Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

Development of an evidence-based scoring system (HF-IS) to assess the quality of heart failure programmes for patients postdischarge from hospital

Aim.  The aim of this study was to develop a potential scoring algorithm for interventions in a chronic heart failure management programme – the Heart Failure Intervention Score – to facilitate quality improvement and programme auditing.

Background.  The overall efficacy of chronic heart failure management programmes has been demonstrated in several meta-analyses. However, meta-analyses did not determine individual interventions in a programme that resulted in beneficial patient outcomes.

Design.  A prospective cross-sectional survey design.

Method.  All chronic heart failure management programmes in Australia (n = 62), identified by a national register, were surveyed to determine programme characteristics and interventions.

Results.  Of the 62 national chronic heart failure management programmes, 48 (77%) completed the survey and 27 individual interventions were identified. Variability in the use of the key interventions was common among the programmes. Each intervention was given an arbitrary weighted score according to the level of supportive evidence available and a total score calculated. Programmes were then categorised into low or high complexity based on several interventions implemented and their weighted score. A total score of ≥190 (median = 178, interquartile range 176–195) was used to divide programmes into two groups. Nine programmes were categorised into high Heart Failure Intervention Score group and majority of these were based in the acute hospital setting (78%). In the low Heart Failure Intervention Score group, there were 39 programmes of which there were a higher proportion of community-based programmes (38%) and programmes in small community hospitals (10%).

Conclusion.  The Heart Failure Intervention Score provides a potential evidence-based quality improvement tool through which a set of minimum standards can be developed. Implementation of the Heart Failure Intervention Score provides guidance to programme coordinators to enable monitoring of standards of heart failure programmes, which may potentially result in better patient outcomes.

Hospital readmission among older adults with congestive heart failure

Older adults with congestive heart failure [CHF] are likely to experience multiple readmissions to hospital. There have been several studies conducted on hospital readmissions; however, generalising the findings is problematic due to the use of variable definitions of what constitutes a readmission. This paper addresses the absence of Australian research comparing groups of older patients with CHF who are readmitted to hospital with those who are not readmitted. It also adopts one of the more frequently used definitions of readmission to aid in future comparability of research. Using a comparative cohort design, a multivariate logistic regression model was used to compare readmitted patients with non-readmitted patients and identify risk factors associated with readmission. Significant risk factors identified were male gender, numerous diagnoses, lengths of stay of 3 days or longer and admission from acute, subacute or aged care facilities. The increased likelihood of readmission among patients from acute, subacute and aged care services warrants further investigation.

Patient self-management in chronic heart failure – establishing concordance between guidelines and practice

 Chronic heart failure (CHF) is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. CHF patients are encouraged to self-manage their illness, such as adhering to medical regimens and monitoring symptoms, to optimise health outcomes and quality of life. In so doing, patients are asked to collaborate with their health service providers with regard to their care. However, patients generally do not self-manage well, even with specialist support. Moreover, self- management interventions are yet to demonstrate morbidity or mortality benefits. Social network approaches to self-management consider the availability and mobilisation of all resources, beyond those of only the patient and healthcare providers. Used in conjunction with e-health platforms, social network approaches may offer a means by which to optimise self-management programmes of the future.

Assessment of cognitive function in heart failure patients

Background
Research on the cognitive capacity of heart failure patients is limited, with a paucity of benchmark information available for this population. It is highly likely that cognitive deficits affect patients' understanding of disease and treatment requirements, as well as limiting their functional capacity and ability to implement treatment plans, and undertake self-care.

Aims
The purpose of this study was to establish a comprehensive neurocognitive profile of the heart failure patient through systematic neurocognitive assessment and to determine whether an association existed between severity of heart failure and cognitive abilities.

Methods
Thirty-eight patients were recruited from the heart failure patient databases of two metropolitan hospitals in Melbourne, Australia. Participants were individually assessed using four standardised, internationally recognised neuropsychological tests that examined current and premorbid intelligence, memory and executive functioning.

Results
Although there was no significant decline from premorbid general intellectual function, other specific areas of deficit, including impaired memory and executive functioning, were identified. There were no significant correlations between heart failure severity and the neurocognitive measures used.

Conclusion
The results support the need to recognise cognitive impairment in people with heart failure and to develop an abbreviated method of assessing cognitive function that can be easily implemented in the clinical setting. Identifying cognitive deficits in this population will be useful in guiding the content and nature of treatment plans to maximise adherence and minimise worsening of heart failure symptoms.

Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Heterogeneity of heart failure management programs in Australia

Background: Heart Failure Management Programs (HFMPs) have proven to be cost-effective in minimising recurrent hospitalisations, morbidity and mortality. However, variability between the programs exists which could translate into variable health outcomes.
Objective: To survey the characteristics of HFMPs throughout Australia and to identify potential heterogeneity in their organisation and structure.
Method: Thirty-nine post-discharge HFMPs were identified from a systematic search of the Australian health-care system in 2002. A comprehensive 19-item questionnaire specifically examining characteristics of HFMPs was sent to co-ordinators of identified programs in early 2003.
Results: All participants responded with six institutions (15%) indicating that their HFMP had ceased operations due to a lack of funding. The survey revealed an uneven distribution of the 33 active HFMPs operating throughout Australia. Overall, 4450 post-discharge HF patients (median: 74; IQR: 24–147) were managed via these programs, representing only 11% of the potential caseload for an Australia-wide network of HFMPs. Heterogeneity of these programs existed in respect to the model of care applied within the program (70% applied a home-based program and 18% a specialist HF clinic) and applied interventions (30% of programs had no discharge criteria and 45% of programs prevented nurses administering/titrating medications). Sustained funding was available to only 52% of the active HFMPs.
Conclusion: Inequity of access to HFMPs in Australia is evident in relation to locality and high service demand, further complicated by inadequate funding. Heterogeneity between these programs is substantial. The development of national benchmarks for evidence-based HFMPs is required to address program variability and funding issues to realise their potential to improve health outcomes.

Gender differences in adherence to sodium-restricted diet patients with heart failure.

Background

Despite the importance of the sodium-restricted diet (SRD) to heart failure (HF) management, patient adherence is poor. Little is known about gender differences in adherence or factors that affect patients' ability to follow SRD recommendations. The purposes of this study were to determine whether there were gender differences in (1) adherence to the SRD; (2) knowledge about SRD and HF self-care; and (3) perceived barriers to following the SRD.
Methods and Results

Forty-one men and 27 women completed the Heart Failure Attitudes and Barriers questionnaire that measured HF self-care, knowledge, and perceived barriers to follow an SRD. Diet adherence was measured by 24-hour urinary sodium excretion (UNa). Women were more adherent to the SRD than men as reflected by 24-hour urine excretion (2713 versus 3859 mg UNa, P = .01). Women recognized signs of excess sodium intake such as fluid buildup (P = .001) and edema (P = .01) more often than men and had better understanding of appropriate actions to take related to following an SRD. There were no gender differences in perceived barriers to follow an SRD.
Conclusions

Although men and women perceived similar barriers, women were more adherent to the SRD and had greater knowledge about following an SRD. Further investigation of this phenomenon is warranted to determine if better adherence contributes to improved outcomes in women.

Extent of heart failure self-care as an endpoint to patient education: a literature review

Background: In western countries the number of chronic heart failure (CHF) management programs has escalated in recent times. One key component of them is to teach self-care behaviours that enable affected individuals to monitor themselves and engage in lifestyles that improve their health status.
Aim: The aim of this article is to describe CHF self-care management and to review the literature which examines the effectiveness of patient education on patients’ performance of self-care behaviours.
Design/method: bibliographical databases were searched for papers published in English between 1982 to 2006. The search used the key words: heart failure, education, self-care and measures. Only randomized controlled trials (RCTs) were selected.
Results: Ten randomized controlled trials were selected that used education as an intervention and, in total, 1064 patients with CHF participated in these studies. The studies were heterogenous as to the sample population, the health outcomes measured, the education interventions, the expertise of the educator, and the length of time that was spent on teaching patients. No consistent patterns of implementation and specific evaluation of its impact were found, although three respective groups of investigators reported signifi cant differences in recurrent hospitalisation rates and mortality rates which were relative to usual care.
Conclusions: Teaching patients appropriate CHF self-care behaviours can significantly improve their health outcomes. Improvements in self-care were demonstrated in seven studies but only three had used validated instruments to measure such changes. This suggests that no firm conclusions can be drawn about changes in self-care practices.