The Management of Patients with Heart Failure - Essay Example

? Defining The Clinical Question Valerie Sanford RN, MSN, CRNP, AACC Duke School of Nursing Dr. Deirdre Thornlow, PhD, RN, CPHQ September 22, 2011 Introduction Heart failure is a chronic condition that affects an estimated 5 million Americans. The one year survival rate has been estimated at 80-90% in patients classified as NYHA class I-II and 50-60% in NYHA class III-IV; which is more than breast cancer, ovarian cancer, and colon cancer. Heart failure is also associated with high morbidity and is the most common discharge diagnosis in patients greater than 65 years of age (Case, Haynes et al. 2010). Many issues surround the management of patients with heart failure that need to be evaluated in order to improve heart failure outcomes. Some studies have shown that education given to patients may be insufficient. Noncompliance with medication, diet, or symptom monitoring caused 15-64% of hospital readmissions. One way to combat these barriers is to design advanced practice nurse led heart failure clinics for outpatient management of heartfailure . Many studies have shown that heart failure clinics designed with advanced practice nurse post hospital follow-up improved patient education and compliance thus decreasing hospital readmissions (Paul 2008). The types of heart failure patient typically followed in advanced practice nurse led clinics are New York Heart Association Classifications II-IV. These patients were classified based on either echocardiography or radiography evidence of pulmonary congestion or signs or symptoms of heart failure. Background Despite advancements in the management of this debilitating condition, such as introduction of beta blockers, aldosterone antagonist, and angiotensin receptor blockers mortality and morbidity among heart failure patients remain high. Generally 25-50% of hospitalized patients will be readmitted within 6 months of discharge (Gustafsson, Schou et al. 2009). The most cited incidents for readmissions are noncompliance with drug therapy, poor compliance with dietary restrictions, fluid restrictions, and inadequate medical therapy (Paul 2008). Thus, it appears that the readmission and mortality rates of heart failure patients maybe the result of less than optimal approach by the patient and provider. In terms of mortality the Framingham Study showed that once patient was diagnosed with heart failure the 6 year mortality was 85% for men and 67% for women . Heart failure puts a significant health and financial burden on patient’s families and society. Estimated cost of heart failure in the US is over $35 million according to the American Heart Association. As we all know the incidence of heart failure increases with age. According to the center for disease control 70% of the people over the age of 60 have heart failure and the number is expected to rise (Ferguson 2008) . For instance in 2000 approximately 12.7% of the American population was 65 years of age or older. It is estimated in 2020 this number will rise to 16.5%. In an effort to reduce 30 day readmissions, mortality, and overall cost a growing number of hospitals and medical groups are forming evidenced based heart failure clinics to combat this epic problem. The population to be evaluated in this project are patient diagnosed with heart failure with either systolic or diastolic impairment that have recently been hospitalized, The purposed intervention is one week follow up post discharge in a nurse practitioner led heart failure clinic. The patients will then be monitored by nurse practitioner and MD . A comparison will then be made to those patients followed by an MD only . The outcome that is proposed is that patients followed in a nurse practitioner and MD collaborative heart failure clinic will have a decrease in 30 day readmission rates to the hospital . Clinical Question Does the addition of a nurse practitioner to a heart failure clinic reduce 30 day readmission rates for heart failure patients? Keywords: A medline search was conducted using the terms “heart failure”, “congestive heart failure”, with one of the following MESH terms “disease management”, “comprehensive healthcare” along with heart failure clinic, cardiomyopathy clinic, and nurse practitioner. This research strategy yielded over 600 articles. LITERATURE SYNTHESIS A study by Stromberg attempts to quantify whether nurse-led education can decrease hospitalization and mortality related to chronic heart failure. There were fewer patients with events (death and admission) after 12 months in the intervention group compared to the control group (29 vs. 40, p=0.03) and fewer after 12 months (7 vs. 20, p=0.05). The intervention group had fewer admissions (33 vs. 56, p=0.047) and days in hospital (350 vs. 592, p=0.045) during the first 3 months. After 12 months, intervention was associated with a 55% decrease in admission/patient/month (0.18 vs. 0.40, p=0.06) and fewer days in the hospital/patient/month (1.2 vs. 3.9, p=0.02). The intervention group had significantly higher self-care scores at 3 and 12 months than the control group (p=0.02 and p=0.01) (Stromberg et al. 2003). Research conducted by Shah and associates investigated 32 patients at risk for, or undergoing HF. Quality and level of treatment for the patients enrolled monitored for 90 days. An Intensity of care was defined dependent on the number of phone calls, visits to the clinic, and diuretic adjustments. Frequency of clinics visits, telephone calls, and diuretic adjustments were used to estimate intensity of care. (RR 1.03, 95%, CI 0.99–1.06, p=0.5) Results indicated that despite attempts to optimize pharmaceutical dosage these patients needed frequent interventions to manage and treat the course of their heart deceives, in order to maintain clinical stability. A direct correlation was found between the degree of renal function after hospitalization, and the intensity of care required as an outpatient. (Shah et al. 2005) A different study by Case et al. reports research in which 6 studies reviewed involved a total of 1,118 patients, who exhibited an above-normal risk factor of hospital readmission and through random study protocols were organized into a control group and an intervention group. Control group patients were given standard care, whereas the intervention group participated in combined multidisciplinary program for Heart Failure management/prevention. The study controlled nurse/patient contact with the intervention group. Medications were adjusted based upon a predetermined test protocol, as patient outcomes over a 6 month period were evaluated with an eye towards hospital readmission or death. Patients were also evaluated for physical and emotional well-being. Final analysis demonstrated that a multidisciplinary approach to heart-failure (HF) management decreased death and readmission rates. Factors complementing the multidisciplinary approach were dietary adherence, precise medication dosage, and general quality of life. (Case et al. 2010) Caldwell and Associates also explored random sampling to investigate clinical conditions, pertaining to patient outcomes. In this case the purpose of assessing an outpatient HF management program. A population of 36 patients was randomly assorted into two groups. Sample was primarily married white men with a mean age of 71 and EF of 47%. The focus was primarily upon outpatient education describing the causes and warning signs of heart failure. The control group received typical standards of care. Understanding of the condition, and in the intervention group at least showed a positive trend. (Caldwell et al. 2005) Fonarow and associates enlisted 214 candidates for heart transplant into a comprehensive HF management initiative. Patients were monitored while under hospitalization, and follow-ups were conducted for up to six months after release from the hospital. The HF management protocol involved a rigorous program of patient education, calibration of medication dosages, typically diuretics and enzyme inhibitor dosages relating to angiotensin. Patient outcomes tended generally to be positive, resulting in an 85% decrease in readmissions to the hospital, and improvement in peak oxygen consumption. There was significant improvement in functional class during the mean follow-up p Read More