A telephone-delivered empowerment intervention with patients diagnosed with heart failure. The effectiveness of telephone‐based post‐discharge nursing care in decreasing readmission rate in patients with heart failure: a systematic review Heart Failure 2012 The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Effectiveness of implementation strategies in improving physician adherence to guideline recommendations in heart failure: a systematic review protocol Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial. Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study. Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Outcomes of chronic heart failure. Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure. Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics) Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. Do heart failure disease management programs make financial sense under a bundled payment system? A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study Wireless Pulmonary Artery Pressure Monitoring Guides Management to Reduce Decompensation in Heart Failure With Preserved Ejection Fraction Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care. Cell therapy for heart disease: Trial sequential analyses of two Cochrane reviews Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme Is “Teach-Back” Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Hemoglobin, exercise training, and health status in patients with chronic heart failure (from the HF-ACTION randomized controlled trial). Nutritional intervention in acute heart failure patients with undernutrition and normalbuminemia: A subgroup analysis of PICNIC study.
BACKGROUND Heart failure ( HF ) is a major public health problem . Case management by nurses using telephone follow-up has been suggested as a convenient and effective mechanism to promote the self-management of HF . Similarly , a patient empowerment approach to the management of chronic disease has been suggested as one that may nurture self-management in individuals with chronic illness . OBJECTIVE The purpose of this study was to examine the effects of a telephone-delivered empowerment intervention ( EI ) on clinical ly and theoretically relevant outcomes in patients with HF , including purpose ful participation in goal attainment , self-management of HF , and perception of functional health . The EI was guided by Rogers ' Science of Unitary Human Beings person-environment process . METHODS A convenience sample of men and women aged 21 years and older with a clinical diagnosis of HF was obtained from a metropolitan hospital located in the southwestern United States . The participants were r and omly assigned to the control group ( n = 45 ) or EI group ( n = 45 ) . All participants received st and ardized HF patient education ; the intervention group also received an EI delivered through telephone follow-up calls from a registered nurse . Repeated- measures analysis of variance was used to evaluate intervention effects . RESULTS The telephone-delivered EI  facilitated self-management of HF through self-care activities in EI group members . CONCLUSION The knowledge gained from this study provides a beginning underst and ing of strategies to enhance health care providers ' ability to facilitate self-management of HF among patients diagnosed with HF Background The importance of comprehensive discharge planning plus post discharge support intervention studies have been advocated for patients with heart failure .  Telephone‐based post‐discharge nursing care was reported as a significant nursing care approach that is believed to promote continuity of care . However , there is a lack of systematic ally examined evidence to support the effectiveness of nurse‐led telephone‐based post‐discharge care for the heart failure patients . Objective The purpose of this study was to examine the best available evidence to determine the effectiveness of telephone‐based post‐discharge nursing care of patient with HF and to quantify the effect on all‐cause readmission rates of these patients . Search strategy A thorough search of published and unpublished literature was conducted from 1990 to 2009 . First , computer data bases such as CINAHL , MEDLINE , COCHRANE EMBASE , and Dissertation Abstract s International were included and then , reference search was conducted with relevant studies . Initial keywords were “ readmission , ” “ heart failure , ” “ * tele * ” , “ nurs * , “ post‐discharge ” , telephone‐based . ” Selection criteria R and omized controlled trial studies using the telephone‐based post‐discharge nursing care was selected . Outcome was defined as frequency of unplanned HF symptoms associated all‐cause hospital readmission rate during the 6 months after discharge . Data collection and analysis Included studies were critically evaluated for method ological quality by independent two review ers . Data were extracted and then analyzed using the JBI‐MASTARI and the RevMan 5 program . Main results A total of 10 r and omized controlled trial studies were included for this study . The study result showed that telephone‐based post‐discharge nursing care was a significant intervention especially decreasing hospital readmission rate among HF patients . Conclusion The findings of this review suggest a positive effect of telephone‐based post‐discharge nursing care and that it is an effective intervention in decreasing readmission rate among HF patients . Implication s for practice / research The results of this systematic review indicate the need for well design ed studies that examine other aspects of post‐discharge nursing telephone interventions to decrease hospital readmission rate among HF patients including : cost‐effectiveness , feasibility and appropriateness Heart failure has been named “ the growing epidemic . ” Over the last decade , the annual number of heart failure hospitalizations has almost doubled with approximately 50 % of patients being rehospitalized within 6 months of discharge [ 1 ] . The complex array of physiologic , psychological , social , and health care delivery issues makes it a challenging chronic disease to manage . Underst and ing the epidemiology and pathophysiology of the syndrome , identifying the predictors and their strength of association with outcomes , and using the available diagnostic modalities cost-effectively are essential in order to devise effective prevention interventions and implement novel therapeutic approaches to curb this epidemic . In this special issue , we have invited a few papers that address such issues and explain why despite the emergence of novel therapeutic approaches , that promise life prolongation and hospital length reduction , this patient population will still be needing rehospitalization and will often have a poor prognosis . This special issue is the extension of an effort that was initiated in 2011 with the first heart-failure-focused issue [ 2 ] . In the pathophysiology section , S. M. R. Kazemi-Bajestani et al. describe the opportunities and challenges of targeting the angiotensin converting enzyme 2 (ACE2)/Ang II/Ang1–7 and apelin/APJ pathways as novel therapeutic modalities in heart failure [ 3 ] . ACE2 and the apelin/APJ are two important peptide systems which exert diverse effects on the cardiovascular system . Dysregulation of such systems may be involved in the predisposition to cardiovascular diseases whereas enhancing their action may have important therapeutic effects . In the same section , D. Lindner et al. provide a comprehensive review on the protective function of signal transducer and activator of transcription 3 ( STAT3 ) in CVB3-induced myocarditis [ 4 ] . The transcription factor ( STAT3 ) is an important mediator of the inflammatory process , and in this original research the investigators examine the role of STAT3 in viral myocarditis and its possible role in the development to dilated cardiomyopathy . Considering the high mortality rate and the availability of life-saving therapies like transplantation and left ventricular assist devices , accurate prognosis determination in HF is clinical ly important . Taking into account the mediocre performance of current established prediction models , such as the Seattle Heart Failure Model [ 5–7 ] , the work by H. Fukuta et al. [ 8 ] on the prognostic value of left ventricular diastolic dysfunction in patients undergoing cardiac catheterization for coronary artery disease sheds light on this extremely important topic . A shared underst and ing of medical conditions between patients and their health care providers has been shown to improve self-care and outcomes [ 9 ] . In the comorbidity section , we demonstrate how certain comorbid conditions may affect patients ' decision-making capacity and interfere with their ability to comply with treatment requirements , recognize and self-manage disease worsening symptoms . Among others , cognitive impairment is increasingly recognized as a common adverse consequence of HF , whereby phenomena such as microembolism , chronic or intermittent cerebral hypoperfusion , and /or impaired cerebral vessel reactivity may lead to cerebral hypoxia and ischemic brain damage . Cognitive decline in HF is characterized by deficits in one or more cognition domains , including attention , memory , executive function , and psychomotor speed . E. Dardiotis et al. [ 10 ] , in a comprehensive review , underscore the importance for healthcare professionals to become familiar with assessment of cognitive performance using st and ardized screening instruments in their routine evaluations of HF patients . Another comorbidity gaining increasing attention in HF patients is depression . There are several pathophysiological mechanisms as well as behavioral processes linking depression and HF . Equally important is screening for depression and there are several valid and reliable screening tools to identify patients at greater risk . Consultation should be provided by a multidisciplinary team , consisting of cardiologists , psychiatrists , and hospital or community nurses so as to carefully plan , execute , and evaluate medical intervention and implement lifestyle changes . D. Mastrogiannis et al. [ 11 ] systematic ally review the existing knowledge regarding current definitions , prognostic implication s , pathophysiological mechanisms , and current and future treatment options in patients with depression and HF . Evidence from the literature supports the possibility of a pathophysiological relationship between cognitive impairment , depression , and HF . Yet , very few studies have sought to investigate this relationship . The paper by Z. N. Sohani and Z. Samaan review s current literature on the association between depression and cognitive impairment  in persons with HF and explores possible mechanisms explaining this complex triad [ 12 ] . Heart failure through neurohumoral activation induces alterations of cardiac metabolism , such as insulin resistance , and promotes increased utilization of noncarbohydrate substrates for energy production [ 13 , 14 ] . Fasting blood ketone bodies as well as fat oxidation have been shown to be increased in this patient population . The result is depletion of myocardial ATP , phosphocreatine , and creatine kinase , leading to decreased efficiency of mechanical work . A direct approach to manipulate cardiac energy metabolism consists in modifying substrate utilization by the failing heart . Trimetazidine , perhexiline , and ranolazine directly inhibit fatty acid oxidation and have been used to increase the ischemic threshold in patients with effort angina . Current research is supporting the concept that shifting the energy substrate preference away from fatty acid metabolism and toward glucose metabolism could be an effective adjunctive treatment in patients with HF . These agents have been shown to improve both glucose metabolism and left ventricular function in diabetic patients with left ventricular dysfunction . In the pharmacotherapy section , we provide a systematic review , in which N. Signoretta et al. [ 15 ] discuss the beneficial therapeutic effects of modulation of cardiac metabolic substrates utilization in patients with HF . In the advanced heart failure section , we provide a thorough review on the current status of mechanical circulatory support in patients with advanced HF . Management of the advanced HF patients with the numerous comorbidities [ 16 , 17 ] requires a significant amount of health care re sources and is becoming a major public health problem . As therapeutical strategies for HF have been refined , the number of patients suffering from the end-stage disease has exp and ed dramatically . Although heart transplantation still represents the gold st and ard therapeutical approach , the shortage of donors universally has made the implantation of mechanical circulatory support devices a well-established management for this disease . The systematic review by K. Spiliopoulos et al. [ 18 ] , outlines the current status of mechanical circulatory support in this patient population . In the chronic follow-up section , we deal with telemonitoring , a novel diagnostic modality that has been suggested to be beneficial for HF patients , targeting optimization of their chronic followup . Telemonitoring is viewed as a means of recording physiological data ( such as body weight , heart rate , arterial blood pressure electrocardiogram recordings , and other data ) by portable devices and transmitting these data remotely ( via a telephone line , a mobile phone , or a computer ) to a server where they can be stored , review ed , and analyzed by the research team . In a systematic review of all r and omized clinical trials evaluating telemonitoring in chronic HF , G. Giamouzis et al. [ 19 ] assess whether telemonitoring provides any substantial benefit in this patient population . We hope that the readers of the journal will find the topics as interesting and important as we did . Gregory Giamouzis George Giannakoulas Javed Butler John A. Elefteriades Carsten Tschope Filippos OBJECTIVE The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life ( QoL ) , readmission rates and healthcare costs for adults with heart failure ( HF ) living independently in the community . METHOD A systematic review of r and omised control trials was undertaken . Using the search terms nurse , education , heart failure , hospitalisation , readmission , rehospitalisation , economic burden , cost , expenditure and quality of life in PubMed , CINAHL and Google Scholar data bases were search ed . Papers pertaining to  nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were review ed . RESULT The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions , reduction in hospitalisation and a cost benefit . Additionally , higher functioning and improved QoL were also identified . CONCLUSION These results suggest that nurse-led patient education for adults with HF  improves QoL and reduces hospital admissions and readmissions . PRACTICE IMPLICATION S Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation Introduction The uptake of Clinical Practice Guideline ( CPG ) recommendations that improve outcomes in heart failure ( HF ) remains suboptimal . We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations , those with clear evidence that benefits outweigh the risks . We will use American , Canadian and European HF guidelines as our reference . Methods and analysis We will conduct a literature search in the data bases of MEDLINE , EMBASE , HEALTHSTAR , CINAHL , Cochrane Library , Campbell Collaboration , Joanna Briggs Institute Evidence Based Practice , Centre for Review s and Dissemination and Evidence Based Practice Centres . We will include prospect i ve studies evaluating implementation interventions aim ed at improving uptake of class I CPG recommendations in HF . We will extract data in duplicate . We will classify interventions according to their level of application ( ie , provider , organisation , systems level ) and common underlying characteristics ( eg , education , decision-support , financial incentives ) using the Cochrane Effective Practice and Organisation of Care Taxonomy . We will assess the impact of the intervention on adherence to the CPGs . Outcomes will include proportion of eligible patients who were : prescribed a CPG-recommended pharmacological treatment ; referred for device consideration ; provided self-care education at discharge ; and provided left ventricular function assessment . We will include clinical outcomes such as hospitalisations , readmissions and mortality , if data is available . We will identify the common elements of successful and failing interventions , and examine the context in which they were applied , using the Process Re design context ual framework . We will synthesis e the results narratively and , if appropriate , will pool results for meta- analysis . Discussion and dissemination In this review , we will assess the impact of implementation strategies and context ual factors on physician adherence to HF CPGs . We will explore why some interventions may succeed in one setting and fail in another . We will disseminate our findings through briefing reports , publications and presentations . Trial registration number CRD42015017155 IMPORTANCE It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure ( HF ) after hospitalization . OBJECTIVE To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF . DESIGN , SETTING , AND PARTICIPANTS We r and omized 1437 patients hospitalized for HF between October 12 , 2011 , and September 30 , 2013 , to the intervention arm ( 715 patients ) or to the usual care arm ( 722 patients ) of the Better Effectiveness After Transition-Heart Failure ( BEAT-HF ) study and observed them for 180 days . The date s of our study analysis were March 30 , 2014 , to October 1 , 2015 . The setting was 6 academic medical centers in California . Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF . INTERVENTIONS The intervention combined health coaching telephone calls and telemonitoring . Telemonitoring used electronic equipment that collected daily information about blood pressure , heart rate , symptoms , and weight . Central ized registered nurses conducted telemonitoring review s , protocol ized actions , and telephone calls . MAIN OUTCOMES AND MEASURES The primary outcome was readmission for any cause within 180 days after discharge . Secondary outcomes were all-cause readmission within 30 days , all-cause mortality at 30 and 180 days , and quality of life at 30 and 180 days . RESULTS Among 1437 participants , the median age was 73 years . Overall , 46.2 % ( 664 of 1437 ) were female , and 22.0 % ( 316 of 1437 ) were African American . The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge , which occurred in 50.8 % ( 363 of 715 ) and 49.2 % ( 355 of 722 ) of patients , respectively ( adjusted hazard ratio , 1.03 ; 95 % CI , 0.88 - 1.20 ; P = .74 ) . In secondary analyses , there were no significant differences in 30-day readmission or 180-day mortality , but there was a significant difference in 180-day quality of life between the intervention and usual care groups . No adverse events were reported . CONCLUSIONS AND RELEVANCE Among patients hospitalized for HF , combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01360203 OBJECTIVES The purpose of this study was to determine whether a heart failure ( HF ) management strategy using continuous intracardiac pressure monitoring could decrease HF morbidity . BACKGROUND Patients with HF may experience frequent decompensations that require hospitalization despite intensive treatment and follow-up . METHODS The COMPASS-HF ( Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure ) study was a prospect i ve , multicenter , r and omized , single-blind , parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who received an implantable continuous hemodynamic monitor . Patients were r and omized to a Chronicle ( Medtronic Inc. , Minneapolis , Minnesota ) ( n = 134 ) or control ( n = 140 ) group . All patients received optimal medical therapy , but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group . Primary end points included freedom from system-related complications , freedom from pressure-sensor failure , and reduction in the rate of HF-related events ( hospitalizations and emergency or urgent care visits requiring intravenous therapy ) . RESULTS The 2 safety end points were met with no pressure-sensor failures and system-related complications in only 8 % of the 277 patients who underwent implantation ( all but 4 complications were successfully resolved ) . The primary efficacy end point was not met because the Chronicle group had a nonsignificant 21 % lower rate of all HF-related events compared with the control group ( p = 0.33 ) . A retrospective analysis of the time to first HF hospitalization showed a 36 % reduction ( p = 0.03 ) in the relative risk of a HF-related hospitalization in the Chronicle group . CONCLUSIONS The implantable continuous hemodynamic monitor-guided care did not significantly reduce total HF-related events compared with optimal medical management . Additional trials will be necessary to establish the clinical benefit of implantable continuous hemodynamic monitor-guided care in patients with advanced HF The aim of this study was to investigate whether , in a r and omized controlled trial ( RCT ) of vulnerable elders with heart failure ( HF ) , advanced practice nurses ( APNs ) who were coordinating care in the transition from hospital to home could improve outcomes , prevent rehospitalizations , and reduce costs when compared with usual care . The APN strategies focused on improving patient and family or caregiver effectiveness in managing their illnesses , strengthening the patient-provider relationship , and managing comorbid conditions while improving overall health . The results were positive . By capitalizing on the patient 's desire to achieve their identified goals , APNs successfully educated patients about the meaning of their symptoms and appropriate self-management strategies ; improved patient-provider communication patterns ; and marshaled caregiver and community re sources to maximize patient adherence to the treatment plan and overall quality of life . While HF was the primary reason for enrollment in the study , optimal health outcomes dem and ed a strong focus on integrating management of comorbid conditions and other long-st and ing health problems . Specific strategies used by the APN to achieve these positive outcomes are addressed in this report . These strategies are compared with nursing interventions used in other RCTs of HF home management . Directions for future research are explored BACKGROUND Outcomes related to chronic heart failure ( HF ) remain relatively poor , despite advances in pharmacological therapy and medical and nursing care . Experts agree that outpatient care may be among the factors that affect HF outcomes . We hypothesized that the method by which outpatient care is delivered may affect outcomes in this patient population . METHODS A prospect i ve , r and omized design was used to compare HF outcomes from 216 patients r and omized to 1 of 2 home health care delivery methods for 3 months after discharge . Care was delivered by the home nurse visit ( HNV ) or the nurse telemanagement ( NTM ) method . In the latter , patients used transtelephonic home monitoring devices to measure their weight , blood pressure , heart rate , and oxygen saturation . These data were transmitted daily to a secure Internet site . An advanced- practice nurse worked collaboratively with a cardiologist and subsequently treated patients via the telephone . Both delivery methods used the same HF-specific clinical guidelines to direct care . Outcomes include HF readmissions and length of stay , anxiety , depression , self-efficacy , and quality of life . Data were primarily tested using a 2-group analysis of variance ( ANOVA ) . We used a repeated- measures ANOVA to conduct preintervention-postintervention analyses . RESULTS After 3 months , patients in the  NTM group ( n = 108 ; mean + /- SD age , 62.9 + /- 13.2 years ; 83 % African American ; 64 % female ) had fewer HF readmissions ( 13 vs 24 ; P</=.001 ) with shorter lengths of stay ( 49.5 vs 105.0 days ; P</=.001 ) compared with the HNV group ( n = 108 ; mean + /- SD age , 63.2 + /- 12.6 years ; 89 % African American ; 62 % female ) . Hospitalization charges at 3 months were less in the NTM group compared with the HNV group ( $ 65 023 vs $ 177 365 ; P</=.02 ) . At 6 and 12 months , cumulative readmission charges in the NTM group were also less ( $ 223 638 vs $ 500 343 [ P<.03 ] and $ 541 378 vs $ 677 710 [ P</=.16 ] , respectively ) compared with the HNV group . Quality of life was significantly improved for both groups when we compared postintervention and preintervention scores . CONCLUSION The adaptation of state-of-the-art computerized technology to closely monitor patients with HF with advanced- practice nurse care under the guidance of a cardiologist significantly improves HF management while reducing the cost of care BACKGROUND Disease management is effective in the general population , but it has not been tested prospect ively in a sample of solely Hispanics with heart failure ( HF ) . We tested the effectiveness of telephone case management in decreasing hospitalizations and improving health-related quality of life ( HRQL ) and depression in Hispanics of Mexican origin with HF . METHODS AND RESULTS Hospitalized Hispanics with chronic HF ( n = 134 ) were enrolled and r and omized to intervention ( n = 69 ) or usual care ( n = 65 ) . The sample was elderly ( 72 + /- 11 years ) , New York Heart Association class III/IV ( 81.3 % ) , and poorly educated ( 78.4 % less than high school education ) . Most ( 55 % ) were unacculturated into US society . Bilingual/bicultural Mexican-American registered nurses provided 6 months of st and ardized telephone case management . Data on hospitalizations were collected from automated systems at 1 , 3 , and 6 months after the index hospital discharge . Health-related quality of life and depression were measured by self-report at enrollment , 3 , and 6 months . Intention to treat analysis was used . No significant group differences were found in HF hospitalizations , the primary outcome variable ( usual care : 0.49 + /- 0.81 [ CI 0.25 - 0.73 ] ; intervention : 0.55 + /- 1.1 [ CI 0.32 - 0.78 ] at 6 months ) . No significant group differences were found in HF readmission rate , HF days in the hospital , HF cost of care , all-cause hospitalizations or cost , mortality , HRQL , or depression . CONCLUSION These results have important implication s because of the current widespread enthusiasm for disease management . Although disease management is effective in the mainstream HF patient population , in Hispanics this ill , elderly , and poorly educated , a different approach may be needed BACKGROUND While there are data to support the use of comprehensive non-pharmacological intervention programs in patients with heart failure ( HF ) , other studies have not confirmed these positive findings . Substantial differences in the type and intensity of disease management programs make it impossible to draw definitive conclusions about the effectiveness , optimal timing and frequency of interventions . AIMS 1 . To determine the effectiveness of two interventions ( basic support vs. intensive support ) compared to ' care as usual ' in HF patients , on time to first major event ( HF readmission or death ) , quality of life and costs . 2 . To investigate the role of underlying mechanisms ( knowledge , beliefs , self-care behaviour , compliance ) on the effectiveness of the two interventions . METHODS This is a r and omised controlled trial in which 1050 patients with heart failure will be r and omised into three treatment arms : care as usual , basic education and support or intensive education and support . Outcomes of this study are ; time to first major event ( HF hospitalisation or death ) , quality of life ( Minnesota Living with HF Question naire , R AND 36 and Ladder of Life ) and costs . Data will be collected during initial admission and then 1 , 6 , 12 , and 18 months after discharge . In addition , data on knowledge , beliefs , self-care behaviour and compliance will be collected . RESULTS The study started in January 2002 and results are expected at the end of 2005 . CONCLUSIONS This study will help health care providers in future to make rational and informed choices about which components of a HF management program should be exp and ed and which components can possibly be deleted Background Disease management programmes ( DMPs ) have been shown to reduce hospital readmissions and mortality in adults with heart failure ( HF ) , but their effectiveness in elderly patients or in those with major comorbidity is unknown . The Multicenter R and omised Trial of a Heart Failure Management Programme among Geriatric Patients ( HF-Geriatrics ) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity . Methods / Design Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain . Each patient should meet at least one of the following comorbidty criteria : Charlson index ≥ 3 , dependence in ≥ 2 activities of daily living , treatment with ≥ 5 drugs , active treatment for ≥ 3 diseases , recent emergency hospitalization , severe visual or hearing loss , cognitive impairment , Parkinson 's disease , diabetes mellitus , chronic obstructive pulmonary disease ( COPD ) , anaemia , or constitutional syndrome . Half of the patients will be r and omly assigned to a 1-year DMP led by a case manager and the other half to usual care . The DMP consists of an educational programme for patients and caregivers on the management of HF , COPD ( knowledge of the disease , smoking cessation , immunizations , use of inhaled medication , recognition of exacerbations ) , diabetes ( knowledge of the disease , symptoms of hyperglycaemia and hypoglycaemia , self-adjustment of insulin , foot care ) and depression ( knowledge of the disease , diagnosis and treatment ) . It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance . The main outcome variables are quality of life , hospital readmissions , and overall mortality during a 12-month follow-up . Discussion The physiological changes , lower life expectancy , comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF . The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty , and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients .Trial registration ( Clinical Trials.gov number , NCT01076465 ) AIMS Hospitalizations for heart failure ( HF ) are common and are associated with significant morbidity , mortality and cost . However , precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood . METHODS AND RESULTS The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the C and esartan in Heart Failure : Assessment of Reduction in Mortality and Morbidity ( CHARM ) programme were prospect ively collected and stratified by ejection fraction ( EF ) . Potential precipitants were collected using a specifically design ed case report form and categorized according to the presence of cardiovascular ( CV ) , non-CV and unknown factors . Associations between these factors and subsequent rehospitalization and mortality rates were examined . Of 1668 patients who experienced HF hospitalization , 1152 had reduced EF ( ≤40 % , HFrEF ) and 516 had preserved EF ( HFpEF ) . Overall , 54 % had CV , 32 % had non-CV and 14 % had unknown factors thought to have precipitated HF , with similar proportions in the HFrEF and HFpEF groups . The most common precipitants were arrhythmia ( 15 % ) , other non-CV factors ( 11 % ) and respiratory infection ( 10 % ) . Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors . However , mortality rates were similar among patients with any of the three categories of precipitating factors . Results were similar in HFrEF and HFpEF . CONCLUSIONS Among chronic HF patients hospitalized for decompensation , the investigator-reported precipitating factor was not associated with the subsequent mortality rate , but was associated with type of readmission : readmissions for CV reasons were more likely when the index precipitant was CV AIMS Disease management programs can reduce hospitalizations in high-risk heart failure ( HF ) patients , but generalizability to the population hospitalized for HF remains to be proven . We aim ed to assess the effectiveness of a discharge and outpatient management program in a non-selected cohort of patients hospitalized for HF . METHODS AND RESULTS Patients admitted with decompensated HF were r and omized to receive usual care ( n=174 ) or an  intervention ( n=164 ) consisting of a comprehensive hospital discharge planning and close follow-up at a HF clinic . After a median of 509 days , there were fewer events ( readmission or death ) in the intervention as compared with the control group ( 156 vs. 250 ) , which represents 47 % ( 95%CI : 29 - 65 ; P<0.001 ) event reduction per observation year . At 1-year , time to first event , time to first all-cause and HF readmission , and time to death were increased in the intervention group ( P<0.001 ) . All-cause and HF readmission rates per observation year were significantly lower , quality of life improved and overall cost of care was reduced in the intervention group . CONCLUSIONS This comprehensive hospital discharge and outpatient management program prolonged time to first event , reduced hospital readmissions , improved survival and quality of life of patients hospitalized for HF , while reducing cost of management BACKGROUND Policy makers have proposed bundling payments for all heart failure ( HF ) care within 30 days of an HF hospitalization in an effort to reduce costs . Disease management ( DM ) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment . Whether a bundled payment approach can address the negative financial impact of DM programs is unknown . METHODS Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs . We used a decision analytic model using data from retrospective cohort studies , meta-analyses , 5 r and omized trials evaluating DM programs , and inpatient cl aims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004 . We determined the costs of DM programs  and  inpatient care  over 30 and 180 days . RESULTS With a baseline readmission rate of 22.9 % , the average cost for readmissions over 30 days was $ 2,272 per patient . Under base-case assumptions , a DM program that reduced readmissions by 21 % would need to cost $ 477 per patient to be cost neutral . Among evaluated published DM programs , 2 of the 5 would increase provider costs ( + $ 15 to $ 283 per patient ) , whereas 3 programs would be cost saving ( -$241 to $ 347 per patient ) . If bundled payments were broadened to include care over 180 days , then program saving estimates would increase , ranging from $ 419 to $ 1,706 per patient . CONCLUSIONS Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions Background Heart failure ( HF ) is a chronic condition affecting nearly 5.7 million Americans and is a leading cause of morbidity and mortality . With an aging population , the cost associated with managing HF is expected to more than double from US $ 31 billion in 2012 to US $ 70 billion by 2030 . Readmission rates for HF patients are high—25 % are readmitted at 30 days and nearly 50 % at 6 months . Low medication adherence contributes to poor HF management and higher readmission rates .  Remote telehealth monitoring programs aim ed at improved medication management and adherence may improve HF management and reduce readmissions . Objective The primary goal of this r and omized controlled pilot study is to compare the MedSentry remote medication monitoring system versus usual care in older HF adult patients who recently completed a HF telemonitoring program .  We hypothesized that remote medication monitoring would be associated with fewer unplanned hospitalizations and emergency department ( ED ) visits , increased medication adherence , and improved health-related quality of life ( HRQoL ) compared to usual care . Methods Participants were r and omized to usual care or use of the remote medication monitoring system for 90 days . Twenty-nine participants were enrolled and the final analytic sample consisted of 25 participants . Participants completed question naires at enrollment and closeout to gather data on medication adherence , health status , and HRQoL. Electronic medical records were review ed for data on baseline classification of heart function and the number of unplanned hospitalizations and ED visits during the study period . Results Use of the medication monitoring system was associated with an 80 % reduction in the risk of all-cause hospitalization and a significant decrease in the number of all-cause hospitalization length of stay in the intervention arm compared to usual care . Objective device data indicated high adherence rates ( 95%-99 % ) among intervention group participants despite finding no significant difference in self-reported adherence between study arms . The intervention group had poorer heart function and HRQoL at baseline , and HRQoL declined significantly in the intervention group compared to controls . Conclusions The MedSentry medication monitoring system is a promising technology that merits continued development and evaluation . The MedSentry medication monitoring system may be useful both as a st and alone system for patients with complex medication regimens or used to complement existing HF telemonitoring interventions . We found significant reductions in risk of all-cause hospitalization and the number of all-cause length of stay in the intervention group compared to controls . Although HRQoL deteriorated significantly in the intervention group , this may have been due to the poorer HF-functioning at baseline in the intervention group compared to controls . Telehealth medication adherence technologies , such as the MedSentry medication monitoring system , are a promising method to improve patient self-management , the quality of patient care , and reduce health care utilization and expenditure for patients with HF and other chronic diseases that require complex medication regimens . Trial Registration Clinical Trials.gov NCT01814696 ; https:// clinical trials.gov/ct2/show/ study /NCT01814696 ( Archived by WebCite ® at http://www.webcitation.org/6giqAVhno Background —No treatment strategies have been demonstrated to be beneficial for the population for patients with heart failure ( HF ) and preserved ejection fraction ( EF ) . Methods and Results —The CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients ( CHAMPION ) trial was a prospect i ve , single-blinded , r and omized controlled clinical trial testing the hypothesis that hemodynamically guided HF management decreases decompensation leading to hospitalization . Of the 550 patients enrolled in the study , 119 had left ventricular EF ≥40 % ( average , 50.6 % ) , 430 patients had low left ventricular EF ( < 40 % ; average , 23.3 % ) , and 1 patient had no documented left ventricular EF .  A microelectromechanical system pressure sensor was permanently implanted in all participants during right heart catheterization . After implant , subjects were r and omly assigned in single-blind fashion to a treatment group in whom daily uploaded pressures were used in a treatment strategy for HF management or to a control group in whom st and ard HF management included weight-monitoring , and pressures were uploaded but not available for investigator use . The primary efficacy end point of HF hospitalization rate > 6 months for preserved EF patients was 46 % lower in the treatment group compared with control ( incidence rate ratio , 0.54 ; 95 % confidence interval , 0.38–0.70 ; P<0.0001 ) . After an average of 17.6 months of blinded follow-up , the hospitalization rate was 50 % lower ( incidence rate ratio , 0.50 ; 95 % confidence interval , 0.35–0.70 ; P<0.0001 ) . In response to pulmonary artery pressure information , more changes in diuretic and vasodilator therapies were made in the treatment group . Conclusions —Hemodynamically guided management of patients with HF with preserved EF reduced decompensation leading to hospitalization compared with st and ard HF management strategies . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00531661 Ambulatory care by physicians especially devoted to the management of heart failure ( HF ) has been reported to have beneficial effects . The aim of this work was to assess the effect of outpatient management at a HF clinic , as compared with care by the usual assistant physician , on prognosis of HF patients . In this non-r and omised study , we prospect ively followed 339 patients after a hospitalisation index for HF , in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting : either a specific outpatient clinic ( n=157 ) or the usual assistant physician ( n=182 ) . The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term . The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic ( adjusted odds ratio 0.23 ; 95 % CI 0.12 - 0.46 ) . Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days ( adjusted hazard ratio 0.52 ; 95 % CI 0.34 - 0.81 ) . The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients Meta‐analyses of cell therapy trials for heart disease have yielded discrepant results . To resolve limitations associated with meta‐analyses , such as imprecision and accumulation of r and om errors , we conducted trial sequential analysis ( TSA ) . R and omized controlled trials that administered autologous bone marrow‐derived cells to patients who suffered acute myocardial infa rct ion ( AMI ) or heart failure ( HF ) were included . TSA has been applied to two clinical outcomes , all‐cause mortality and hospitalization for HF , and to left ventricular ejection fraction ( LVEF ) , as a surrogate of heart function . The results suggest that there is evidence of reduction of the risk of mortality and hospitalization in HF , but insufficient evidence to determine treatment effect in AMI . Moreover , the treatment does not improve LVEF by more than a mean difference of 4 % when administered to either AMI or HF patients . The required number of participants to include in a meta‐ analysis to detect treatment effect was also estimated Objective Heart failure ( HF ) is a major health problem result ing in a high financial burden for the healthcare system . Many previous HF management programmes reduced adverse clinical outcomes and costs , but they usually involved several professional figures as well as huge investments , requiring re sources and budgets not often available in our healthcare system . We evaluated the effects of our HF management programme , which included patient education and regular outpatient contact with the HF team , on re-hospitalisation and death , optimising the few re sources already available at our hospital . Methods Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were r and omised to the intervention group ( nurse-led education programme , facilitated telephone communication and follow-up visits with an internist at 15 days , 1 and 6 months ) or to the usual care group ( follow-up by their primary care physician ) . The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period . Results There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group ( P = NS ) . Fourteen patients ( 14 % ) in the intervention group and eight patients ( 8 % ) in the control group died during the study period ( P = NS ) . Unplanned outpatient visits were less frequent in the intervention group than in the control group ( 39 [ 28 % ] versus 99 [ 72 % ] , P < 0.001 ) . Conclusions The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status . More intense follow-up monitoring and more re sources are needed to achieve better results Background : Heart failure ( HF ) is a chronic and costly condition that affects approximately 5.8 million people in the United States , with an additional 670 000 diagnosed yearly . With high 30-day hospital readmission rates , the importance of determining effective means of preventing readmissions is imperative . Despite published guidelines emphasizing the importance of education in preventing readmissions , the most effective means of educating hospitalized patients with HF about their self-care remains unknown . Objective : The aim of this study was to determine if hospitalized HF patients educated with the teach-back method retain self-care educational information and whether it is associated with fewer hospital readmissions . Methods : A prospect i ve cohort study design included 276 patients older than 65 years hospitalized with HF over a 13-month period . Patients were educated and evaluated using the teach-back method as part of usual care . Data on ability to recall educational information while hospitalized and during follow-up approximately 7 days after hospital discharge were collected . Readmissions were confirmed through follow-up telephone calls and review of medical records . Results : Patients correctly answered 3 of 4 , or 75 % , of self-care teach-back questions 84.4 % of the time while hospitalized and 77.1 % of the time during follow-up telephone call . Greater time spent teaching was significantly associated with correctly answered questions ( P < .001 ) . Patients who answered teach-back questions correctly while hospitalized and during follow-up had nonsignificant ( P = .775 and .609 ) reductions in all-cause 30-day hospital readmission rates , but a trend toward significance ( P = .15 ) was found in patients who had readmissions for HF . Conclusions : The teach-back method is an effective method used to educate and assess learning . Patients educated longer retained significantly more information than did patients with briefer teaching . Correctly answered HF-specific teach-back questions were not associated with reductions in 30-day hospital readmission rates . Future studies that include patients r and omized to receive usual care or teach-back education to compare readmissions and knowledge acquisition would provide further comparison of teach-back effectiveness Anemia is common in patients with chronic heart failure ( HF ) , with a prevalence ranging from 10 % to 56 % , and may be a risk factor for poor outcomes . Anemia in HF remains poorly understood , with significant gaps in its impact on health-related quality of life ( HRQoL ) , with most studies in HF being retrospective or from registries . The purpose of this study was to explore the relation of hemoglobin ( Hgb ) with HRQoL and training-induced changes in HRQoL in a cohort of patients in Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training ( HF-ACTION ) . Using data from HF-ACTION , a r and omized controlled trial of exercise training in patients with HF and low left ventricular ejection fractions , HRQoL was measured using the Kansas City Cardiomyopathy Question naire ( KCCQ ) at baseline , 3 and 12 months , and annually up to 4 years . Treatment group effects on HRQoL were estimated using linear mixed models according to the intention-to-treat principle . It was hypothesized that baseline Hgb would be correlated with baseline KCCQ scales and that Hgb would moderate the beneficial effect of exercise training on HRQoL. Hgb level was not significantly correlated with baseline HRQoL. Baseline Hgb did not moderate the beneficial effect of exercise training on KCCQ overall or subscales relative to usual care . In conclusion , in the HF-ACTION cohort , there was no correlation with baseline Hgb and baseline HRQoL as measured by the KCCQ . In addition , the beneficial effects of HRQoL from exercise training were not modulated by baseline Hgb BACKGROUND & AIMS Hypoalbuminemia is common in acute heart failure ( HF ) patients and has been associated with increased hospital mortality and long-term mortality . Undernutrition is a factor causing hypoalbuminemia . The PICNIC study results show that a nutritional intervention in undernourished acute HF patients reduces the risks of all-cause death and of readmission for HF . We aim ed to investigate whether the efficacy of a nutritional intervention is consistent among the subgroups of patients with and without hypoalbuminemia . METHODS In PICNIC study , a total of 120 malnourished hospitalized patients due to acute HF were r and omized to conventional HF treatment or conventional HF treatment combined with an individualized nutritional intervention . The primary endpoint was a composite of all-cause death or readmission for worsening of HF , with a maximum follow-up of 12 months . In this post-hoc sub- analysis we assessed the interaction of the effects of a nutritional intervention among patients with and without hypoalbuminemia . Analysis was by intention to treat . RESULTS 59 ( 49,2 % ) patients demonstrated hypoalbuminemia and 61 ( 50,8 % ) had normalbuminemia  . At 12 months , the number of events for the primary endpoint in the intervention group compared with the control group was consistent among patients with hypoalbuminemia ( 28.6 % intervention vs 61.3 % control , HR 0,35 , 95 % CI 0,15 - 0,81 ) and those without ( 25.8 % intervention vs 60 % control , HR 0,35 , 95 % CI 0,15 - 0,79 ; interaction p = 0,86 ) . CONCLUSION There was no evidence that the relative efficacy of a nutritional intervention in undernourished acute HF patients was different between patients with normalbuminemia and those with hypoalbuminemia
Main Findings : The results indicate that an intervention involving any human factor principles may nearly double an individual ’s probability of not being readmitted .
Principal Conclusions : Interventions with human factor principles reduce readmissions among HF patients .
Background : Human factors play an important role in health-care outcomes of heart failure ( HF ) patients .
A systematic review and meta- analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies .
Purpose : To investigate how the 8 guiding principles of choice , rest , environment , activity , trust , interpersonal relationships , outlook , and nutrition reduce HF readmissions .