A systematic review and meta-analysis of the effects of clinical pathways on length of stay,hospital costs and patient outcomes

Background  

To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy.     

Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study

Background  

Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.     

Influence of co-existing atrial fibrillation on the efficacy of atorvastatin treatment in patients with dilated cardiomyopathy: a pilot study

Introduction  

The aim of the study was to assess the influence of co-existing atrial fibrillation (AF) on inflammatory condition factors, left ventricular function, clinical course and the efficacy of statin treatment of congestive heart failure in the course of dilated cardiomyopathy (DCM).     

A cluster randomized trial to assess the impact of clinical pathways for patients with stroke: rationale and design of the Clinical Pathways for Effective and Appropriate Care Study [NCT00673491]

Background  

Patients with stroke should have access to a continuum of care from organized stroke units in the acute phase, to appropriate rehabilitation and secondary prevention measures. Moreover to improve the outcomes for acute stroke patients from an organizational perspective, the use of multidisciplinary teams and the delivery of continuous stroke education both to the professionals and to the public, and the implementation of evidence-based stroke care are recommended. Clinical pathways are complex interventions that can be used for this purpose. However in stroke care the use of clinical pathways remains questionable because little prospective controlled data has demonstrated their effectiveness. The purpose of this study is to determine whether clinical pathways could improve the quality of the care provided to the patients affected by stroke in hospital and through the continuum of the care.     

Community Direct Access Service for Early Detection and Treatment of Clinical Deterioration

Introduction

The number of patients entering a heart failure program at the heart failure unit at St Vincent’s University Hospital (Dublin, Ireland) is increasing. However, the impact of a community direct access service on the workload pattern of a heart failure unit and its appropriateness remain poorly described. The workload of this hospital-based heart failure unit was analyzed over a 3-year period to assess changing workload patterns and to examine the appropriateness and outcome of patients’ direct access to the unit.

Methods

Clinical audits from the heart failure unit for the years 2002, 2003, and 2004 were reviewed, and the types of visits were classified and expressed as a percentage of total patient contact. A prospective, observational study was designed to examine the volume and nature of community direct access to the heart failure unit. Unscheduled contact was defined as a telephone call to the heart failure unit from a patient or carer seeking advice and/or reporting clinical deterioration. All unscheduled contact was triaged by a heart failure clinical nurse specialist, and advice was given on what to do, including immediate same-day referral to the heart failure clinic (termed an unscheduled visit).

Results

Twenty-eight percent of all unscheduled contacts resulted in an unscheduled visit to the unit. Eighty percent of unscheduled visits to the unit demonstrated evidence of clinical deterioration confirmed by physician examination. Eighty-nine percent of patients with clinical deterioration required an increase in oral medications, 10% required administration of an intravenous diuretic, and 1% required direct hospital admission. Unscheduled visits to the unit account for 20% of all clinical reviews annually. None of the unscheduled contacts that were resolved over the telephone (47%) or referred to the family physician or emergency department (25%) resulted in an admission with heart failure.

Conclusion

This study underlines the necessity for, and efficacy of, a community direct access service for heart failure patients in redirecting the course of clinical deterioration.

     

Preventable hospitalization and access to primary health care in an area of Southern Italy

Background  

Ambulatory care-sensitive conditions (ACSC), such as hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease and asthma, are conditions that can be managed with timely and effective outpatient care reducing the need of hospitalization. Avoidable hospitalizations for ACSC have been used to assess access, quality and performance of the primary care delivery system. The aims of this study were to quantify the proportion of avoidable hospital admissions for ACSCs, to identify the related patient's socio-demographic profile and health conditions, to assess the relationship between the primary care access characteristics and preventable hospitalizations, and the usefulness of avoidable hospitalizations for ACSCs to monitor the effectiveness of primary health care.     

Hospital costs for treatment of acute heart failure: economic analysis of the REVIVE II study

Background  

Acute heart failure (AHF) is the leading cause of hospital admission among older Americans. The Randomized EValuation of Intravenous Levosimendan Efficacy (REVIVE II) trial compared patients randomly assigned to a single infusion of levosimendan (levo) or placebo (SOC), each in addition to local standard treatments for AHF. We report an economic analysis of REVIVE II from the hospital perspective.     

Evaluation of physicians' professional performance: An iterative development and validation study of multisource feedback instruments

Background

The burden of patients with heart failure on health care systems is widely recognised, although there have been few attempts to quantify individual patterns of care and differences in health service utilisation related to age, socio-economic factors and the presence of co-morbidities. The aim of this study was to assess the typical profile, trajectory and resource use of a cohort of Australian patients with heart failure using linked population-based, patient-level data.

Methods

Using hospital separations (Admitted Patient Data Collection) with death registrations (Registry of Births, Deaths and Marriages) for the period 2000?C2007 we estimated age- and gender-specific rates of index admissions and readmissions, risk factors for hospital readmission, mean length of stay (LOS), median survival and bed-days occupied by patients with heart failure in New South Wales, Australia.

Results

We identified 29,161 index admissions for heart failure. Admission rates increased with age, and were higher for males than females for all age groups. Age-standardised rates decreased over time (256.7 to 237.7/100,000 for males and 235.3 to 217.1/100,000 for females from 2002?C3 to 2006?C7; p?=?0.0073 adjusted for gender). Readmission rates (any cause) were 27% and 73% at 28-days and one year respectively; readmission rates for heart failure were 11% and 32% respectively. All cause mortality was 10% and 28% at 28 days and one year. Increasing age was associated with more heart failure readmissions, longer LOS and shorter median survival. Increasing age, increasing Charlson comorbidity score and male gender were risk factors for hospital readmission. Cohort members occupied 954,888 hospital bed-days during the study period (any cause); 383,646 bed-days were attributed to heart failure admissions.

Conclusions

The rates of index admissions for heart failure decreased significantly in both males and females over the study period. However, the impact on acute care hospital beds was substantial, with heart failure patients occupying almost 200,000 bed-days per year in NSW over the five year study period. The strong age-related trends highlight the importance of stabilising elderly patients before discharge and community-based outreach programs to better manage heart failure and reduce readmissions.     

Risk Factors for In‐Hospital Mortality in Heart Failure Patients: Does Rurality,Payer or Admission Source Matter?

Purpose

Considering the high prevalence of heart failure and the economic burden of the disease, factors that influence in‐hospital mortality are of importance in improving outcomes of care for this patient population. The purpose of this study was to examine the determinants of in‐hospital mortality for adult heart failure patients.

Methods

The study design is a retrospective observational study design using the 2010 Nebraska Hospital Discharge data set including 4,319 hospitalizations for 3,521 heart failure patients admitted to 79 hospitals in Nebraska. Hierarchical logistic regression models including patient‐ and hospital‐specific random intercepts were analyzed. Covariates included in the analysis were patient age in years, gender, comorbidity status, length of stay, primary payer, type and source of admission, transfers, and rurality of county of residence.

Results

Overall, 3.5% of heart failure patients died during their hospital stay. In logistic regression analysis that adjusted for age, sex, and comorbidities, the odds of dying in hospital for heart failure patients increased with age (OR = 1.03, 95% CI: 1.01‐1.04), co‐morbidity (OR = 1.15; 95% CI: 1.05‐1.25) and length of stay (OR = 1.03, 95% CI: 1.01‐1.05). The patient's gender, payer source, rurality of county of residence, source, and type of admission were not risk factors for in‐hospital death.

Conclusion

Increasing age, comorbidity and length of stay were risk factors for in‐hospital death for heart failure. An understanding of the risk factors for in‐hospital death is critical to improving outcomes of care for heart failure patients.     

Heart failure guidelines and prescribing in primary care across Europe

Background  

Major international differences in heart failure treatment have been repeatedly described, but the reasons for these differences remain unclear. National guideline recommendations might be a relevant factor. This study, therefore, explored variation of heart failure guideline recommendations in Europe.     

The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis

Objective  

To measure the effectiveness of strategies to implement clinical guidelines and the influence of organisational characteristics on hospital care.     

Heart failure in sub-Saharan Africa: a literature review with emphasis on individuals with diabetes

Purpose

Heart failure is the ultimate complication of cardiac involvements in diabetes. The purpose of this review was to summarize current literature on heart failure among people with diabetes mellitus in sub-Saharan Africa (SSA).

Method

Bibliographic search of published data on heart failure and diabetes in sub-Saharan Africa over the past 26 years.

Results

Heart failure remains largely unexplored in general population and among people with diabetes in Africa. Heart failure accounts for over 30% of hospital admission in specialized cardiovascular units and 3%–7% in general internal medicine. Over 11% of adults with heart failure have diabetes. Risk factors for heart failure among those with diabetes include classical cardiovascular risk factors, without evidence of diabetes distinctiveness for other predictors common in Africa. Prevention, management, and outcomes of heart failure are less well known; recent data suggest improvement in the management of risk factors in clinical settings.

Conclusions

Diabetes mellitus is growing in SSA. Related cardiovascular diseases are emerging as potential health problem. Heart failure as cardiovascular complication remains largely unexplored. Efforts are needed through research to improve our knowledge of heart failure at large in Africa. Multilevel preventive measures, building on evidences from other parts of the world must go along side.     

Measures of body composition and risk of heart failure in the elderly: The Rotterdam study

Objectives  

The incidence of heart failure increases with aging. Aim of the present, study was to determine whether measures body composition predict incident heart failure in older adults.     

Structured chronic primary care and health-related quality of life in chronic heart failure

Background  

Structured care is proposed as a lever for improving care for patients with chronic conditions. The purpose of this study was to explore the associations of structured care characteristics, derived from the Chronic Care Model, with health-related quality of life (HRQOL) and optimal clinical management in chronic heart failure (CHF) patients in primary care, as well as the association between optimal management and HRQOL.     

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.     

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care

Background  

Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care.     

Early recognition of heart failure in patients with diabetes type 2 in primary care. A prospective diagnostic efficiency study. (UHFO-DM2)

Background  

We hypothesize that the prevalence of unknown heart failure in diabetic patients aged 60 years and over is relatively high (15% or more) and that a cost-effective strategy can be developed to detect heart failure in these patients. The strategy is expected to include some signs and symptoms (such as dyspnoea, orthopnoea, pulmonary crepitations and laterally displaced apical beat), natriuretic peptide measurements (Amino-terminal B-type natriuretic peptide) and possibly electrocardiography. In a subset of patients straightforward echocardiography may show to be cost-effective. With information from our study the detection of previously unknown heart failure in diabetic patients could be improved and enable the physician to initiate beneficial morbidity and mortality reducing heart failure treatment more timely.     

Quality and availability of consumer information on heart failure in Australia

Background  

Provision of consumer information and patient education are considered an essential part of chronic disease management programmes developed for patients with heart failure. This study aimed to review the quality and availability of consumer information materials for people with heart failure in Australia.     

The effect of hospital discharge price increases on publicly reported measures of quality

Objective

To determine if increases in hospital discharge prices are associated with improvements in clinical quality or patient experience.

Data Sources

This study used Medicare cost report data and publicly available Medicare.gov Care Compare quality measures for approximately 3000 short-term care general hospitals between 2011 and 2018.

Study Design

We separately regressed quality measure scores on a lag of case mix adjusted discharge price, hospital fixed effects, and year indicators. Clinical quality measures included 30-day readmission rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, hip and knee replacement, and pneumonia; risk-adjusted 30-day mortality rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, and stroke; and 90-day complication rate for hip and knee replacement. Patient experience measures included the summary star rating and 10 domain measures reported through the Hospital Consumer Assessment of Healthcare Providers and Systems survey. We tested for heterogeneous effects by hospital ownership, number of beds, the commercial share of overall discharges, and market concentration.

Data Collection/Extraction Methods

We linked hospitals identified in Medicare cost reports to Medicare.gov Care Compare quality measures. We excluded hospitals for which we could not identify a discharge price or that had an unrealistic price.

Principal Findings

There was no positive association between lagged discharge price and any clinical quality measure. For patient experience measures, a 2% increase in discharge price was not associated with overall patient satisfaction but was associated with small, statistically significant increases ranging from 0.01% to 0.02% (relative to mean scores) for seven of ten domain measures. There was a positive association for five of ten patient experience measures in competitive markets and one measure in both moderately concentrated and heavily concentrated markets.

Conclusions

We found no evidence that hospitals use higher prices to make investments in clinical quality; patient experience improved, but only negligibly.     

A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial [ISRCTN11535170]

Background  

Self-management programs for patients with heart failure can reduce hospitalizations and mortality. However, no programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care.