Annabel Hickey

A systematic approach to chronic heart failure care: a consensus statement

The National Heart Foundation of Australia assembled an expert panel to provide guidance on policy and system changes to improve the quality of care for people with chronic heart failure (CHF). The recommendations have the potential to reduce emergency presentations, hospitalisations and premature death among patients with CHF. Best‐practice management of CHF involves evidence‐based, multidisciplinary, patient‐centred care, which leads to better health outcomes. A CHF care model is required to achieve this. Although CHF management programs exist, ensuring access for everyone remains a challenge. This is particularly so for Aboriginal and Torres Strait Islander peoples, those from non‐metropolitan areas and lower socioeconomic backgrounds, and culturally and linguistically diverse populations. Lack of data and inadequate identification of people with CHF prevents efficient patient monitoring, limiting information to improve or optimise care. This leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. Expanding current cardiac registries to include patients with CHF and developing mechanisms to promote data linkage across care transitions are essential. As the prevalence of CHF rises, the demand for multidisciplinary workforce support will increase. Workforce planning should provide access to services outside of large cities, one of the main challenges it is currently facing. To enhance community‐based management of CHF, general practitioners should be empowered to lead care. Incentive arrangements should favour provision of care for Aboriginal and Torres Strait Islander peoples, those from lower socioeconomic backgrounds and rural areas, and culturally and linguistically diverse populations. Ongoing research is vital to improving systems of care for people with CHF. Future research activity needs to ensure the translation of valuable knowledge and high‐quality evidence into practice.

The paradox of readmission: effect of a quality improvement program in hospitalized patients with heart failure.

BACKGROUND Congestive heart failure (CHF) is an increasingly common condition associated with significant hospital resource utilization. Initiating better disease management at the time of initial hospital admission has the potential to reduce readmissions. OBJECTIVE To evaluate the impact of a multifaceted quality improvement program on 12-month hospital utilization in patients admitted to hospital with CHF. DESIGN Prospective longitudinal study comparing baseline and intervention cohorts. PARTICIPANTS All consecutive patients with CHF discharged alive from 3 metropolitan hospitals during the baseline (October 1, 2000 to April 17, 2001) and intervention (February 15, 2002 to August 31, 2002) study periods. Active prospective case-finding identified 220 baseline and 235 intervention participants; full data was available on 197 baseline and 219 intervention participants. INTERVENTIONS Education and performance feedback for hospital and primary care practitioners; clinical decision support tools; individualized, guideline-based treatment plans; patient education and self-management support; and improved hospital-community integration. MEASUREMENTS Twelve-month all-cause hospital readmission, 12-month mortality, readmission-free survival, heart failure-specific readmission, and total hospital days over 12 months. RESULTS Intervention patients had a higher rate of all-cause readmission (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.10-2.46) but a trend to reduction in mortality (OR = 0.68; 95% CI = 0.44-1.07). There was no difference in frequency of hospitalizations per year, number of hospital days, or the composite outcome of death or readmission. CONCLUSIONS The intervention improved care processes and may have reduced mortality, but at the cost of higher readmission rates. Better understanding of intervention components, intensity, and targeting may optimize the effectiveness of disease management programs.

Quality of care of patients hospitalized with congestive heart failure

Background:  Congestive heart failure (CHF) is an increasingly prevalent poor‐prognosis condition for which effective interventions are available. It is therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.

Quality of care of patients hospitalized with acute coronary syndromes

Abstract

Implementing a community-based model of exercise training following cardiac, pulmonary, and heart failure rehabilitation

PURPOSE: Encouraging patients to continue regular activity beyond the period of formal cardiac, heart failure, or pulmonary rehabilitation is a challenge faced by all program coordinators. The purpose of this study was to evaluate the feasibility of a community model run by fitness instructors as long-term maintenance for patients exiting a disease-specific rehabilitation program. METHODS: Heartmoves programs were established in close proximity to all major tertiary hospitals in Brisbane, Queensland, Australia, and all eligible patients were offered supported referral to a program. Referred patients and rehabilitation staff were surveyed regarding perceived barriers to attendance. Referral rates and individual attendance rates for the first 12 weeks were recorded. RESULTS: Over 12 months, 241 patients were referred to a community Heartmoves class, of whom 141 (59%) attended at least once and 76 (32% of referrals, 54% of initial attendees) attended more than 6 of the first 12 weeks. Preattendance surveys identified concerns about quality and safety, as well as social and logistic barriers. The programs proved to be sustainable, as evidenced by the growth of programs from 18 at the end of the project to 31 over a 18-month period. CONCLUSIONS: A supported referral pathway to Heartmoves provides a feasible and acceptable model for maintenance exercise following cardiac, heart failure, and pulmonary rehabilitation. Strategies that recognize and address barriers perceived by participants and by rehabilitation program staff should be part of the supported referral process.

Improving medication titration in heart failure by embedding a structured medication titration plan

BACKGROUND To improve up-titration of medications to target dose in heart failure patients by improving communication from hospital to primary care. METHODS This quality improvement project was undertaken within three heart failure disease management (HFDM) services in Queensland, Australia. A structured medication plan was collaboratively designed and implemented in an iterative manner, using methods including awareness raising and education, audit and feedback, integration into existing work practice, and incentive payments. Evaluation was undertaken using sequential audits, and included process measures (use of the titration plan, assignment of responsibility) and outcome measures (proportion of patients achieving target dose) in HFDM service patients with reduced left ventricular ejection fraction. RESULTS Comparison of the three patient cohorts (pre-intervention cohort A n=96, intervention cohort B n=95, intervention cohort C n=89) showed increase use of the titration plan, a shift to greater primary care responsibility for titration, and an increase in the proportion of patients achieving target doses of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (A 37% vs B 48% vs C 55%, p=0.051) and beta-blockers (A 38% vs B 33% vs C 51%, p=0.045). Combining all three cohorts, patients not on target doses when discharged from hospital were more likely to achieve target doses of ACEI/ARB (p<0.0001) and beta blockers (p<0.0001) within six months if they received a medication titration plan. CONCLUSIONS A medication titration plan was successfully implemented in three HFDM services and improved transitional communication and achievement of target doses of evidence-based therapies within six months of hospital discharge.

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Large-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers decrease mortality and hospitalisation in patients with heart failure (HF) associated with a reduced left ventricular ejection fraction. This has led to high prescription rates; however, these drugs are generally prescribed at much lower doses than the doses achieved in the RCTs. A number of strategies have been evaluated to improve medication titration in HF, including forced medication up-titration protocols, point-of-care decision support and extended scope of clinical practice for nurses and pharmacists. Most successful strategies have been multifaceted and have adapted existing multidisciplinary models of care. Furthermore, given the central role of general practitioners in long-term monitoring and care coordination in HF patients, these strategies should engage with primary care to facilitate the transition between the acute and primary healthcare sectors.