Complexity of management and health outcomes in a prospective cohort study of 573 heart failure patients in Australia : does more equal less?

Aims and objectives : To compare the efficacy of chronic heart failure management programmes (CHF-MPs) according to a scoring algorithm used to quantify the level of applied interventions–the Heart Failure Intervention Score (HF-IS).

Background : The overall efficacy of heart failure programmes has been proven in several meta-analyses. However, the debate continues as to which components are essential in a heart failure programme to improve patient outcomes.

Design : Prospective cohort study of patients participating in heart failure programmes.

Method : Forty-eight of 62 (77%) programmes in Australia participating in a national register of CHF-MPs were evaluated using the HF-IS: derived from a summed and weighted score of each intervention applied by the CHF-MP (27 interventions overall). The CHF-MPs were prospectively categorised as relatively low (HF-IS < 190 – n = 39 programmes & 407 patients) or high (HF-IS ≥ 190 – n = 9 programmes & 166 patients) in complexity. Six-month morbidity and mortality rates in 573 consecutively recruited patients with systolic dysfunction and in New York Heart Association Class II–IV were prospectively examined.

Results : Patients exposed to CHF-MPs with a high HF-IS had a lower rate of unplanned, all-cause hospitalisation (n = 24, 14% vs. n = 102, 25%) compared with CHF-MPs with a low HF-IS within six months. On an adjusted basis, CHF-MPs with a high HF-IS were associated with a reduced risk of unplanned hospitalisation and/or death within six months and remained event-free longer.

Conclusion : High complexity CHF-MPs applying more evidence-based interventions are associated with a higher event-free survival over six months.

Relevance to clinical practice : The HF-IS is an easy-to-use evidence-based tool to assist programme coordinators to improve the quality of their heart failure programme which may also improve patient 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.

Medicine non-adherence in kidney transplantation

Background: The increasing prevalence of chronic kidney disease, the relative shortage of kidney donors and the economic- and health-related costs of kidney transplant rejection make the prevention of adverse outcomes following transplantation a healthcare imperative. Although strict adherence to immunosuppressant medicine regimens is key to preventing kidney rejection, evidence suggests that adherence is sub-optimal. Strategies need to be developed to help recipients of kidney transplants adhere to their prescribed medicines. Findings: This review has found that a number of factors contribute to poor adherence, for example, attitudes towards medicine taking and forgetfulness. Few investigations have been conducted, however, on strategies to enhance medicine adherence in kidney transplant recipients. Strategies that may improve adherence include pharmacist-led interventions (incorporating counselling, medicine reviews and nephrologist liaison) and nurse-led interventions (involving collaboratively working with recipients to understand their routines and offering solutions to improve adherence). Strategies that have shown to have limited effectiveness include supplying medicines free of charge and providing feedback on a participant's medicine adherence without any educational or behavioural interventions. Conclusion: Transplantation is the preferred treatment option for people with end-stage kidney disease. Medicine non-adherence in kidney transplantation increases the risk of rejection, kidney loss and costly treatments. Interventions are needed to help the transplant recipient take all their medicines as prescribed to improve general well-being, medicine safety and reduce healthcare costs. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Invasive cane toad triggers chronic physiological stress and decreased reproductive success in an island endemic

Understanding the mechanisms that afford invasive species their ecological success as important agents of global change is key to addressing their biodiversity impacts. Species invasions that occur on small islands are especially detrimental and suggest that invaders intensify their ecological impacts by exploiting novel ecological functions. However, it remains unknown whether such strong impacts are also a consequence of an invader's indirect effect (e.g. causing physiological stress or reproductive failure) on island species. Therefore, it is valuable to quantify the physiological mechanisms through which invasive species can exert indirect effects on the performance, and ultimately the fitness of island endemics. In this study, we investigated whether the invasive cane toad (Rhinella marina) caused indirect competitive impacts on the endemic Fijian ground frog (Platymantis vitiana) on the small (60 ha) Viwa Island, Fiji. We used large (4 × 10 000 m2), natural and replicated enclosures to monitor ground frog stress hormone levels, reproductive hormone cycle, body condition, breeding and survival in the presence/absence of the cane toad. We conducted monthly sampling to analyse annual patterns in testosterone for males, estradiol and progesterone for females, corticosterone for both sexes and body condition of ground frogs in replicated enclosures or natural habitats with high/low cane toad densities. We also measured survival and reproductive success of ground frogs in enclosures. Results showed that in both enclosures and natural habitats with high cane toad densities, ground frogs had a significant reduction in body condition, increased urinary corticosterone metabolites and suppressed sex steroid metabolites. Most importantly, annual field surveys showed significant reduction in ground frog reproductive success (fewer eggs were laid in enclosures with toads present); however, survival was not severely reduced. Our study clearly demonstrated that on small islands, invasive species may exploit broader ecological roles with strong indirect effects that amplify their impacts beyond those seen on continents. Overall, the effects of cane toad competition had the capacity to strongly reduce ground frog reproductive success. We strongly advocate management actions that either minimize invasion or limit the strength of invasive-native species interactions (e.g. through habitat conservation) to prevent further extinctions on islands.

A modeling intervention in heart failure

BACKGROUND: Peak oxygen uptake (VO(2)) testing is commonly used to assess chronic heart failure (CHF) patients' exercise tolerance. The test requires maximal effort; however, many participants have low confidence (self-efficacy) to perform optimally. PURPOSE: This randomized controlled trial examined the effectiveness of a modeling intervention to increase Peak VO(2) (PVO(2)) and self-efficacy in people diagnosed with CHF. METHODS: Twenty participants with a diagnosis of CHF were randomized to either an intervention (modeling DVD) or a control group. Both groups completed a measure of self-efficacy prior to performing two PVO(2) tests, each separated by 7 days. After completing the first test (T1) the intervention group watched a 10-min coping model DVD. All participants returned 1 week later (T2) to complete identical study procedures. RESULTS: Analysis of covariance results showed that compared with the participants in the control group, those assigned to the modeling intervention had higher PVO(2) at T2, F (1, 19) = 4.38, p = 0.05, eta (2) = 0.21 and self-efficacy, F (1, 19) = 5.80, p < 0.05, eta (2) = 0.25. Only partial support was found for change in self-efficacy mediating treatment outcome (PVO(2)). CONCLUSIONS: Watching a modeling video is associated with increased PVO(2) and self-efficacy. These results have implications for testing patients in a clinical setting to maximize exercise tolerance test results.

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions

Background: There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation. Methods: A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients' primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm. Results: There were 1999 participants (54% male) with a mean age of 63years (range 18-101), enrolled in the study. Participants' primary health conditions at enrolment were: diabetes 915 (46%), chronic respiratory disease 463 (23%), cardiac disease 260 (13%), peripheral vascular disease, and 181 (9%) and aged care 180 (9%). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95% CI, 1.16-2.13, p=0.003) and admissions (OR 1.67, 95% CI.1.21 to 2.30, p=0.002) after adjusting for differences in age and comorbidities. Conclusion: This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.

The role of religion and spirituality in coping with kidney disease and haemodialysis in Thailand

BACKGROUND: People with chronic kidney disease (CKD) face various problems including psychological, socioeconomic and physical effects associated with CKD and its treatment. They need to develop strategies to help them cope with CKD and life challenges. Religion and spirituality are important coping strategies, but their role in helping people cope with CKD and haemodialysis (HD) in Thailand is relatively unknown.

AIMS: To investigate the role of religion and spirituality in coping with CKD and its treatment in Thailand.

DESIGN: An exploratory, qualitative approach was undertaken using semistructured individual interviews.
METHOD: Purposive sampling was used to recruit participants. Face-to-face, in-depth individual interviews using open questions were conducted during January and February 2012. Interviews were audio-recorded and transcribed verbatim. Data were analysed using the framework method of qualitative data analysis.

FINDINGS: Twenty people receiving HD participated: age range 23-77 years, mean 53.7 (±16.38 SD). Ten were women. Participants reported use of religious and spiritual practices to cope with CKD and its treatment, including religious and spiritual explanations for developing CKD, karmic disease, making merit, reading Dharma books, praying and chanting to save life and making a vow to Pran-Boon.

CONCLUSION: Religion and spirituality provide powerful coping strategies that can help Thai people with CKD overcome the associated distress and difficulties. Religion and spirituality cannot be separated in Thai culture because Thai people are both religious and spiritual.

Comparative acoustic performance and mechanical properties of silk membranes for the repair of chronic tympanic membrane perforations

The acoustic and mechanical properties of silk membranes of different thicknesses were tested to determine their suitability as a repair material for tympanic membrane perforations. Membranes of different thickness (10-100μm) were tested to determine their frequency response and their resistance to pressure loads in a simulated ear canal model. Their mechanical rigidity to pressure loads was confirmed by tensile testing. These membranes were tested alongside animal cartilage, currently the strongest available myringoplasty graft as well as paper, which is commonly used for simpler procedures. Silk membranes showed resonant frequencies within the human hearing range and a higher vibrational amplitude than cartilage, suggesting that silk may offer good acoustic energy transfer characteristics. Silk membranes were also highly resistant to simulated pressure changes in the middle ear, suggesting they can resist retraction, a common cause of graft failure resulting from chronic negative pressures in the middle ear. Part of this strength can be explained by the substantially higher modulus of silk films compared with cartilage. This allows for the production of films that are much thinner than cartilage, with superior acoustic properties, but that still provide the same level of mechanical support as thicker cartilage. Together, these in vitro results suggest that silk membranes may provide good hearing outcomes while offering similar levels of mechanical support to the reconstructed middle ear.