evaluation of a community based heart failure programme. authors. anita bell, public health...
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Evaluation of a community based heart failure programme.
Authors.Anita Bell, Public Health PhysicianVeronique Gibbons, Research Fellow in Primary CareGerry Devlin, Consultant CardiologistRaewyn Fisher, Consultant CardiologistKeith Buswell, General PractitionerRoss Lawrenson, Professor in Primary Care
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Background• Heart failure (HF) is a significant
cause of hospitalisation and has a poor prognosis
• There can be differences in utilisation of HF services between urban and rural populations (e.g. Clark, MJA, 2007)
• There are significant difference in investigations and prescribing for cardiovascular disease between urban and rural populations (Fraser, NZ Rural Lit Review, 2009, Gibbons NZMJ 2006)
• Previous NZ research has shown inequalities in HF outcomes for indigenous Māori (Bramley, NZMJ, 2004; Riddell, NZMJ, 2005)
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Aims• To improve jointly with primary and secondary
care, the diagnosis and management of HF in the community
• To improve communication between 1⁰ and 2⁰ care
• To support general practice teams• To reduce admissions or re-admissions for HF
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Participants
• Identified two rural communities with high needs populations – Te Kuiti
• Clients were identified from GP computerised records with a coded diagnosis of heart failure
• All clients were assigned a pathway regarding his or her care
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Participants
• Identified two rural communities with high needs populations – Te Kuiti and Tokoroa
• Clients were identified from GP computerised records with a coded diagnosis of heart failure
• All clients were assigned a pathway regarding his or her care
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Baseline Findings• 404 patients• Age at dx: mean 65.6 yrs
(NZ Euro 69.1,Māori 59.9)• Gender: Male 51%• Ethnicity: NZ European
53%, Māori 31%, Pacific 9.2%
• Smokers: 33% NZ Euro, 54% Māori, 11% Pacific
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Baseline Findings – Symptoms
• 57% SOE on exertion• 20% Orthopnoea• 19% Paroxysmal Nocturnal
Dyspnoea• 31% Peripheral Oedema
(ankles)
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Baseline Findings – Comorbidities
• 38% Diabetes• 67.5% Obesity (BMI >30)• 18% COPD• 12% End Stage Renal
Failure
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Baseline Findings – use of investigations
• 27% BNP• 58% Chest X-ray• 38% ECG• 31% Echo• 26% None identified
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Baseline findings - prescriptions
• 81% Diuretic• 14% Aldosterone antagonist• 67% ACE inhibitor• 52% Beta blocker• 11% Angiotensin Receptor Blocker
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Participants - Clinic
• Prioritisation to HF clinic was based on:– HF history, – Investigations, – Medication – The number of GP and/or
hospital admissions over the previous two years
• 131/404 patients were invited to attend HF clinic (intervention)
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Intervention
• Client seen by Cardiologist or Registrar and HF nurse at clinic
• Clients needing medication titration followed-up by HF nurse in the community
• All clinic clients followed-up by HF nurse by either phone or home visit
• Contact made with GP to inform the outcome of clinic visit before clinic letter arrives (particularly where there are medication changes)
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Evaluating the service
• A formal evaluation of the service was carried out at the end of the first year of the service at both pilot sites
• The evaluation involved quantitative and qualitative aspects in the design
• Quantitative - Baseline data included demographic information, risk factors, investigations and medications
• Qualitative - Key stakeholders were invited to participate in face-to-face interviews; clients and GPs were invited to complete an anonymous survey regarding the service.
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After 12 months• 126/131 had an echo at clinic:
– 57.9% EF >50 (mostly normal)– 20.6% EF 41-50– 21.4% EF <40– 46% had diastolic dysfunction
• 60% of clients required medication altered or started: – 15% had beta blocker altered, – 1 in 5 had ACEI dose altered, – less than 10% had an ARB or angiotensin altered.
• 10% were referred to main hospital for further investigations such as angiography
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Key stakeholder interviewsKey stakeholder interviews
• Related to development, initiation and implementation of the service
• Key areas: Management Administration Clinical structure and process Cardiologist position Communication – Service Communication – Patients Other issues
Google images
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GP surveyGP survey
• 70% response rate• 60% GPs from Te Kuiti and 40% from
Tokoroa• All respondents aware of the service
and 90% had referred into the service• 70% reported a marked improvement
in their clients condition • 90% felt the information regarding
their client had improved• The input of the heart failure
specialist nurse was well received• The positive feedback for the
availability of echocardiography locally was unanimous
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Client Satisfaction Survey
• Sixty percent of clients completed the survey - 44% male, 40% female, 16% blank
• 58% European, 22% Māori, 6% other, 14% blank
• Factors such as the locality of the service, consideration of the staff, cultural and health needs at the clinic all scored highly
• Almost 40% felt their heart failure had improved, 50% felt the same
• 30% reported doing a lot more since attending the service
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Changes observed after service Changes observed after service interventionintervention
Before % After % % Change
Knowledge of medications 74 84 +13.5
Weigh regularly 46 76 +65
Check legs for swelling 70 84 +20
Take note of breathing 60 72 +20
Do none of the above 12 2 -83.3
Know much about heart failure 36 48 + 33
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Added input from the nurseAdded input from the nurse
• Nurse had motivated clients to make lifestyle changes (42%) .
• Approx 50% reported nurse had helped with other problematic health issues
• 90% were happy to have the nurse visit them at home
• Telephone contact was reported as the most common means of communication with the nurse followed by rural hospital follow up visits
• 60% felt attendance at the clinic had been of benefit to their families
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Summary of main outcomesSummary of main outcomes
• The service was acceptable to clients, GPs and secondary care
• The service was successful in achieving all initial indicators
• Self-management improved as a result of the service
• The service worked well to support the management of HF clients in primary care
• Greater access to echo and to a community cardiologist was well received by GPs
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RecommendationsRecommendations
• GP should be encouraged to use BNP as a screening tool to assess in the first instance whether a patient has heart failure.
• Continue to move towards a more nurse-led service especially in the two areas of Te Kuiti and Tokoroa.
• The use of electronic aids should be developed.
• Work should be carried out to look at the need for development of psychosocial input which is recommended for heart failure management and a range of other chronic diseases.