Yih-Kai Chan

Prolonged impact of home versus clinic-based management of chronic heart failure : Extended follow-up of a pragmatic, multicentre randomized trial cohort

OBJECTIVESnWe compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).nnnMETHODSnWe followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.nnnRESULTSn280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n=143) or clinic-based (n=137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p=0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p=0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p=0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p<0.01 for rate and duration of hospital stay).nnnCONCLUSIONSnRelative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.nnnTRIAL REGISTRATIONnAustralian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803).

An Absolute Risk Prediction Model to Determine Unplanned Cardiovascular Readmissions for Adults with Chronic Heart Failure

BACKGROUNDnFrequent readmissions are a hallmark of chronic heart failure (CHF). We sought to develop an absolute risk prediction model for unplanned cardiovascular readmissions following hospitalisation for CHF.nnnMETHODSnAn inception cohort was obtained from the WHICH? trial, a prospective, multi-centre randomised controlled trial which was a head-to-head comparison of the efficacy of a home-based intervention versus clinic-based intervention for adults with CHF. A Coxs proportional hazards model (taking into account the competing risk of death) was used to develop a prediction model. Bootstrap methods were used to identify factors for the final model. Based on these data a nomogram was developed.nnnRESULTSnOf the 280 participants in the WHICH? trial 37 (13%) were readmitted for a cardiovascular event (including CHF) within 28 days, and a further 149 (53%) were readmitted within 18 months for a cardiovascular event. In the proposed competing risk model, factors associated with an increased risk of hospitalisation for CHF were: age (HR 1.07, 95% CI 0.90-1.26) for each 10-year increase in age; living alone (HR 1.09, 95% CI 0.74-1.59); those with a sedentary lifestyle (HR 1.44, 95% CI, 0.92-2.25) and the presence of multiple co-morbid conditions (HR 1.69, 95% CI 0.38-7.58) for five or more co-morbid conditions (compared to individuals with one documented co-morbidity). The C-statistic of the final model was 0.80.nnnCONCLUSIONnWe have developed a practical model for individualising the risk of short-term readmission for CHF. This model may provide additional information for targeting and tailoring interventions and requires future prospective evaluation.

Exploring the potential to remain “Young @ Heart”: Initial findings of a multi-centre, randomised study of nurse-led, home-based intervention in a hybrid health care system

BACKGROUNDnDisease management programs have been shown to improve health outcomes in high risk individuals in many but not all health care systems.nnnMETHODSnYoung @ Heart is a multi-centre, randomised controlled study of a nurse-led, home-based intervention (HBI) program vs. usual care (UC) in privately insured patients in Australia aged ≥ 45 years following an acute cardiac admission. Intensity of HBI is tailored to an individuals clinical stability, management and risk profile. The primary endpoint is the rate of all-cause stay during a mean of 2.5 years follow-up.nnnRESULTSnA target of 602 adults (72% men) were randomised to HBI (n=306) or UC (n=296); their initial profiles being well matched. At baseline, 71% were overweight (body mass index 29.7 ± 3.9 kg/m(2)) and 66% had an elevated blood pressure (153 ± 18/89 ± 7 mm Hg). Over half had a history of smoking and 39% had a sub-optimal total cholesterol level >4 mmol/L. Overall, 62% (376 cases) were treated for coronary artery disease (27% with multi-vessel disease and 39% underwent cardiac revascularisation). A further 20% (120 cases) were treated for a cardiac arrhythmia (predominantly atrial fibrillation) and 19% type 2 diabetes mellitus. At 7-14 days post-discharge, 293 (96%) HBI patients received a home visit triggering urgent clinical review and/or enhanced clinical management in many patients.nnnCONCLUSIONSnThe Young @ Heart intervention is a well accepted and potentially effective intervention to reduce recurrent hospital stay in privately insured cardiac patients in Australia.

Composite outcome measures in a pragmatic clinical trial of chronic heart failure management: A comparative assessment

BACKGROUNDnA number of composite outcomes have been developed to capture the perspective of the patient, clinician and objective measures of health in assessing heart failure outcomes. To date there has been a limited examination in the composition of these outcomes.nnnMETHODS AND RESULTSnThree commonly used scoring systems in heart failure trials: Packers composite, Patient Journey and the African American Heart Failure Trial (A-HeFT) scores were compared in assessing outcomes from the Which heart failure intervention is most cost-effective & consumer friendly in reducing hospital care (WHICH(?)) Trial. Comparability and interpretability of these outcomes and the influence of each component to the final outcome were examined. Despite all three composite outcomes incorporating mortality, hospitalisation and quality of life (QoL), the contribution of each individual component to the final outcomes differed. The component with the most influence in deteriorating condition for the Packers composite was hospitalisation (67.7%), while in Patient Journey it was QoL (61.5%) and for A-HeFT composite score it was mortality (45.4%).nnnCONCLUSIONSnThe contribution made by each component varied in subtle, but important ways. This study emphasises the importance of understanding the value system of the composite outcomes to enable meaningful interpretation of results.

Long-term tolerance and efficacy of adjunctive exenatide therapy on glycaemic control and bodyweight in type 2 diabetes: a retrospective study from a specialist diabetes outpatient clinic

Weight gain and hypoglycaemia are common adverse effects associated with anti‐diabetic treatments.

Applying Heart Failure Management to Improve Health Outcomes: But WHICH One?

We report on our learning from many years of research testing the value of nurse-led, multidisciplinary, home-based management of heart failure. We discuss and highlight the key challenges we have experienced in testing this model of care relative to alternatives and evolving patient population. Accordingly, we propose a pragmatic approach to adapt current models of care to meet the needs of increasingly complex (and costly) patients with multimorbidity.