- Author
- Shulamit Bernard, Erica Brody, Kathleen Lohr
- Date published
- June 2007
- Pages
- 68
- ISBN
- 0-9548968-7-4
- Download publication [757kb PDF]
Overview
Heart failure represents a serious health system challenge. It accounts for 1 million inpatient days (2 per cent of all National Health Service [NHS] inpatient bed days) and 5 per cent of all emergency medical admissions to hospital (The National Collaborating Centre for Chronic Conditions, 2003). Hospital admissions for heart failure are expected to rise by 50 per cent over the next 25 years largely because of the ageing of the population and the accompanying increase in the underlying causes of heart failure such as coronary heart disease. Patients with heart failure tend to have frequent and prolonged hospital admissions. As a result, caring for these patients is costly, with estimates of the annual cost of heart failure to the NHS ranging from £400m (Cowie, 2002) to £716m (The National Collaborating Centre for Chronic Conditions, 2003), or around 1.8 per cent of the total NHS budget; much of this cost is attributed to the cost of hospitalisation (The National Collaborating Centre for Chronic Conditions, 2003).
The underlying causes of, and effective treatments for, heart failure are well understood. This information has underpinned the development of multiple evidence-based guidelines for the treatment of this serious condition (Hunt, 2005; Arnold et al, 2006; Swedberg et al, 2005). Nevertheless, heart failure continues to cause significant morbidity and mortality, quite apart from substantial direct healthcare spending. The imbalance between knowledge of heart failure treatment and effective delivery of guideline-concordant care suggests what Woolf and Johnson characterise as a lack of ‘fidelity’ in the heart failure care delivered; fidelity in this context refers to ‘the extent to which the system provides patients the precise interventions they need, delivered properly, precisely when they need them’ (Woolf and Johnson, 2005, p 545).
The emphasis of the evidence summarised in this report, therefore, is not effective clinical treatments per se but rather evidence regarding health system delivery modalities related to the care of heart failure patients.
Project overview
What works to improve quality in healthcare is a perennial question. Health services research, clinical medicine and social science literature all contain a huge number of articles that discuss interventions designed to improve quality. The interventions vary widely in terms of design, underlying assumptions and the context in which they have been implemented. However, although the number of publications that discuss quality improvement is unwieldy and ever increasing, the empirical evidence about the effects such interventions have on healthcare processes and outcomes is sparse and difficult to access. The Quality Enhancing Interventions (QEI) project seeks to address these difficulties and is gathering together available evidence on a range of interventions designed to improve quality of care.
The findings will form the basis of a searchable resource that will allow decision-makers to find relevant research evidence on particular interventions to improve quality and the context in which they have been implemented, and to access information on different approaches applied to a particular disease or population group.
Within each of the major themes we are developing subcategories and clusters of specific interventions to build a taxonomy of QEIs.
Clinical care delivery models vary for different diseases. Effective care processes will reflect the predisposing factors, the cause (etiology), course and consequences of a particular disease, as well as available therapy options and their cost. Depending on the nature of the disease, care may be delivered most appropriately in primary or emergency or palliative care settings; it may be focused to different extents on prevention as well as management or cure; it may be characterised by an acute episode or by chronic symptoms. The schematic above shows the main types of healthcare delivery settings (note that they are not mutually exclusive). For each of the clinical conditions we focus on, we will use the schematic shown to indicate the relative concentration of care processes within these settings. Heart failure is considered primarily to be a chronic condition so the bulk of research literature focuses on it. However, chronic care is often delivered in a primary care setting, and acute exacerbations of the disease can occur so we also review approaches to appropriate care delivery in these settings.
Methods
We used a ‘best evidence’ approach to conduct our literature review. We focused primarily on evidence from review articles and guidelines issued by national professional organisations. We conducted electronic searches of MEDLINE®, focusing on articles classified as ‘review’ articles; we included systematic evidence reviews issued by the Cochrane Collaboration. We conducted our searches using a series of steps to identify articles related to the following four main topic areas: heart failure, health systems, healthcare quality and healthcare outcomes. Search strategies are provided in the full report. The review includes research designs ranging from systematic reviews, randomised controlled trials and quasi-experimental studies through to observational studies. Broad inclusion criteria were adopted because of the methodological challenges inherent in assessing organisational and delivery models for chronic illness in general and heart failure in particular.
Findings
This review focused primarily on three areas related to the organisation and delivery of healthcare for patients with heart failure:
- adequate diagnosis so that appropriate treatment can be initiated
- chronic care management
- inpatient treatment for acute exacerbations.
The evidence is summarised in the table below:
| Area of focus | Summary of evidence |
| Adequate diagnosis so that appropriate treatment can be initiated | • Evidence of the effectiveness of open access to echocardiography is limited. • Evidence supports the use of an algorithm for heart failure investigation that uses less expensive tests, such as electrocardiogram and/or blood tests of natriuretic peptides, as a means of triaging patients who need an echocardiogram. |
| Chronic care management | • The extant evidence on the effectiveness of disease management in heart failure programmes is mixed. • The evidence supports multidisciplinary management and multifaceted interventions; however, there is no conclusive evidence about how to organise the delivery of these programmes. • There is some evidence to suggest that, compared with general practitioners (GPs), cardiologists provide care that is more consistent with guidelines and have better patient outcomes. This is particularly the case for the likelihood of patients receiving ACE inhibitors and beta blockers. • Chronic care management activities can be delivered effectively by nurses with advanced training and support and back-up from physicians. • The evidence supports the delivery of chronic care interventions in multiple ways including specialty clinics, home-based interventions and disease management programmes; no one model emerged as superior. • The evidence suggests that chronic care management can be provided in a GP’s office with the support of a nurse specially trained to monitor these patients. • There is some evidence that suggests that telemonitoring may be as effective as, or more effective than, other disease management programmes for decreasing patient risk of hospitalisation and increasing quality of life. Additional research is needed to fully assess the value of telemonitoring for improving patient outcomes |
| Inpatient treatment for acute exacerbations | • Evidence supports transitional care, begun during the hospital stay and continuing into the community, delivered by an advanced practice nurse; it can reduce length of hospital stay and risk of readmission. • The evidence supports starting care management strategies during the inpatient hospital stay to lower the risk of readmission. |
