Study sees intriguing CHF findings Down Under
One intervention showed benefits 18 months later
Researchers in Australia report in the Archives of Internal Medicine when CHF patients received one home care intervention a week after they were discharged from the hospital, the benefits could be seen 18 months later.
Simon Stewart, BA, BN; David Horowitz, MBBS, PhD; and the rest of their research team from the cardiology unit at Queen Elizabeth hospital in Woodville, South Australia, compared two groups of about 50 CHF patients. One group was randomized to usual care, and the other received a home care intervention by a nurse and a pharmacist a week after getting out of the hospital.
In the 18 months following the hospitalization, the intervention group had nearly half the number of unplanned readmissions (64 vs. 125) and a fourth of the out-of-hospital deaths (two vs. nine). Among patients who were admitted to the hospital again, patients who received the home visit had shorter stays and had fewer readmissions. The intervention group also had half the hospital costs as the patients who went the usual route.
The patients in the control group (who received usual care) were reviewed by their regular physician post-discharge and received a planned hospital outpatient review by a cardiologist within four weeks of discharge.
The authors wrote that getting family members to step up their supervision of the patient at home, improving compliance, teaching about the goals of treatment, and getting better use out of available medical care may help account for the differences in outcome of the two groups. But what exactly the visiting practitioners did to get the results "is unlikely to be elucidated."
"We cannot dissect out mechanisms of benefit easily, but suspect that improved patient understanding and compliance are critical factors, as is appreciation of any early clinical deterioration post-discharge," Horowitz says, responding to questions from CHF Disease Management by e-mail. "Obviously, old age, decreased mentation, and infirmity, as well as polypharmacy and poor understanding may all be relevant here."
Patients in both groups are described as receiving proper pharmacotherapy of diuretics, digoxin, and ACE inhibitors and presented these symptoms of CHF:
• left ventricular ejection fraction of 55% or lower;
• NYHA Class II, III or IV status;
• a history of at least one admission for acute heart failure.
The goals of the single intervention were:
• Optimize medication management.
• Identify early clinical deterioration.
• Intensify medical follow-up and caregiver vigilance where appropriate.
The report notes that almost all of the visited patients showed they didn’t know enough about why they were taking the medications, as well as what the desired and undesired effects were. About half of the patients were not complying with their medication regimen. At the time of the visit, a third of the patients were referred to their primary care physician because they seemed to be deteriorating or having adverse effects to their medication.
Horowitz notes the study group was not limited to one visit because of cost constraints. But they were conscious of cost-effectiveness considerations to make it easier to implement if the practice is accepted in the future. (A study intervention costs $190 Australian, or about $295 U.S.)
The nurses who participated in the intervention were experienced in cardiac patient management, such as those who had an extensive coronary care unit background.
Unlike the recent study from the University of Pennsylvania, there was no interaction between the intervention staff and the patients when they were still in the hospital before discharge. (See cover story for more on Mary D. Naylor’s study at the University of Pennsylvania.)
In terms of the mental status of patients, Horowitz says "cognition was not necessarily normal, but patients were discharged home rather than to a nursing home, etc."
In the study, the authors listed three ways to refine the intervention:
• Provide specific education materials about diet, fluid management, and exercise for CHF patients.
• Identify which patients showed the highest potential to suffer recurrent admissions.
• Offer repeated visits to patients who had recurrent admissions despite having had the initial intervention.
Horowitz says work is continuing. "The hospital has no formal ongoing support program. But we will shortly be presenting the results of a larger and more detailed study performed by Simon Stewart."
Suggested readings
1. Archives of Internal Medicine 1999; 159:256-261
2. Rich MW, et al. Effect of a multi-disciplinary intervention on medication compliance with CHF. Am J Med 1996; 101:270-276.
3. Alessi C, et al. The process of care in preventive in-home comprehensive geriatric assessment. J Am Geriatr Soc 1997; 45:1,044-1,050.
4. Stewart S, et al. Effects of a home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc 1998; 46:174-180.
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