Specialist Nurse-Led Intervention in Outpatients with Congestive Heart Failure

Congestive heart failure (CHF) encompasses a spectrum of clinical syndromes and presentations. It affects 1–2% of the population in the UK and is associated with significant mortality which is comparable to most cancers. It accounts for more than 5% of adult medical admissions in the UK, with significant annual re-admission rates. Improved understanding of the pathophysiology of CHF has resulted in significant advancements in CHF management. Current pharmacologic agents, such as ACE inhibitors, β-adrenoceptor antagonists and spironolactone, influence symptoms and improve mortality. Despite this, many patients still require hospitalization. Multiple, potentially reversible factors are involved which, if addressed effectively, may result in significant reductions in re-admission rates. Patients with CHF often have other conditions, such as respiratory disease, resulting in prolonged lengths of stay. Suboptimal care and failure to adhere to management guidelines is also a preventable cause for re-admission. There has been an increasing need to develop adjunctive, non-pharmacologic strategies for managing CHF, which are designed to improve the patient’s functional status and quality of life. Key elements include systematic follow-up care and patient education. The concept of intensive outpatient or home-based CHF intervention has been developed and extensively evaluated in several randomized controlled trials. Early studies were inconclusive but provided an indication that discharge planning and home-based education are valuable strategies. Recently, an increasing number of studies utilizing the CHF nurse practitioner have provided positive results for non-pharmacologic intervention and demonstrate the potential of these interventions to reduce admissions to hospital by up to 50%. These studies had specific inclusion criteria and could not be generalized to the CHF population as a whole. The Study to Evaluate the effectiveness of Nurse-led Intervention in the management of outpatients with heart Failure (SENIF) explored whether a similar approach to CHF management was beneficial in a typical outpatient population of patients with CHF. Over 12 months, fewer intervention group patients required admission, resulting in 69% fewer hospital days. Cost effectiveness of nurse-led intervention has been suggested in several studies including SENIF, resulting from reduced hospitalizations and re-admissions, which vastly outweighed the modest increase in expenditure required to run the programs. Hospitalizations because of CHF impact greatly on limited healthcare resources. Specialist nurse-led intervention in CHF is a cost-effective, non-pharmacological strategy to help optimize CHF management.     

Improved care for patients with congestive heart failure

BACKGROUND: Congestive heart failure (CHF) affects 4.9 million people, mostly elderly, in the United States; 550,000 new cases are diagnosed each year. Evidence-based treatment approaches offer opportunities to reduce mortality, complications, and rehospitalization rates. STRATEGIES TO IMPROVE CARE FOR PATIENTS WITH CONGESTIVE HEART FAILURE: Seven key components of care tailored to the patient's clinical condition and comorbidities that should be provided to all patients with CHF, in the absence of contraindications or intolerance: (1) left ventricular systolic function assessment, (2) angiotension-converting enzyme-inhibitor or angiotensin receptor blockers at discharge for CHF patients with systolic dysfunction (left ventricular ejection fraction < 40%), (3) anticoagulation at discharge for CHF patients with chronic or recurrent atrial fibrillation, (4) smoking cessation advice and counseling, (5) discharge instructions that address activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen, (6) influenza immunization (seasonal), and (7) pneumococcal immunization. Hospitals should also consider beta-blocker therapy at discharge for stabilized patients without contraindications. CONCLUSION: The 5 Million Lives Campaign's focus on delivering reliable, evidence-based care for patients with CHF is part of an overall strategy to reduce medically induced harm.     

Women physicians are early adopters of on-line continuing medical education

INTRODUCTION: On-line continuing medical education (CME) provides advantages to physicians and to medical educators. Although practicing physicians increasingly use on-line CME to meet their educational needs, the overall use of on-line CME remains limited. There are few data to describe the physicians who use this new educational medium; yet, they clearly are the innovators and early adopters who will facilitate the growth of this educational technology. It would be useful to instructional designers and CME developers to better understand the characteristics of this influential group. METHODS: We studied the actual use of several different on-line CME programs within three different groups of physicians. The on-line programs were developed as part of research studies funded by the National Institutes of Health, with no relationship to commercial interests. They were presented to physicians using mass mailouts (two physician groups) or personal contact and were accompanied by incentives to reduce resistance to the new technology. We compared the characteristics of physicians who chose to use these on-line programs with demographic data from larger populations representing the groups from which these users originated. RESULTS: We found that physicians who used these on-line CME programs were younger than average and, importantly, more likely to be female than expected. This finding was consistent across different types of physician populations and different types of CME programs. DISCUSSION: Based on data reflecting actual use of on-line CME, younger physicians appear to be adopting on-line CME more rapidly than others, and women physicians appear to be adopting on-line CME at a faster rate than their male counterparts. This latter finding conflicts with the impression provided by some survey-based studies that male physicians are more likely than female physicians to use on-line CME. The data suggest that the growth of on-line CME is most likely occurring in diffusion networks dominated by relatively new medical school graduates and, possibly, women physicians. These results provide valuable insight to those who seek to develop and market on-line CME and those who seek to reach women physicians with CME programs.     

Unobserved health care expenditures: How important is censoring in register data?

Accurate information on individuals' health service use is important for evaluating health policies and analyzing health care demand. Although register data are considered to be more reliable than survey data, little is known about the extent and effect of censoring of the expenditure distribution in register data. We exploit a recent change in the health provider remuneration system in several Swiss cantons to empirically investigate whether censoring occurs when individuals do not have to disclose their health service use below their deductible level. Applying a difference‐in‐differences approach, we find that between CHF 6.70 (1.7%) to CHF 9.64 (2.4%) of all health service use paid out‐of‐pocket are not observed (per capita per year). This effect seems to be driven by high‐deductible plans where observed out‐of‐pocket expenditures declined by CHF 30.34 (7.6%) after the change. Although statistically significant, these effects are almost negligible in economic terms. We therefore concluded that, if anything, censoring is a very limited issue in Swiss health insurance claims data.     

Congestive heart failure due to diastolic or systolic dysfunction. Frequency and patient characteristics in an ambulatory setting.

OBJECTIVE: To determine the age- and sex-specific frequencies and characteristics of patients with diastolic and systolic dysfunction heart failure. DESIGN: Retrospective medical record survey encompassing 1 year. SETTING: Community-based family practice office. PATIENTS: One hundred thirty-six patients who met the modified Framingham criteria for the diagnosis of congestive heart failure (CHF) and had a known left ventricular ejection fraction. Diastolic dysfunction was defined as an ejection fraction of 45% or greater and systolic dysfunction heart failure as an ejection fraction of less than 45%. MAIN OUTCOME MEASURES: Age- and sex-specific frequency; patient comorbid conditions; medications taken; and number of emergency department visits, hospitalizations, and deaths. RESULTS: The frequency of CHF increased with age for men and women (1.3% for patients 45-54 years old to 8.8% for patients > 75 years old). The distribution according to left ventricular ejection fraction and age varied according to sex. Women had later onset of CHF that was predominantly diastolic dysfunction heart failure. Men had proportionately more systolic dysfunction heart failure at all ages. Forty percent of all patients with CHF had diastolic heart failure, and these patients had fewer functional limitations (76% with New York Heart Association classes I and II), fewer hospitalizations for CHF, and a trend toward fewer deaths during the study year compared with patients with systolic dysfunction. CONCLUSIONS: Congestive heart failure is a heterogeneous condition in this family practice setting, and diastolic dysfunction heart failure occurs frequently. Further study of the natural history and treatment of diastolic dysfunction heart failure should be performed in the primary care setting.     

A survey of current use of angiotensin-converting-enzyme inhibitors by Scottish physicians in the treatment of chronic cardiac failure

318 consultant physicians in Scotland were sent a questionnaire on their use of angiotensin converting enzyme (ACE) inhibitors to treat chronic heart failure (CHF). 229 (72%) replies were received. Of these 91% used ACE inhibitors for CHF; 22% were geriatricians, 58% general physicians and 20% cardiologists. All groups reserved ACE inhibitors for patients uncontrolled by diuretics alone. Compared to general physicians, cardiologists used ACE inhibitors in preference to other vasodilators and digoxin, used higher doses and commenced treatment more often on a day-patient basis. Cardiologists also commonly started treatment with captopril even if continuing with enalapril. Geriatricians used ACE inhibitors as frequently as cardiologists but at lower doses; they did not report side-effects more frequently. Further investigation of the safety and possible cost savings of supervised day-patient rather than in-patient, introduction of ACE inhibitors for CHF is now merited. To avoid an extended period of patient observation after the first dose of ACE inhibitor, captopril might also be given as the initial therapy, even if continuing with enalapril. This policy would also reduce the risk of any hypotensive response being prolonged.     

Improvement of primary care for patients with chronic heart failure: a pilot study

Background  

Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.     

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.     

Patients with congestive heart failure and healthy controls differ in vitamin D-associated lifestyle factors

We have recently hypothesized that low vitamin D status may contribute to the pathogenesis of congestive heart failure (CHF). This study was aimed at evaluating, in a pilot study, whether CHF patients have indications for a low vitamin D status during earlier periods of their lives. We performed a case-controlled study in 150 CHF patients and 150 controls. Study participants had to answer a questionnaire that included several items concerning vitamin D-associated lifestyle factors during childhood, adolescence, and adulthood. A vitamin D score was constructed. This score takes into consideration that ultraviolet-B (UVB) exposure is the major vitamin D source for humans and that those lifestyle factors, which are associated with regular UVB exposure, can guarantee an adequate vitamin D status at best. The vitamin D score was significantly higher in controls than in patients (p < 0.001). Compared with the controls, more patients lived in large cities (p < 0.001), fewer patients were members of a sport club (p < 0.001), and fewer patients had summer holidays every year (p < 0.01). Patients also reported significantly less alcohol consumption during adulthood than controls (p < 0.001). Our results demonstrate that CHF patients and controls differed in several vitamin D-associated lifestyle factors and in alcohol consumption during earlier periods of their lives.     

Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics

BACKGROUND: Many patients with congestive heart failure (CHF) receive care solely from a primary care physician, while some receive care from both a primary care physician and a cardiologist. Patients in the latter type of care relationships have not been described. The principal objectives of our study were to determine what percentage of patients with CHF are comanaged, the characteristics of comanaged CHF patients, and when in the natural history of CHF this relationship is initiated. METHODS: A retrospective record review was conducted of all patients who met the modified Framingham criteria for the diagnosis of CHF in a large community-based family practice office. Comanagement was defined as an ongoing relationship with a cardiologist characterized by a minimum of one visit to the cardiologist's office in the year of evaluation. We divided the natural history of CHF into 4 stages to describe the timing of the initial referral to the cardiologist: I Prediagnosis; II Diagnosis; III Progression; and IV Terminal. RESULTS: Of 151 patients identified with CHF, 36% of the patients were comanaged by a primary care physician and a cardiologist. The comanagement relationship often began early in the development of CHF, 20% at stage I and 54% at stage II. The patients who were comanaged were younger, predominately men, had a greater frequency of myocardial infarction, were more likely to have decreased systolic function, were on more cardiac medications, and had fewer hospitalizations for CHF exacerbations compared with CHF patients managed solely by family physicians. CONCLUSIONS: Comanagement of patients with CHF is a common occurrence, and comanaged CHF patients have distinct characteristics from those managed solely by family physicians. These results have implications for the quality and cost of caring for patients with CHF and suggest that more detailed study is required.     

One-Year Stability of Care Dependency in Patients With Advanced Chronic Organ Failure

ObjectivesCare dependency is a determinant of quality of life and survival among patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), or chronic renal failure (CRF). The objectives of this study were to explore the profiles of care dependency in patients with advanced COPD, CHF, or CRF; to study the changes in care dependency during 1-year follow-up; and to study whether 1-year changes in care dependency are comparable between patients with advanced COPD, CHF, or CRF.DesignLongitudinal observational study.ParticipantsClinically stable patients with advanced COPD (n = 105), CHF (n = 80), or CRF (n = 80) were recruited at outpatient clinics of 7 Dutch hospitals.MeasurementsPatients were visited at home at baseline, and at 4, 8, and 12 months to assess demographic and clinical characteristics, comorbidities (Charlson comorbidity index), care dependency (Care Dependency Scale), mobility, health status, and symptom burden.ResultsCOPD and CHF patients reported a higher baseline level of care dependency than patients with CRF. Care dependency differed between patients with COPD, CHF, or CRF in the items ‘getting (un)dressed,’ ‘hygiene,’ ‘contact with others,’ and ‘sense of rules/values.’ One-year follow-up was completed by 206 patients (77.7%). Patients with COPD were more likely to experience an increase in care dependency. An increase in care dependency was associated with higher age, higher number of hospital admissions, decrease in health status, and worsening of Charlson comorbidity index score.ConclusionsCare dependency profiles differ between patients with COPD, CHF, or CRF. Patients with advanced COPD are at risk for a 1-year increase in care dependency. Regular assessment of care dependency and addressing care dependency in palliative care programs for patients with advanced COPD, CHF, or CRF are needed.     

Survival associated with two sets of diagnostic criteria for congestive heart failure

Congestive heart failure (CHF) definitions vary across epidemiologic studies. The Framingham Heart Study criteria include CHF signs and symptoms assessed by a physician panel. In the Cardiovascular Health Study, a committee of physicians adjudicated CHF diagnoses, confirmed by signs, symptoms, clinical tests, and/or medical therapy. The authors used data from the Cardiovascular Health Study, a population-based cohort study of 5,888 elderly US adults, to compare CHF incidence and survival patterns following onset of CHF as defined by Framingham and/or Cardiovascular Health Study criteria. They constructed an inception cohort of nonfatal, hospitalized CHF patients. Of 875 participants who had qualifying CHF hospitalizations between 1989 and 2000, 54% experienced a first CHF event that fulfilled both sets of diagnostic criteria (concordant), 31% fulfilled only the Framingham criteria (Framingham only), and 15% fulfilled only the Cardiovascular Health Study criteria (Cardiovascular Health Study only). No significant survival difference was found between the Framingham-only group (hazard ratio = 0.87, 95% confidence interval: 0.71, 1.07) or the Cardiovascular Health Study-only group (hazard ratio = 0.89, 95% confidence interval: 0.68, 1.15) and the concordant group (referent). Compared with Cardiovascular Health Study central adjudication, Framingham criteria for CHF identified a larger group of participants with incident CHF, but all-cause mortality rates were similar across these diagnostic classifications.     

Overcoming bias in estimating the volume-outcome relationship

OBJECTIVE: To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. DATA SOURCES: The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997. STUDY DESIGN: The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume. PRINCIPAL FINDINGS: When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates. CONCLUSIONS: Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.     

A story of maladies, misconceptions and mishaps: effective management of heart failure

Congestive heart failure (CHF) is a common chronic disease with effective therapy, yet interventions to improve outcomes have met with limited success. Though problems in self-management are suspected causes for deterioration, few efforts have been made to understand how self-management could be improved to enhance the lives of affected patients. We conducted semi-structured interviews of 19 patients with CHF treated at an urban United States hospital to elucidate their knowledge and beliefs about CHF and to understand what underlies their self-care routines. A comparison of the themes generated from these interviews with the common-sense model for self-management of illness threats, clarifies how patients' perceptions and understanding of CHF affected their behaviors. Patients had an acute model of CHF. They did not connect chronic symptoms with a chronic disease, CHF, and did not recognize that these symptoms worsened over time from their baseline of moderate, chronic distress, to a severe state that required urgent care. As a consequence, they often did not manage symptoms on a routine basis and did not, therefore, prevent or minimize exacerbations. When they worsened, many patients reported barriers to reaching their physicians and most reported seeking care primarily in an emergency room. These in depth responses elucidate how the interplay between acute and chronic models of a chronic illness effect self-management behaviors. These factors play a previously not understood role in patient's efforts to understand and manage the ever-present but symptomatically variable chronic illness that is CHF. These new concepts illustrate the tools that may be needed to effectively manage this serious and disabling illness, and suggest possible ways to enhance the self-management process and ultimately improve patients' lives.     

The incidence and severity of burn injuries following Project Burn Prevention.

Project Burn Prevention, an educational program about burn safety, was implemented in the Greater Boston area from October 1977 through May 1978. The program consisted of three components: a media campaign, a school-initiated intervention, and a community-initiated intervention. Estimates of burn incidence and severity of injury because of scald, flame, electrical or contact burns, or smoke inhalation were made on all patients coming to target- or comparison-area hospitals for a four-year period before the program, the eight months during the program, and the 12 months after the program. Analysis of burn incidence during and after the interventions showed that the school-initiated intervention did not reduce the incidence or severity of burn injuries. The community-initiated intervention may have brought about a moderate, temporary reduction in the rate of burn injuries, although the increase in burn incidence observed for the media campaign of educational messages broadcast to the Greater Boston area suggests that the more plausible explanation for this effect is random variation in burn incidence.     

Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway

High quality chronic disease management requires coordinated care across different healthcare settings, involving multidisciplinary teams of professionals, and performance evaluation systems able to measure this care. Inter-organizational performance should be measured considering the professional relationships between general practitioners (GPs) and specialists, who are usually linked through informal referral networks.The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GPs and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. The analysis focuses on the identification and classification of networks, following CHF patients (n = 15,841) through primary care and inpatient care using administrative data, and on the assessment of process and outcome indicators for CHF patients in these referral networks.We demonstrate the existence of informal links between GPs and hospitals based on patterns of patient flow. These networks which are not geographically based vary in the intensity of relationships and quality of care. Such referral networks may represent the most effective accountability level for chronic disease management, since they encompass the multiple care settings experienced by patients. Overall, an integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.     

Spotlight on the Pharmacoeconomics of Candesartan Cilexetil in Chronic Heart Failure and Hypertension

The addition of candesartan cilexetil (Atacand®, Amias®, Biopress®, Kenzen®, Ratacand®) to standard therapy for chronic heart failure (CHF) provided important clinical benefits at little or no additional cost in France, Germany, and the UK, according to a detailed economic analysis focusing on major cardiovascular events and prospectively collected resource-use data from the CHARM-Added and CHARM-Alternative trials in patients with CHF and left ventricular (LV) systolic dysfunction. Results of a corresponding cost-effectiveness analysis showed that candesartan cilexetil was either dominant over placebo or was associated with small incremental costs per life-year gained, depending on the country and whether individual trial or pooled data were used. Preliminary data from a US cost-effectiveness analysis based on CHARM data also showed favorable results for candesartan cilexetil.Two cost-effectiveness analyses of candesartan cilexetil in hypertension have been published, both conducted in Sweden. Data from the SCOPE trial in elderly patients with hypertension, which showed a significant reduction in nonfatal stroke with candesartan cilexetil-based therapy versus non-candesartan cilexetil-based treatment, were incorporated into a Markov model and an incremental cost-effectiveness ratio of €12 824 per quality-adjusted life-year (QALY) gained was calculated (2001 value). Another modelled cost-effectiveness analysis of candesartan cilexetil was based on the ALPINE trial, in which the incidence of new-onset diabetes was significantly lower in patients with newly diagnosed hypertension who were randomized to candesartan cilexetil (with or without felodipine) than among those who received hydrochlorothiazide (with or without atenolol). Although candesartan cilexetil was dominant over hydrochlorothiazide, the ALPINE cost-effectiveness analysis relied on a small number of clinical events and did not evaluate the incremental cost of candesartan cilexetil per life-year or QALY gained.In conclusion, despite some inherent limitations, economic analyses incorporating CHARM data and conducted primarily in Europe have shown that candesartan cilexetil appears to be cost effective when added to standard CHF treatment in patients with CHF and compromized LV systolic function. The use of candesartan cilexetil as part of antihypertensive therapy in elderly patients with elevated blood pressure was also deemed to be cost effective in a Swedish analysis, primarily resulting from a reduced risk of nonfatal stroke (as shown in the SCOPE study); however, the generalizability of results to other contexts has not been established. Cost-effectiveness analyses comparing candesartan cilexetil with ACE inhibitors or other angiotensin receptor blockers in CHF or hypertension are lacking, and results reported for candesartan cilexetil in a Swedish economic analysis of ALPINE data focusing on outcomes for diabetes require confirmation and extension.     

Germany's disease management program: improving outcomes in congestive heart failure

Hospital admissions among patients with congestive heart failure (CHF) are a major contributor to health care costs. A comprehensive disease management program for CHF was developed for private and statutory health insurance companies in order to improve health outcomes and reduce rehospitalization rates and costs. The program comprises care calls, written training material, telemetric monitoring, and health reports. Currently, 909 members from six insurance companies are enrolled. Routine evaluation, based on medical data warehouse software, demonstrates benefits in terms of improved health outcomes and processes of care. Economical evaluation of claims data indicates significant cost savings in a pre/post study design.