First symptoms and health care pathways in hospitalized patients with acute heart failure: ICPS2 survey. A report from the Heart Failure Working Group (GICC) of the French Society of Cardiology

BackgroundAcute heart failure (AHF) is a common serious condition that contributes to about 5% of all emergency hospital admissions in Europe.HypothesisTo assess the type and chronology of the first AHF symptoms before hospitalization and to examine the French healthcare system pathways before, during and after hospitalization.Material and MethodsA retrospective observational study including patients hospitalized for AHFResults793 patients were included, 59.0% were men, 45.6% identified heart failure (HF) as the main cause of hospitalization; 36.0% were unaware of their HF. Mean age was 72.9 ± 14.5 years. The symptoms occurring the most before hospitalization were dyspnea (64.7%) and lower limb edema (27.7%). Prior to hospitalization, 47% had already experienced symptoms for 15 days; 32% of them for 2 months. Referral to hospital was made by the emergency medical assistance service (SAMU, 41.6%), a general practitioner (GP, 22.3%), a cardiologist (19.5%), or the patient (16.6%). The modality of referral depended more on symptom acuteness than on type of symptoms. A sudden onset of AHF symptoms led to making an emergency call or to spontaneously attending an emergency room (ER), whereas cardiologists were consulted when symptoms had already been present for over 15 days. Cardiologists referred more patients to cardiology departments and fewer patients to the ER than general practitioners or the SAMU.ConclusionThis study described the French healthcare system pathways before, during and after hospitalization AHF. AHF clinic network should be developed to provide adequate care for all HF patients and create awareness regarding AHF symptoms.     

Awareness and misconception of hypertension in Canada: results of a national survey

BACKGROUND: The Canadian Heart Health Surveys were the last Canadian population-based physical measures surveys (conducted between 1988 and 1992) that determined that hypertension in Canada was poorly managed. Hypertension was undetected in almost one-half of all hypertensive Canadians surveyed, and only 13% of those with hypertension were treated and controlled to recommended blood pressure targets. The reasons for poor control are likely multifactorial; however, a lack of public awareness and understanding of hypertension may contribute to the epidemic of uncontrolled hypertension in Canada. METHODS: A national telephone survey was conducted comprising 1001 randomly selected men and women older than 40 years of age to determine the level of public awareness, understanding and misconception of hypertension in Canada. The survey was balanced for region, age and sex. RESULTS: Thirty-four per cent of respondents had been diagnosed with high blood pressure or hypertension by a health care professional, but only 58% of respondents had ever discussed their blood pressure with a physician, and only 44% were able to identify their own blood pressure or differentiate blood pressure levels considered to be above or below recommended targets. Overall, respondents had a poor understanding of the consequences of high blood pressure or hypertension. The majority were unaware of the association between hypertension and heart disease (80%), heart attack (66%), kidney disease (98%), damage to blood vessels (95%) and premature death (74%). Respondents also had limited knowledge of lifestyle issues affecting hypertension, despite 44% indicating that they were overweight and 18% identifying themselves as smokers. Almost two-thirds (63%) thought hypertension had clearly identifiable signs or symptoms, although they believed that hypertension was not a serious medical condition. Most respondents (59%) falsely believed that they would not develop hypertension and 38% thought that they would be able to control hypertension without the aid of a physician if they did have hypertension. CONCLUSIONS: While hypertension-related complications are preventable, lack of public awareness and misconceptions about hypertension and hypertensive complications are common and may, in part, be associated with ongoing inadequate Canadian awareness, treatment and control rates for hypertension. Increasing public awareness of hypertension using public education and health provider strategies should be a high national health priority.     

Impact of clinical symptoms and referral volume on endoscopy for detecting peptic ulcer and gastric neoplasms

BACKGROUND: We investigated the volume of dyspeptic patients referred by general practitioners (GPs) to upper gastrointestinal endoscopy and the impact on endoscopic findings. We also examined the correlation between clinical symptoms and endoscopic findings. METHODS: We collected data on patients sent for upper gastrointestinal endoscopy by GPs of 30 healthcare centres in 1996 in our hospital referral area of 260,000 inhabitants. In addition, national and local cancer registries were used to enumerate the gastric cancer cases detected in 1996. RESULTS: The study population consisted of 3378 patients, mean age 58 years (interquartile range 25 years, male:female 1:1.3). Among the 30 healthcare centres, referral volumes for upper gastrointestinal endoscopy varied from 0.6 to 9.2 per 1000 inhabitants per year (median 3.3/1000/year). In healthcare units with 'high' (> or = 3.3/1000/year, 15 healthcare units, 1297 patients) and 'low' (<3.3/1000/year, 15 healthcare units, 2065 patients) referral volumes, the detection rates were as follows: duodenal ulcer (DU) 3.5% (n = 46) versus 4.0% (n = 83, P = 0.5), gastric ulcer (GU) 4.9% (n = 64) versus 5.3% (n = 110, P = 0.6), gastropathy 43.8% (n = 568) versus 35.6% (n = 736, P < 0.001), gastric cancer 0.5% (n = 6) versus 0.5% (n = 11, P = 0.8), gastric polyps 2.4% (n = 31) versus 1.5% (n = 30, P < 0.05). Independent risk factors for gastric cancer were age (OR 6.5 per decade, 95% CI 2.4-17.9), male sex (OR 5.5, 95% CI 1.8-17.1) and alarming symptoms and/or signs (OR 3.6, 95% CI 1.2-10.7); for GU, Helicobacter pylori (OR 2.6, 95% CI 1.9-3.5) and alarming symptoms (OR 2.0, 95% CI 1.4-2.7); for DU, male sex (OR 1.6, 95% CI 1.1-2.2) and H. pylori (OR 3.9, 95% CI 2.7-5.5); and for gastric polyp(s), age (OR 2.0 per decade, 95% CI 1.1-3.5) and high referral volume (OR 1.7, 95% CI 1.0-2.0). A high referral volume did not associate positively either with the number of peptic ulcers or gastric cancer. CONCLUSIONS: Alarm symptoms associate strongly with significant gastric lesions such as GU and cancer. Increased referral volume results in an increased number of gastropathy and gastric polyp(s), but not of peptic ulcer or cancer.     

Knowledge and attitudes regarding the personally controlled electronic health record: an Australian national survey

The personally controlled electronic health record (PCHER) was designed to bring important information together to facilitate effective communication between clinicians and so improve patient care. This national cross‐sectional survey of 405 healthcare providers and consumers found that they had relatively low awareness and knowledge about the PCEHR; that 62% of respondents believed that healthcare providers with access to the PCEHR would be able to provide better quality of care but only 50% of respondents would sign up to have a PCEHR.     

The Heart Failure Association Atlas: rationale,objectives, and methods

Heart failure (HF) constitutes the growing cardiovascular burden and the major public health issue, but comprehensive statistics on HF epidemiology and related management in Europe are missing. The Heart Failure Association (HFA) Atlas has been initiated in 2016 in order to close this gap, representing the continuity directly rooted in the European Society of Cardiology (ESC) Atlas of Cardiology. The major aim of the HFA Atlas is to establish a contemporary dataset on HF epidemiology, resources and reimbursement policies for HF management, organization of the National Heart Failure Societies (NHFS) and their major activities, including education and HF awareness. These data are gathered in collaboration with the network of NHFS of the ESC member and ESC affiliated countries. The dataset will be continuously improved and advanced based on the experience and enhanced understanding of data collection in the forthcoming years. This will enable revealing trends, disparities and gaps in knowledge on epidemiology and management of HF. Such data are highly needed by the clinicians of different specialties (aside from cardiologists and cardiac surgeons), researchers, healthcare policy makers, as well as HF patients and their caregivers. It will also allow to map the snapshot of realities in HF care, as well as to provide insights for evidence‐based health care policy in contemporary management of HF. Such data will support the ESC/HFA efforts to improve HF management ant outcomes through stronger recommendations and calls for action. This will likely influence the allocation of funds for the prevention, treatment, education and research in HF.     

Celiac disease in the developing countries： A new and challenging public health problem

In the past, celiac disease was believed to be a chronic enteropathy, almost exclusively affecting people of European origin. The availability of new, simple, very sensitive and specific serological tests （anti-gliadin, anti- endomysium and anti-transglutaminase antibody assays） have shown that celiac disease is common not only in Europe and in people of European ancestry but also in the developing countries where the major staple diet is wheat （Southern Asia, the Middle East, North West and East Africa, South America）, both in the general population and in the groups at risk. Gluten intolerance thus appears to be a widespread public health problem and an increased level of awareness and clinical suspicion are needed in the New World where physicians must learn to recognize the variable clinical presentations （classical, atypical and silent forms） of celiac disease. In the developing countries, both serological screening in the general population and serological testing in groups at risk are necessary for an early identification of celiac patients. The gluten-free diet poses a challenging public health problem in the developing countries, especially since commercial gluten-free products are not available.     

Current concept in the diagnosis,treatment and rehabilitation of patients with congestive heart failure

Heart failure(HF) is a major public health problem with a prevalence of 1%-2% in developed countries. The underlying pathophysiology of HF is complex and as a clinical syndrome is characterized by various symptoms and signs. HF is classified according to left ventricular ejection fraction(LVEF) and falls into three groups: LVEF ≥ 50%-HF with preserved ejection fraction(HFpEF), LVEF 40%-HF with reduced ejection fraction(HFrEF), LVEF 40%-49%-HF with mid-range ejection fraction. Diagnosing HF is primarily a clinical approach and it is based on anamnesis, physical examination, echocardiogram, radiological findings of the heart and lungs and laboratory tests, including a specific markers of HF-brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide as well as other diagnostic tests in order to elucidate possible etiologies. Updated diagnostic algorithms for HFpEF have been recommended(H2 FPEF, HFA-PEFF). New therapeutic options improve clinical outcomes as well as functional status in patients with HFrEF(e.g., sodium-glucose cotransporter-2-SGLT2 inhibitors) and such progress in treatment of HFrEF patients resulted in new working definition of the term "HF with recovered left ventricular ejection fraction". In line with rapid development of HF treatment, cardiac rehabilitation becomes an increasingly important part of overall approach to patients with chronic HF for it has been proven that exercise training can relieve symptoms, improve exercise capacity and quality of life as well as reduce disability and hospitalization rates. We gave an overview of latest insights in HF diagnosis and treatment with special emphasize on the important role of cardiac rehabilitation in such patients.     

Global Perspectives in Hospitalized Heart Failure: Regional and Ethnic Variation in Patient Characteristics,Management, and Outcomes

Heart failure (HF) is a public health problem of global proportions afflicting more than 25 million patients worldwide. Despite stable or declining per capita hospitalization rates in the USA and several European countries, there are over one million hospitalizations for HF annually in the USA, with similar numbers in Europe, accounting for 6.5 million hospital days and the majority of the approximately $40 billion spent each year on HF-related care. Moreover, clinical trial data suggest that post-discharge survival and readmissions have largely remained unchanged. Thus, understanding geographic and ethnic variations in HF is essential to formulating public policy at the local, national, regional, and international levels and setting the agenda for basic, translational, and clinical research endeavors. This paper aims to describe regional and ethnic variations in patient characteristics, management, and outcomes in hospitalized HF.     

Insulin therapy in Europe

The prevalence of type 1 diabetes is rising in all European countries, particularly in Scandinavia and the UK. Insulin therapy in Europe is strongly influenced by the results of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), both of which showed the importance of tight metabolic control in patients with diabetes. The importance of tight glycemic control is also emphasized in the Saint Vincent Declaration, which established 5-year goals for antidiabetic therapy in Europe. Insulin therapy in Europe has been significantly improved over the past 10 years, owing to a number of developments. These include increased use of intensive insulin therapy in patients with type 1 diabetes; the development of new insulin analogs, including insulin glargine for injection therapy and short-acting agents that are particularly suitable for use in pumps and the establishment of comprehensive and standardized treatment goals and guidelines. Nevertheless, important obstacles must still be overcome to optimize therapy for patients with diabetes and reduce the long-term complications of this disease. These obstacles include low public awareness of diabetes and its symptoms, training of physicians as well as patients that is often insufficient to ensure adherence to professional guidelines for diabetes care, and limitations in communication among professional care providers.     

Nurses' knowledge of heart failure self-management

Heart failure (HF) is increasing in prevalence. Patient education is essential and is included in both ambulatory and hospital performance measures used to ensure quality care. Nurses are often the primary providers of education to patients with HF. This study assessed nurses' knowledge of basic principles of HF self-management. The study surveyed 49 nurses who regularly provided care to patients with HF at a hospital in the southeastern United States. A 20-item, true/false survey was administered to participants. Mean HF self-management knowledge score was 15.97 (79.85% correct). Consistent with previous studies, nurses scored lowest on knowledge related to transient dizziness (16.3% answered correctly), daily weight monitoring (36.2% answered correctly), and asymptomatic hypotension (58.3% answered correctly). Findings confirm previous work suggesting that nurses may not be adequately prepared to educate patients with HF about self-management.     

Natural language processor as a tool to assess heparin induced thrombocytopenia awareness

The life-threatening consequences of heparin induced thrombocytopenia (HIT) may be prevented with early recognition, prompt heparin withdrawal and direct thrombin inhibitor use. To determine the level of HIT awareness, electronic term recognition software can be used to query the electronic medical record (EMR) to assess the thought process and test ordering behavior of health care providers confronted with falling platelet counts. We sought to assess the awareness of HIT in a large teaching institution using these tools. Mayo Clinic databases were queried to identify a cohort of hospitalized adults receiving heparin (06/1/08–06/1/09). Serial platelet counts for each patient were scrutinized for a 50% decrement from baseline. “Clinician awareness” was defined by mention of HIT (determined by electronic term recognition software) within the hospital record by any member of the healthcare team or requisition of platelet factor 4/heparin antibody testing. During this time period, 34,694 adults were hospitalized and 24,956 received heparin. Only 3,239 (13%) patients had more than 1 platelet count during the hospital stay. Of 199 patients (6.1%) with ≥50% platelet count drop, clinician awareness was 36%. The absolute platelet count was the only independent variable associated with HIT awareness (P < 0.001). Both appropriate platelet count monitoring and HIT awareness are low at this large teaching institution. Software tools for monitoring awareness and providing realtime alerts of significant platelet count decrements may be useful.     

Acute undifferentiated fever in Binh Thuan province, Vietnam: imprecise clinical diagnosis and irrational pharmaco-therapy

OBJECTIVES: To describe the characteristics of patients consulting commune primary healthcare posts for acute undifferentiated fever not being malaria (AUF), and to explore the diagnostic and therapeutic responses of the healthcare workers. METHODS: All patients presenting with AUF at 12 commune health posts and one clinic at the provincial malaria station, Binh Thuan, a dengue endemic province in southern Vietnam, were included. Record forms were used to fill in patient and diseases characteristics, pre-referral treatment, signs and symptoms, provisional diagnosis and installed treatment, referral and final outcome. RESULTS: Two thousand ninety-six patients were included from April 2001 to March 2002. The median delay to attend the health posts was, 0.87 day for > 5, 1.15 days for children aged 5-15 years and 1.41 days for adults (P < 0.001). Sixty-five per cent of patients took some measures before consulting the health post, of whom 82% applied self-medication and 69% took antibiotics. Pre-referral medication with antibiotics increased with age (RR 1.012 per year of age; 95% CI: 1.004-1.019). The diagnostic and therapeutic response of healthcare workers was very unspecific. The tourniquet test was inappropriately used as general discriminating test, not only for detecting dengue haemorrhagic fever. Empiric antibiotic therapy was installed in 77.2% of cases. CONCLUSIONS: Management of uncomplicated fever, not being malaria, at the primary healthcare level in Vietnam is non-specific, dominated by searching signs of hemorrhagic dengue and empiric antibiotic treatment. This can probably be improved by better education.     

Utility of thoracic sonography for follow-up examination of chronic heart failure patients with previous decompensation

BACKGROUND: Thoracic sonography searching for pleural effusion is helpful in diagnosing heart failure (HF) in emergency situations, but utility of this test for follow-up examination of chronic HF patient is unknown. HYPOTHESIS: Thoracic sonography searching for pleural effusion may be suitable for monitoring deterioration in chronic HF outpatients during long-term follow-up. METHODS: Patients with stable HF at the time of study entry, but with previous deterioration (n = 46) were recruited and followed between June 2003 and September 2005. Evaluated HF-related variables included symptoms and signs of HF, pleural effusion on an ultrasonogram, and B-type natriuretic peptide (BNP) levels. RESULTS: During the study period, 26 patients developed deterioration in chronic HF and 20 maintained a stable clinical course. Of the 26 patients with deteriorating HF, 25 (96%) demonstrated objective HF-related sign(s) under examination. Among the signs tested in the present study, pleural effusion on a sonogram was the leading HF-related sign (77%), followed by rales (46%) and edema (46%). Eleven patients (42%) presented with only one feature, in which pleural effusion on a sonogram was the most frequent (7 of 11 patients). Using plasma BNP levels as a reference for HF deterioration, sonographic detection of pleural effusion exhibited the highest sensitivity (74%), best negative predictive value (73%), and highest predictive accuracy (78%) for identifying patients with higher BNP levels at deterioration compared to stable periods. CONCLUSIONS: Thoracic sonography allows sensitive detection of HF deterioration and improves clinical decision making in outpatient clinic during follow-up examination of HF patient with previous decompensation.     

Improvement of HF: initiative to increase awareness and improve the management of patients with heart failure in Europe

Heart failure is a major healthcare problem, with possibly over 10 million patients in Europe suffering from the syndrome. Its prevalence is increasing partly because the proportion of elderly population is likewise increasing. The guidelines on the diagnosis and treatment of heart failure have been published by the European Society of Cardiology and represent a landmark for judging current medical practice. Evidence suggests that heart failure is frequently underdiagnosed and undertreated, and the majority of patients may not be receiving appropriate care. Both primary healthcare physicians and hospital cardiologists are responsible for proper diagnosis and appropriate treatment of patients with heart failure. The "Improvement of HF" initiative has been developed by an International Advisory Board to increase awareness and improve the management of heart failure among primary healthcare physicians in Europe. The study first investigates how primary healthcare physicians perceive heart failure should be diagnosed and treated, and examines the availability of required resources. Subsequently, primary healthcare physicians will be interviewed to assess their actual practice by reviewing relevant case notes, covering diagnosis and treatment. The program will consist of a research phase and an educational phase. For the research phase, 10 regional centers (including both urban and rural areas) in each of the 14 participating countries in Europe will be identified, with each center randomly selecting 10 primary healthcare physicians. Each physician will supply case notes of 9 of his/her patients with diagnosed heart failure or at high risk of having heart failure. The results of the survey would identify any need to change not only perceptions but clinical practice in the diagnosis and treatment of heart failure and will be used to organize an educational program. A further study is planned in order to assess the impact of the initiative.     

Physician incentives and disclosure of payment methods to patients

OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients' awareness of and interest in physician payment information or its potential impact on patients' evaluation of their care. DESIGN: Cross-sectional survey SETTING: Managed care and indemnity plans of a large, national health insurer. PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%). MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians' payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Non-managed fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians' payment METHOD: Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary. CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted.     

Awareness of HIV/AIDS and its oral manifestations among people living with HIV in Dar es Salaam,Tanzania

The aim of this study was to investigate the awareness of the oral manifestations of HIV/AIDS and general issues about HIV and AIDS among people living with HIV (PLHIV) in Dar es Salaam, Tanzania. A structured questionnaire was used to collect information from 187 participants chosen by convenience sampling from NGOs supporting PLHIV. A total of 13.4% of the participants were completely unaware of the oral manifestations of HIV/AIDS whereas all participants were fully aware of general symptoms of AIDS. There were no significant associations between awareness of oral manifestations and general awareness of HIV/AIDS, or level of education. Participants were relatively well aware of the different types of oral manifestations (e.g. oral ulcers 87%, oral candidiasis 84%) while their knowledge of the management of specific oral manifestations and the problems associated with oral manifestations was more limited. It is recommended that health authorities in Tanzania establish population-oriented health education for improving knowledge about oral disease in HIV/AIDS and that oral health professionals provide sound information to PLHIV in community-outreach oral healthcare programmes.     

Heart failure programmes in countries with a primary care‐based health care system. Are additional trials necessary? Design of the DEAL‐HF study

BACKGROUND: Several randomised studies of heart failure (HF) management programmes in the United States, Australia and Europe have shown a considerable reduction in hospitalisation rates for HF. In this article, a comprehensive review of these studies will be provided and their applicability to countries, with a primary care-based healthcare system, will be discussed. In addition, the design of the Deventer-Alkmaar HF Project (DEAL-HF), a randomised study of the effect of a nurse and physician-directed intervention over 1 year in The Netherlands, will also be presented. AIM: To discuss the applicability of the results of available studies on heart failure management programmes to countries with well-structured primary care facilities and to determine whether additional trials should be conducted in these countries. METHODS: We performed a literature search in PubMed. In a review of the available studies, essential methodological aspects, in particular, the population involved, the sample size, follow-up period, setting, type of intervention, and the outcome parameters, are discussed critically. Also, the applicability of these studies to countries with a primary care-based healthcare system and easy access to medical care is evaluated. CONCLUSION: Applicability of the results of the available studies on the efficacy of heart failure management programmes to countries with a primary care-based health care system is doubtful. An efficacy trial in a country with a well-established primary care-based healthcare system, such as The Netherlands, is due to report soon (DEAL-HF).     

The impact of the covid-19 pandemic on diabetes care: the perspective of healthcare providers across Europe

AimsCovid-19 caused changes on the delivery of diabetes care. This study aimed to explore perceptions of healthcare providers across Europe concerning 1) the impact of covid-19 on delivery of diabetes care; 2) impact of changes in diabetes care on experienced workload; 3) experiences with video consultation in diabetes care.MethodsCross-sectional survey among healthcare providers in the Netherlands, United Kingdom, Turkey, Ukraine and Sweden, with a focus on primary care.ResultsThe survey was completed by 180 healthcare providers. During the COVID-19 pandemic 57.1% of respondents provided less diabetes care and 72.8% observed a negative impact on people with diabetes. More than half of respondents (61.9%) expressed worries to some extent about getting overloaded by work. Although the vast majority considered their work meaningful (85.6%). Almost half of healthcare providers (49.4%) thought that after the pandemic video-consultation could be blended with face-to-face contact.ConclusionsLess diabetes care was delivered and a negative impact on people with diabetes was observed by healthcare providers. Despite healthcare providers’ feeling overloaded, mental wellbeing seemed unaffected. Video consultations were seen as having potential. Given the remaining covid-19 risks and from the interest of proactive management of people with diabetes, these findings urge for further exploration of incorporating video consultation in diabetes care.