Controlled Trial of Integrated Heart Failure Managemen - Essay Example

The program utilized different designs: (1) a clinical review on the patient at a hospital-based heart failure clinic early after hospitalization, focusing on aggravating yet still curable factors and the currently administered pharmacological treatment (2) a 1.5 to 2- hour individual and group education sessions with the cardiologist and the study nurse making the patients understand the “symptoms and signs of heart failure, the importance of monitoring of daily body weight and action plans should weight change, effects of medications and importance of compliance and recommendations regarding exercise and diet” (p. 140); (3) a patient’s personal diary to record medication, daily body weight, clinical notes, and appointments; (4) provision of information booklets to further educate patients, and (5) a follow-up plan requiring patients to alternately visit the general practitioner (GP) and heart failure clinic, aside from the time they find it deem necessary.

The trial designed as “a cluster-randomized, controlled trial of integrated primary/secondary cared compared with usual care for patients with heart failure” (p. 139), was participated in by 197 heart failure patients admitted at the Auckland Hospital. These patients eligible at a set minimum exclusion criteria were randomly assigned to either the intervention group (IG) (100 patients/64 GPs) – recipient of the designed integrated heart failure management program – or the control group (CG) (97 patients/68 GPs) – recipient of the usual care for heart failure patients. In grouping the patients, the GP was used as the unit of randomization to ensure non-contamination on the management of the control group.

Due to the study team’s unawareness of the medical management of the patients during hospitalization, the study started ahead of the actual intervention. Data were gathered at two end-points: (1) primary end-points – “combined end-point of death or hospital readmission (time to the first event) and quality of life questionnaire” (p. 140), and (2) secondary endpoints – “all-cause hospital readmissions, all-cause hospital bed days, and readmissions for worsening heart failure” (p. 141). Data were analyzed first, with the individual as the unit of randomization, and second, with the GP as the unit of randomization.

Results of the study reveal two main beneficial effects of the program: (1) improved quality of life, specifically physical functioning, and (2) reduced total hospital readmission (mainly, the prevention of multiple readmissions [56 IG vs 95 CG, 2P=0.015], fewer readmission for heart failure [15 IG vs 42 CG, 2P=0.036], and reduced total bed days [528 IG vs 726 CG, 2P=0·0001]). Whereas these overall effects rate fairly small, these stand reliable and generalizable to similar healthcare settings. Which among the different designs of the program had actually produced the positive effects noted remains indeterminate and calls for further study.

Although the common presence in all the trials of the heart failure nurse practitioner appears to be vital. Nevertheless, this multi-design integrated heart failure management program as tested in a hospital setting proved potential to improve the quality of life of heart failure patients that consequentially could lessen the public health burden of this deadly disease. However, the uncertainty as to which of the design actually effected beneficial results plus the relative smallness of gathered data obviously requires further development of the program. Read More