K. McDonald

Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge.

Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented.

Can we reduce preventable heart failure readmissions in patients enrolled in a Disease Management Programme

BackgroundDisease Management Programmes (DMPs) are successful in reducing hospital readmissions in heart failure (HF). However, there remain a number of patients enrolled in a DMP who are readmitted with HF. The primary aim of the study was to determine the proportion of preventable readmissions (PR). The secondary aim was to recognise patient characteristics which would identify certain patients at risk of having a PR.MethodsA retrospective chart search was performed on patients readmitted over a 1-year period.Results38.5% of readmissions were classified as PR. None of these patients made prior contact with the DMP. Admission levels of BNP, potassium, urea and creatinine were significantly lower in the PR group.ConclusionDMP have proven benefits in reducing hospital readmission nonetheless a significant proportion of these readmissions are preventable. Further work is required to prospectively analyse why these patients fail to contact the DMP.

Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure: a marker of diastolic dysfunction and clinical risk

BackgroundB-type natriuretic peptide (BNP) is widely accepted in the evaluation of left ventricular systolic dysfunction and heart failure. However, little is known of the implications of elevated BNP levels in individuals with preserved systolic function (PSF).AimsTo investigate the drivers and clinical implications of elevated BNP levels in asymptomatic individuals with established PSF.MethodsWe enrolled 154 individuals who all underwent physical examination, BNP evaluation and Doppler-echocardiographic studies. They were divided into those above and below the median BNP level (50pg/ml).ResultsIndependent predictors of higher BNP were older age, more severe left ventricular hypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival and multivariable analysis demonstrated more death and/or admission in those above the median BNP (HR: 4.79, p = 0.007).ConclusionsElevated BNP is the strongest, independent predictor of serious adverse cardiovascular outcomes in this population and requires closer clinical follow-up.

Diagnosis of new onset heart failure in the community: the importance of a shared-care approach and judicious use of BNP

BackgroundBrain natriuretic peptide (BNP) may help general practitioners (GPs) to “rule-out” heart failure (HF) and reduce referral burden on specialist assessment clinics.AimsTo determine the diagnostic value of BNP in HF referrals by GPs to a specialist unit.MethodsFrom 2003 to 2007, 327 GP referrals were made to a HF new patient diagnostic clinic (NDC) with a provisional diagnosis of HF. The NDC provides rapid assessment of potential HF patients and ensures appropriate therapy and follow-up for those with a confirmed diagnosis. HF diagnosis was confirmed by the Framingham criteria.ResultsHF was present in 39% of cases referred (mean age 75xa0±xa010xa0years, 49% male). The inclusion of BNP as a “rule-out” test with a cut-off value of 100xa0pg/mL would have reduced the number of patients originally referred to the NDC by 175. However, this would have resulted in delayed diagnosis and treatment of 20 (16%) “false-negative” patients.ConclusionsAvailability of BNP to GPs would improve referral patterns but with high risk of delayed diagnosis. The data underline the need for a shared-care approach to the new diagnosis of HF.

A comparison of HFrEF vs HFpEF's clinical workload and cost in the first year following hospitalization and enrollment in a disease management program

BACKGROUNDnAdmission with heart failure (HF) is a milestone in the progression of the disease, often resulting in higher intensity medical care and ensuing readmissions. Whilst there is evidence supporting enrolling patients in a heart failure disease management program (HF-DMP), not all reported HF-DMPs have systematically enrolled patients with HF with preserved ejection fraction (HFpEF) and there is a scarcity of literature differentiating costs based on HF-phenotype.nnnMETHODSn1292 consenting, consecutive patients admitted with a primary diagnosis of HF were enrolled in a hospital based HF-DMP and categorized as HFpEF (EF≥45%) or HFrEF (EF<45%). Hospitalizations, primary care, medications, and DMP workload with associated costs were evaluated assessing DMP clinic-visits, telephonic contact, medication changes over 1year using a mixture of casemix and micro-costing techniques.nnnRESULTSnThe total average annual cost per patient was marginally higher in patients with HFrEF €13,011 (12,011, 14,078) than HFpEF, €12,206 (11,009, 13,518). However, emergency non-cardiovascular admission rates and average cost per patient were higher in the HFpEF vs HFrEF group (0.46 vs 0.31 per patient/12months) & €655 (318, 1073) vs €584 (396, 812). In the first 3months of the outpatient HF-DMP the HFrEF population cost more on average €791 (764, 819) vs €693 (660, 728).nnnCONCLUSIONnThere are greater short-term (3-month) costs of HFrEF versus HFpEF as part of a HF-DMP following an admission. However, long-term (3-12month) costs of HFpEF are greater because of higher non-cardiovascular rehospitalisations. As HFpEF becomes the dominant form of HF, more work is required in HF-DMPs to address prevention of non-cardiovascular rehospitalisations and to integrate hospital based HF-DMPs into primary healthcare structures.