methods and resultsThis was a quasi-observational, pre- and post-trial with a parallel nonequivalent group. We enrolled 174 inpatients having CHF with reduced ejection fraction and New York Heart Association (NYHA) Class II–IV, and a total of 197 hospital admissions. A comparative follow-up was performed from 15 December 2014 to 15 December 2015. Among 197 consecutive hospital admissions, 76 (39%) were included in the preintervention or usual care group and 121 (61%) were assigned to the postintervention group. After 1year, in comparison with the preintervention group, the postintervention group had shorter average LOS in days (7.6days vs. 11.1days, p<0.002), lower 1-year readmission rate (36% vs. 57%, p<0.003), and lower in-house mortality (1.6% vs. 7.8%, p=0.03), but similar baseline mortality scores (38.2 vs. 38.6, p=0.7), 30-day and 90-day readmission rates (15% vs. 18.3%, p=0.62 and 27.6% vs. 30%, p=0.65), and 30-day readmission risk score (24.9% vs. 26.2%, p=0.09). By regression analysis, the DMProg intervention was an independent factor for 1-year readmission reduction (p=0.001). Kaplan–Meier survival analysis favored the postintervention group (log-rank, p<0.001). ConclusionDMProg significantly decreased 1-year readmission rates, LOS, and in-house mortality.

Multidisciplinary COPD disease management program: impact on clinical outcomes

ABSTRACTObjectives: We hypothesized performance improvement interventions would improve COPD guideline-recommended care and decrease COPD exacerbations in primary care clinic practices.Methods: We initiated a performance improvement project in 12 clinics to improve COPD outcomes incorporating physician education, case management, web-based decision support (CareManagerTM), and performance feedback. We collected baseline and one-year follow up data on 242 patients who had COPD with acute exacerbations. We analyzed data by two methods. First, the 12 clinics were cluster randomized to 4 intervention (117 patients) and 8 control (125 patients) clinics which all had access to CareManagerTM but only intervention clinic physicians received case management, academic detailing, and decision support assistance. Exacerbation rates and guideline adherence were compared. Second, data from all 12 clinics were pooled in a quasi-experimental design comparing baseline and post-implementation of CareManagerTM to determine the value of system-wide performance improvement during the study period.Results: In the randomized analysis, baseline demographics were similar. No differences (p = 0.79) occurred in exacerbation rates between intervention and control clinics although both groups had decreased numbers of exacerbations from baseline to follow up (p < 0.05). The pooled data from all 12 clinics demonstrated a reduction (p < 0.05) in mean exacerbations/patient from 2.3 (CI 2.0–2.6) during baseline to 1.4 (CI 1.1–1.7) at one-year follow up. Emergency department visits and hospitalizations/patient decreased (p = 0.003). Patients naïve at study start to depression screening, pneumococcal vaccination, inhaled control medications or smoking cessation had fewer (p < 0.05) exacerbations after these interventions.Conclusion: We observed no difference in exacerbation rates between clinics receiving case management, academic detailing, and ongoing assistance with decision support and controls. Implementation of a web-based disease management system (CareManagerTM) along with health system-wide COPD performance improvement efforts was associated with fewer COPD exacerbations and increased adherence to guideline recommendations.

Prognostic and Therapeutic Implications of Frailty in Older Adults with Heart Failure

Frailty is increasingly recognized in older adults with cardiovascular disease, particularly in those with heart failure (HF). A growing body of evidence has shown that frailty has a negative effect on survival, hospitalizations, disability, and quality of life. Beyond frailty, additional domains captured by a comprehensive geriatric assessment contribute incremental value in predicting outcomes and identifying treatment targets. Exercise training is ideally suited to this setting as it can concomitantly improve physical frailty and HF symptoms. Multidisciplinary disease management programs offer a number of benefits for frail HF patients; invasive procedures carry a higher risk of morbidity than in non-frail counterparts, and evidence-based drugs and devices have an uncertain value and warrant further research. While more data accrues, difficult therapeutic decisions should be individualized using a shared patient-centered decision making approach.