A telephone-delivered empowerment intervention with patients diagnosed with heart failure. The effectiveness of telephone‐based post‐discharge nursing care in decreasing readmission rate in patients with heart failure: a systematic review Heart Failure 2012 The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Effectiveness of implementation strategies in improving physician adherence to guideline recommendations in heart failure: a systematic review protocol Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial. Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study. Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Outcomes of chronic heart failure. Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure. Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics) Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. Do heart failure disease management programs make financial sense under a bundled payment system? A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study Wireless Pulmonary Artery Pressure Monitoring Guides Management to Reduce Decompensation in Heart Failure With Preserved Ejection Fraction Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care. Cell therapy for heart disease: Trial sequential analyses of two Cochrane reviews Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme Is “Teach-Back” Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Hemoglobin, exercise training, and health status in patients with chronic heart failure (from the HF-ACTION randomized controlled trial). Nutritional intervention in acute heart failure patients with undernutrition and normalbuminemia: A subgroup analysis of PICNIC study. Application of implantable hemodynamic monitoring in the management of patients with diastolic heart failure: a subgroup analysis of the COMPASS-HF trial. N-terminal pro-B-type natriuretic peptide-guided, intensive patient management in addition to multidisciplinary care in chronic heart failure a 3-arm, prospective, randomized pilot study. Randomized trial of Telemonitoring to Improve Heart Failure Outcomes (Tele-HF): study design. Unrecognized Cognitive Impairment and Its Effect on Heart Failure Readmissions of Elderly Adults. Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial Design and methods of the Pro-B Type Natriuretic Peptide Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study. Tailored Telemonitoring in patients with heart failure: results from a multicentre randomized controlled trial (the TEHAF-study) The effect of a tailored message intervention on heart failure readmission rates, quality of life, and benefit and barrier beliefs in persons with heart failure. Gout, allopurinol use, and heart failure outcomes. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. CHAMPION trial rationale and design: the long-term safety and clinical efficacy of a wireless pulmonary artery pressure monitoring system. Pulmonary artery pressure‐guided heart failure management: US cost‐effectiveness analyses using the results of the CHAMPION clinical trial Quality of life and chronic heart failure therapy guided by natriuretic peptides: results from the ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) study. N-terminal pro brain natriuretic peptide-guided management in patients with heart failure and preserved ejection fraction: findings from the Trial of Intensified versus standard medical therapy in elderly patients with congestive heart failure (TIME-CHF). Joint Commission requirements for discharge instructions in patients with heart failure: is understanding important for preventing readmissions? Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care? Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction: results from Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) program. Effect of Patient Activation on Self-Management in Patients With Heart Failure Health-related quality of life as a predictor of hospital readmission and death among patients with heart failure. Patient-centered disease management (PCDM) for heart failure: study protocol for a randomised controlled trial Pilot Testing of a Multicomponent Home Care Intervention for Older Adults With Heart Failure: An Academic Clinical Partnership Education by a dietitian in patients with heart failure results in improved adherence with a sodium-restricted diet: a randomized trial. Effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the PATCH randomized controlled trial Swiss Interdisciplinary Management Programme for Heart Failure (SWIM-HF): a randomised controlled trial study of an outpatient inter-professional management programme for heart failure patients in Switzerland. Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study. Association of Discharge Summary Quality With Readmission Risk for Patients Hospitalized With Heart Failure Exacerbation Cognitive impairment and self-care in heart failure Rationale and design of the GUIDE-IT study: Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure. PROspective MEmory Training to improve HEart failUre Self-care (PROMETHEUS): study protocol for a randomised controlled trial Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB‐HF) trial: Design and rationale Tele-guidance of chronic heart failure patients enhances knowledge about the disease. A multi-centre, randomised controlled study. Rationale and design of PRIMA II: A multicenter, randomized clinical trial to study the impact of in-hospital guidance for acute decompensated heart failure treatment by a predefined NT-PRoBNP target on the reduction of readmIssion and Mortality rAtes. Heart failure symptom monitoring and response training. Use of Remote Monitoring to Improve Outcomes in Patients with Heart Failure: A Pilot Trial Heart failure management: multidisciplinary care has intrinsic benefit above the optimization of medical care. Clinical Effectiveness, Access to, and Satisfaction with Care Using a Telehomecare Substitution Intervention: A Randomized Controlled Trial Reduced in-hospital mortality for heart failure with clinical pathways: the results of a cluster randomised controlled trial Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT-proBNP Guided Management of Heart Failure--SIGNAL-HF (Swedish Intervention study--Guidelines and NT-proBNP AnaLysis in Heart Failure). A new programme of multidisciplinary care for patients with heart failure in Poznań: one-year follow-up. A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure Effectiveness of an interactive platform, and the ESC/HFA heartfailurematters.org website in patients with heart failure: design of the multicentre randomized e-Vita heart failure trial. A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial Long-Term Results of Intensified, N-Terminal-Pro-B-Type Natriuretic Peptide–Guided Versus Symptom-Guided Treatment in Elderly Patients With Heart Failure: Five-Year Follow-Up From TIME-CHF Increasing exercise capacity and quality of life of patients with heart failure through Wii gaming: the rationale, design and methodology of the HF‐Wii study; a multicentre randomized controlled trial Just-in-time evidence-based e-mail "reminders" in home health care: impact on patient outcomes. Heart failure--related mortality and hospitalization in the year following admission to a long-term care facility: the geriatric outcomes and longitudinal decline in heart failure (GOLD-HF) study. Optimising self-care support for people with heart failure and their caregivers: development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping Low Literacy Is Associated with Increased Risk of Hospitalization and Death Among Individuals with Heart Failure Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Patient-centred home-based management of heart failure Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study
BACKGROUND Heart failure ( HF ) is a major public health problem . Case management by nurses using telephone follow-up has been suggested as a convenient and effective mechanism to promote the self-management of HF . Similarly , a patient empowerment approach to the management of chronic disease has been suggested as one that may nurture self-management in individuals with chronic illness . OBJECTIVE The purpose of this study was to examine the effects of a telephone-delivered empowerment intervention ( EI ) on clinical ly and theoretically relevant outcomes in patients with HF , including purpose ful participation in goal attainment , self-management of HF , and perception of functional health . The EI was guided by Rogers ' Science of Unitary Human Beings person-environment process . METHODS A convenience sample of men and women aged 21 years and older with a clinical diagnosis of HF was obtained from a metropolitan hospital located in the southwestern United States . The participants were r and omly assigned to the control group ( n = 45 ) or EI group ( n = 45 ) . All participants received st and ardized HF patient education ; the intervention group also received an EI delivered through telephone follow-up calls from a registered nurse . Repeated- measures analysis of variance was used to evaluate intervention effects . RESULTS The telephone-delivered EI  facilitated self-management of HF through self-care activities in EI group members . CONCLUSION The knowledge gained from this study provides a beginning underst and ing of strategies to enhance health care providers ' ability to facilitate self-management of HF among patients diagnosed with HF Background The importance of comprehensive discharge planning plus post discharge support intervention studies have been advocated for patients with heart failure .  Telephone‐based post‐discharge nursing care was reported as a significant nursing care approach that is believed to promote continuity of care . However , there is a lack of systematic ally examined evidence to support the effectiveness of nurse‐led telephone‐based post‐discharge care for the heart failure patients . Objective The purpose of this study was to examine the best available evidence to determine the effectiveness of telephone‐based post‐discharge nursing care of patient with HF and to quantify the effect on all‐cause readmission rates of these patients . Search strategy A thorough search of published and unpublished literature was conducted from 1990 to 2009 . First , computer data bases such as CINAHL , MEDLINE , COCHRANE EMBASE , and Dissertation Abstract s International were included and then , reference search was conducted with relevant studies . Initial keywords were “ readmission , ” “ heart failure , ” “ * tele * ” , “ nurs * , “ post‐discharge ” , telephone‐based . ” Selection criteria R and omized controlled trial studies using the telephone‐based post‐discharge nursing care was selected . Outcome was defined as frequency of unplanned HF symptoms associated all‐cause hospital readmission rate during the 6 months after discharge . Data collection and analysis Included studies were critically evaluated for method ological quality by independent two review ers . Data were extracted and then analyzed using the JBI‐MASTARI and the RevMan 5 program . Main results A total of 10 r and omized controlled trial studies were included for this study . The study result showed that telephone‐based post‐discharge nursing care was a significant intervention especially decreasing hospital readmission rate among HF patients . Conclusion The findings of this review suggest a positive effect of telephone‐based post‐discharge nursing care and that it is an effective intervention in decreasing readmission rate among HF patients . Implication s for practice / research The results of this systematic review indicate the need for well design ed studies that examine other aspects of post‐discharge nursing telephone interventions to decrease hospital readmission rate among HF patients including : cost‐effectiveness , feasibility and appropriateness Heart failure has been named “ the growing epidemic . ” Over the last decade , the annual number of heart failure hospitalizations has almost doubled with approximately 50 % of patients being rehospitalized within 6 months of discharge [ 1 ] . The complex array of physiologic , psychological , social , and health care delivery issues makes it a challenging chronic disease to manage . Underst and ing the epidemiology and pathophysiology of the syndrome , identifying the predictors and their strength of association with outcomes , and using the available diagnostic modalities cost-effectively are essential in order to devise effective prevention interventions and implement novel therapeutic approaches to curb this epidemic . In this special issue , we have invited a few papers that address such issues and explain why despite the emergence of novel therapeutic approaches , that promise life prolongation and hospital length reduction , this patient population will still be needing rehospitalization and will often have a poor prognosis . This special issue is the extension of an effort that was initiated in 2011 with the first heart-failure-focused issue [ 2 ] . In the pathophysiology section , S. M. R. Kazemi-Bajestani et al. describe the opportunities and challenges of targeting the angiotensin converting enzyme 2 (ACE2)/Ang II/Ang1–7 and apelin/APJ pathways as novel therapeutic modalities in heart failure [ 3 ] . ACE2 and the apelin/APJ are two important peptide systems which exert diverse effects on the cardiovascular system . Dysregulation of such systems may be involved in the predisposition to cardiovascular diseases whereas enhancing their action may have important therapeutic effects . In the same section , D. Lindner et al. provide a comprehensive review on the protective function of signal transducer and activator of transcription 3 ( STAT3 ) in CVB3-induced myocarditis [ 4 ] . The transcription factor ( STAT3 ) is an important mediator of the inflammatory process , and in this original research the investigators examine the role of STAT3 in viral myocarditis and its possible role in the development to dilated cardiomyopathy . Considering the high mortality rate and the availability of life-saving therapies like transplantation and left ventricular assist devices , accurate prognosis determination in HF is clinical ly important . Taking into account the mediocre performance of current established prediction models , such as the Seattle Heart Failure Model [ 5–7 ] , the work by H. Fukuta et al. [ 8 ] on the prognostic value of left ventricular diastolic dysfunction in patients undergoing cardiac catheterization for coronary artery disease sheds light on this extremely important topic . A shared underst and ing of medical conditions between patients and their health care providers has been shown to improve self-care and outcomes [ 9 ] . In the comorbidity section , we demonstrate how certain comorbid conditions may affect patients ' decision-making capacity and interfere with their ability to comply with treatment requirements , recognize and self-manage disease worsening symptoms . Among others , cognitive impairment is increasingly recognized as a common adverse consequence of HF , whereby phenomena such as microembolism , chronic or intermittent cerebral hypoperfusion , and /or impaired cerebral vessel reactivity may lead to cerebral hypoxia and ischemic brain damage . Cognitive decline in HF is characterized by deficits in one or more cognition domains , including attention , memory , executive function , and psychomotor speed . E. Dardiotis et al. [ 10 ] , in a comprehensive review , underscore the importance for healthcare professionals to become familiar with assessment of cognitive performance using st and ardized screening instruments in their routine evaluations of HF patients . Another comorbidity gaining increasing attention in HF patients is depression . There are several pathophysiological mechanisms as well as behavioral processes linking depression and HF . Equally important is screening for depression and there are several valid and reliable screening tools to identify patients at greater risk . Consultation should be provided by a multidisciplinary team , consisting of cardiologists , psychiatrists , and hospital or community nurses so as to carefully plan , execute , and evaluate medical intervention and implement lifestyle changes . D. Mastrogiannis et al. [ 11 ] systematic ally review the existing knowledge regarding current definitions , prognostic implication s , pathophysiological mechanisms , and current and future treatment options in patients with depression and HF . Evidence from the literature supports the possibility of a pathophysiological relationship between cognitive impairment , depression , and HF . Yet , very few studies have sought to investigate this relationship . The paper by Z. N. Sohani and Z. Samaan review s current literature on the association between depression and cognitive impairment  in persons with HF and explores possible mechanisms explaining this complex triad [ 12 ] . Heart failure through neurohumoral activation induces alterations of cardiac metabolism , such as insulin resistance , and promotes increased utilization of noncarbohydrate substrates for energy production [ 13 , 14 ] . Fasting blood ketone bodies as well as fat oxidation have been shown to be increased in this patient population . The result is depletion of myocardial ATP , phosphocreatine , and creatine kinase , leading to decreased efficiency of mechanical work . A direct approach to manipulate cardiac energy metabolism consists in modifying substrate utilization by the failing heart . Trimetazidine , perhexiline , and ranolazine directly inhibit fatty acid oxidation and have been used to increase the ischemic threshold in patients with effort angina . Current research is supporting the concept that shifting the energy substrate preference away from fatty acid metabolism and toward glucose metabolism could be an effective adjunctive treatment in patients with HF . These agents have been shown to improve both glucose metabolism and left ventricular function in diabetic patients with left ventricular dysfunction . In the pharmacotherapy section , we provide a systematic review , in which N. Signoretta et al. [ 15 ] discuss the beneficial therapeutic effects of modulation of cardiac metabolic substrates utilization in patients with HF . In the advanced heart failure section , we provide a thorough review on the current status of mechanical circulatory support in patients with advanced HF . Management of the advanced HF patients with the numerous comorbidities [ 16 , 17 ] requires a significant amount of health care re sources and is becoming a major public health problem . As therapeutical strategies for HF have been refined , the number of patients suffering from the end-stage disease has exp and ed dramatically . Although heart transplantation still represents the gold st and ard therapeutical approach , the shortage of donors universally has made the implantation of mechanical circulatory support devices a well-established management for this disease . The systematic review by K. Spiliopoulos et al. [ 18 ] , outlines the current status of mechanical circulatory support in this patient population . In the chronic follow-up section , we deal with telemonitoring , a novel diagnostic modality that has been suggested to be beneficial for HF patients , targeting optimization of their chronic followup . Telemonitoring is viewed as a means of recording physiological data ( such as body weight , heart rate , arterial blood pressure electrocardiogram recordings , and other data ) by portable devices and transmitting these data remotely ( via a telephone line , a mobile phone , or a computer ) to a server where they can be stored , review ed , and analyzed by the research team . In a systematic review of all r and omized clinical trials evaluating telemonitoring in chronic HF , G. Giamouzis et al. [ 19 ] assess whether telemonitoring provides any substantial benefit in this patient population . We hope that the readers of the journal will find the topics as interesting and important as we did . Gregory Giamouzis George Giannakoulas Javed Butler John A. Elefteriades Carsten Tschope Filippos OBJECTIVE The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life ( QoL ) , readmission rates and healthcare costs for adults with heart failure ( HF ) living independently in the community . METHOD A systematic review of r and omised control trials was undertaken . Using the search terms nurse , education , heart failure , hospitalisation , readmission , rehospitalisation , economic burden , cost , expenditure and quality of life in PubMed , CINAHL and Google Scholar data bases were search ed . Papers pertaining to  nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were review ed . RESULT The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions , reduction in hospitalisation and a cost benefit . Additionally , higher functioning and improved QoL were also identified . CONCLUSION These results suggest that nurse-led patient education for adults with HF  improves QoL and reduces hospital admissions and readmissions . PRACTICE IMPLICATION S Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation Introduction The uptake of Clinical Practice Guideline ( CPG ) recommendations that improve outcomes in heart failure ( HF ) remains suboptimal . We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations , those with clear evidence that benefits outweigh the risks . We will use American , Canadian and European HF guidelines as our reference . Methods and analysis We will conduct a literature search in the data bases of MEDLINE , EMBASE , HEALTHSTAR , CINAHL , Cochrane Library , Campbell Collaboration , Joanna Briggs Institute Evidence Based Practice , Centre for Review s and Dissemination and Evidence Based Practice Centres . We will include prospect i ve studies evaluating implementation interventions aim ed at improving uptake of class I CPG recommendations in HF . We will extract data in duplicate . We will classify interventions according to their level of application ( ie , provider , organisation , systems level ) and common underlying characteristics ( eg , education , decision-support , financial incentives ) using the Cochrane Effective Practice and Organisation of Care Taxonomy . We will assess the impact of the intervention on adherence to the CPGs . Outcomes will include proportion of eligible patients who were : prescribed a CPG-recommended pharmacological treatment ; referred for device consideration ; provided self-care education at discharge ; and provided left ventricular function assessment . We will include clinical outcomes such as hospitalisations , readmissions and mortality , if data is available . We will identify the common elements of successful and failing interventions , and examine the context in which they were applied , using the Process Re design context ual framework . We will synthesis e the results narratively and , if appropriate , will pool results for meta- analysis . Discussion and dissemination In this review , we will assess the impact of implementation strategies and context ual factors on physician adherence to HF CPGs . We will explore why some interventions may succeed in one setting and fail in another . We will disseminate our findings through briefing reports , publications and presentations . Trial registration number CRD42015017155 IMPORTANCE It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure ( HF ) after hospitalization . OBJECTIVE To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF . DESIGN , SETTING , AND PARTICIPANTS We r and omized 1437 patients hospitalized for HF between October 12 , 2011 , and September 30 , 2013 , to the intervention arm ( 715 patients ) or to the usual care arm ( 722 patients ) of the Better Effectiveness After Transition-Heart Failure ( BEAT-HF ) study and observed them for 180 days . The date s of our study analysis were March 30 , 2014 , to October 1 , 2015 . The setting was 6 academic medical centers in California . Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF . INTERVENTIONS The intervention combined health coaching telephone calls and telemonitoring . Telemonitoring used electronic equipment that collected daily information about blood pressure , heart rate , symptoms , and weight . Central ized registered nurses conducted telemonitoring review s , protocol ized actions , and telephone calls . MAIN OUTCOMES AND MEASURES The primary outcome was readmission for any cause within 180 days after discharge . Secondary outcomes were all-cause readmission within 30 days , all-cause mortality at 30 and 180 days , and quality of life at 30 and 180 days . RESULTS Among 1437 participants , the median age was 73 years . Overall , 46.2 % ( 664 of 1437 ) were female , and 22.0 % ( 316 of 1437 ) were African American . The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge , which occurred in 50.8 % ( 363 of 715 ) and 49.2 % ( 355 of 722 ) of patients , respectively ( adjusted hazard ratio , 1.03 ; 95 % CI , 0.88 - 1.20 ; P = .74 ) . In secondary analyses , there were no significant differences in 30-day readmission or 180-day mortality , but there was a significant difference in 180-day quality of life between the intervention and usual care groups . No adverse events were reported . CONCLUSIONS AND RELEVANCE Among patients hospitalized for HF , combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01360203 OBJECTIVES The purpose of this study was to determine whether a heart failure ( HF ) management strategy using continuous intracardiac pressure monitoring could decrease HF morbidity . BACKGROUND Patients with HF may experience frequent decompensations that require hospitalization despite intensive treatment and follow-up . METHODS The COMPASS-HF ( Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure ) study was a prospect i ve , multicenter , r and omized , single-blind , parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who received an implantable continuous hemodynamic monitor . Patients were r and omized to a Chronicle ( Medtronic Inc. , Minneapolis , Minnesota ) ( n = 134 ) or control ( n = 140 ) group . All patients received optimal medical therapy , but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group . Primary end points included freedom from system-related complications , freedom from pressure-sensor failure , and reduction in the rate of HF-related events ( hospitalizations and emergency or urgent care visits requiring intravenous therapy ) . RESULTS The 2 safety end points were met with no pressure-sensor failures and system-related complications in only 8 % of the 277 patients who underwent implantation ( all but 4 complications were successfully resolved ) . The primary efficacy end point was not met because the Chronicle group had a nonsignificant 21 % lower rate of all HF-related events compared with the control group ( p = 0.33 ) . A retrospective analysis of the time to first HF hospitalization showed a 36 % reduction ( p = 0.03 ) in the relative risk of a HF-related hospitalization in the Chronicle group . CONCLUSIONS The implantable continuous hemodynamic monitor-guided care did not significantly reduce total HF-related events compared with optimal medical management . Additional trials will be necessary to establish the clinical benefit of implantable continuous hemodynamic monitor-guided care in patients with advanced HF The aim of this study was to investigate whether , in a r and omized controlled trial ( RCT ) of vulnerable elders with heart failure ( HF ) , advanced practice nurses ( APNs ) who were coordinating care in the transition from hospital to home could improve outcomes , prevent rehospitalizations , and reduce costs when compared with usual care . The APN strategies focused on improving patient and family or caregiver effectiveness in managing their illnesses , strengthening the patient-provider relationship , and managing comorbid conditions while improving overall health . The results were positive . By capitalizing on the patient 's desire to achieve their identified goals , APNs successfully educated patients about the meaning of their symptoms and appropriate self-management strategies ; improved patient-provider communication patterns ; and marshaled caregiver and community re sources to maximize patient adherence to the treatment plan and overall quality of life . While HF was the primary reason for enrollment in the study , optimal health outcomes dem and ed a strong focus on integrating management of comorbid conditions and other long-st and ing health problems . Specific strategies used by the APN to achieve these positive outcomes are addressed in this report . These strategies are compared with nursing interventions used in other RCTs of HF home management . Directions for future research are explored BACKGROUND Outcomes related to chronic heart failure ( HF ) remain relatively poor , despite advances in pharmacological therapy and medical and nursing care . Experts agree that outpatient care may be among the factors that affect HF outcomes . We hypothesized that the method by which outpatient care is delivered may affect outcomes in this patient population . METHODS A prospect i ve , r and omized design was used to compare HF outcomes from 216 patients r and omized to 1 of 2 home health care delivery methods for 3 months after discharge . Care was delivered by the home nurse visit ( HNV ) or the nurse telemanagement ( NTM ) method . In the latter , patients used transtelephonic home monitoring devices to measure their weight , blood pressure , heart rate , and oxygen saturation . These data were transmitted daily to a secure Internet site . An advanced- practice nurse worked collaboratively with a cardiologist and subsequently treated patients via the telephone . Both delivery methods used the same HF-specific clinical guidelines to direct care . Outcomes include HF readmissions and length of stay , anxiety , depression , self-efficacy , and quality of life . Data were primarily tested using a 2-group analysis of variance ( ANOVA ) . We used a repeated- measures ANOVA to conduct preintervention-postintervention analyses . RESULTS After 3 months , patients in the  NTM group ( n = 108 ; mean + /- SD age , 62.9 + /- 13.2 years ; 83 % African American ; 64 % female ) had fewer HF readmissions ( 13 vs 24 ; P</=.001 ) with shorter lengths of stay ( 49.5 vs 105.0 days ; P</=.001 ) compared with the HNV group ( n = 108 ; mean + /- SD age , 63.2 + /- 12.6 years ; 89 % African American ; 62 % female ) . Hospitalization charges at 3 months were less in the NTM group compared with the HNV group ( $ 65 023 vs $ 177 365 ; P</=.02 ) . At 6 and 12 months , cumulative readmission charges in the NTM group were also less ( $ 223 638 vs $ 500 343 [ P<.03 ] and $ 541 378 vs $ 677 710 [ P</=.16 ] , respectively ) compared with the HNV group . Quality of life was significantly improved for both groups when we compared postintervention and preintervention scores . CONCLUSION The adaptation of state-of-the-art computerized technology to closely monitor patients with HF with advanced- practice nurse care under the guidance of a cardiologist significantly improves HF management while reducing the cost of care BACKGROUND Disease management is effective in the general population , but it has not been tested prospect ively in a sample of solely Hispanics with heart failure ( HF ) . We tested the effectiveness of telephone case management in decreasing hospitalizations and improving health-related quality of life ( HRQL ) and depression in Hispanics of Mexican origin with HF . METHODS AND RESULTS Hospitalized Hispanics with chronic HF ( n = 134 ) were enrolled and r and omized to intervention ( n = 69 ) or usual care ( n = 65 ) . The sample was elderly ( 72 + /- 11 years ) , New York Heart Association class III/IV ( 81.3 % ) , and poorly educated ( 78.4 % less than high school education ) . Most ( 55 % ) were unacculturated into US society . Bilingual/bicultural Mexican-American registered nurses provided 6 months of st and ardized telephone case management . Data on hospitalizations were collected from automated systems at 1 , 3 , and 6 months after the index hospital discharge . Health-related quality of life and depression were measured by self-report at enrollment , 3 , and 6 months . Intention to treat analysis was used . No significant group differences were found in HF hospitalizations , the primary outcome variable ( usual care : 0.49 + /- 0.81 [ CI 0.25 - 0.73 ] ; intervention : 0.55 + /- 1.1 [ CI 0.32 - 0.78 ] at 6 months ) . No significant group differences were found in HF readmission rate , HF days in the hospital , HF cost of care , all-cause hospitalizations or cost , mortality , HRQL , or depression . CONCLUSION These results have important implication s because of the current widespread enthusiasm for disease management . Although disease management is effective in the mainstream HF patient population , in Hispanics this ill , elderly , and poorly educated , a different approach may be needed BACKGROUND While there are data to support the use of comprehensive non-pharmacological intervention programs in patients with heart failure ( HF ) , other studies have not confirmed these positive findings . Substantial differences in the type and intensity of disease management programs make it impossible to draw definitive conclusions about the effectiveness , optimal timing and frequency of interventions . AIMS 1 . To determine the effectiveness of two interventions ( basic support vs. intensive support ) compared to ' care as usual ' in HF patients , on time to first major event ( HF readmission or death ) , quality of life and costs . 2 . To investigate the role of underlying mechanisms ( knowledge , beliefs , self-care behaviour , compliance ) on the effectiveness of the two interventions . METHODS This is a r and omised controlled trial in which 1050 patients with heart failure will be r and omised into three treatment arms : care as usual , basic education and support or intensive education and support . Outcomes of this study are ; time to first major event ( HF hospitalisation or death ) , quality of life ( Minnesota Living with HF Question naire , R AND 36 and Ladder of Life ) and costs . Data will be collected during initial admission and then 1 , 6 , 12 , and 18 months after discharge . In addition , data on knowledge , beliefs , self-care behaviour and compliance will be collected . RESULTS The study started in January 2002 and results are expected at the end of 2005 . CONCLUSIONS This study will help health care providers in future to make rational and informed choices about which components of a HF management program should be exp and ed and which components can possibly be deleted Background Disease management programmes ( DMPs ) have been shown to reduce hospital readmissions and mortality in adults with heart failure ( HF ) , but their effectiveness in elderly patients or in those with major comorbidity is unknown . The Multicenter R and omised Trial of a Heart Failure Management Programme among Geriatric Patients ( HF-Geriatrics ) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity . Methods / Design Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain . Each patient should meet at least one of the following comorbidty criteria : Charlson index ≥ 3 , dependence in ≥ 2 activities of daily living , treatment with ≥ 5 drugs , active treatment for ≥ 3 diseases , recent emergency hospitalization , severe visual or hearing loss , cognitive impairment , Parkinson 's disease , diabetes mellitus , chronic obstructive pulmonary disease ( COPD ) , anaemia , or constitutional syndrome . Half of the patients will be r and omly assigned to a 1-year DMP led by a case manager and the other half to usual care . The DMP consists of an educational programme for patients and caregivers on the management of HF , COPD ( knowledge of the disease , smoking cessation , immunizations , use of inhaled medication , recognition of exacerbations ) , diabetes ( knowledge of the disease , symptoms of hyperglycaemia and hypoglycaemia , self-adjustment of insulin , foot care ) and depression ( knowledge of the disease , diagnosis and treatment ) . It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance . The main outcome variables are quality of life , hospital readmissions , and overall mortality during a 12-month follow-up . Discussion The physiological changes , lower life expectancy , comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF . The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty , and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients .Trial registration ( Clinical Trials.gov number , NCT01076465 ) AIMS Hospitalizations for heart failure ( HF ) are common and are associated with significant morbidity , mortality and cost . However , precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood . METHODS AND RESULTS The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the C and esartan in Heart Failure : Assessment of Reduction in Mortality and Morbidity ( CHARM ) programme were prospect ively collected and stratified by ejection fraction ( EF ) . Potential precipitants were collected using a specifically design ed case report form and categorized according to the presence of cardiovascular ( CV ) , non-CV and unknown factors . Associations between these factors and subsequent rehospitalization and mortality rates were examined . Of 1668 patients who experienced HF hospitalization , 1152 had reduced EF ( ≤40 % , HFrEF ) and 516 had preserved EF ( HFpEF ) . Overall , 54 % had CV , 32 % had non-CV and 14 % had unknown factors thought to have precipitated HF , with similar proportions in the HFrEF and HFpEF groups . The most common precipitants were arrhythmia ( 15 % ) , other non-CV factors ( 11 % ) and respiratory infection ( 10 % ) . Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors . However , mortality rates were similar among patients with any of the three categories of precipitating factors . Results were similar in HFrEF and HFpEF . CONCLUSIONS Among chronic HF patients hospitalized for decompensation , the investigator-reported precipitating factor was not associated with the subsequent mortality rate , but was associated with type of readmission : readmissions for CV reasons were more likely when the index precipitant was CV AIMS Disease management programs can reduce hospitalizations in high-risk heart failure ( HF ) patients , but generalizability to the population hospitalized for HF remains to be proven . We aim ed to assess the effectiveness of a discharge and outpatient management program in a non-selected cohort of patients hospitalized for HF . METHODS AND RESULTS Patients admitted with decompensated HF were r and omized to receive usual care ( n=174 ) or an  intervention ( n=164 ) consisting of a comprehensive hospital discharge planning and close follow-up at a HF clinic . After a median of 509 days , there were fewer events ( readmission or death ) in the intervention as compared with the control group ( 156 vs. 250 ) , which represents 47 % ( 95%CI : 29 - 65 ; P<0.001 ) event reduction per observation year . At 1-year , time to first event , time to first all-cause and HF readmission , and time to death were increased in the intervention group ( P<0.001 ) . All-cause and HF readmission rates per observation year were significantly lower , quality of life improved and overall cost of care was reduced in the intervention group . CONCLUSIONS This comprehensive hospital discharge and outpatient management program prolonged time to first event , reduced hospital readmissions , improved survival and quality of life of patients hospitalized for HF , while reducing cost of management BACKGROUND Policy makers have proposed bundling payments for all heart failure ( HF ) care within 30 days of an HF hospitalization in an effort to reduce costs . Disease management ( DM ) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment . Whether a bundled payment approach can address the negative financial impact of DM programs is unknown . METHODS Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs . We used a decision analytic model using data from retrospective cohort studies , meta-analyses , 5 r and omized trials evaluating DM programs , and inpatient cl aims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004 . We determined the costs of DM programs  and  inpatient care  over 30 and 180 days . RESULTS With a baseline readmission rate of 22.9 % , the average cost for readmissions over 30 days was $ 2,272 per patient . Under base-case assumptions , a DM program that reduced readmissions by 21 % would need to cost $ 477 per patient to be cost neutral . Among evaluated published DM programs , 2 of the 5 would increase provider costs ( + $ 15 to $ 283 per patient ) , whereas 3 programs would be cost saving ( -$241 to $ 347 per patient ) . If bundled payments were broadened to include care over 180 days , then program saving estimates would increase , ranging from $ 419 to $ 1,706 per patient . CONCLUSIONS Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions Background Heart failure ( HF ) is a chronic condition affecting nearly 5.7 million Americans and is a leading cause of morbidity and mortality . With an aging population , the cost associated with managing HF is expected to more than double from US $ 31 billion in 2012 to US $ 70 billion by 2030 . Readmission rates for HF patients are high—25 % are readmitted at 30 days and nearly 50 % at 6 months . Low medication adherence contributes to poor HF management and higher readmission rates .  Remote telehealth monitoring programs aim ed at improved medication management and adherence may improve HF management and reduce readmissions . Objective The primary goal of this r and omized controlled pilot study is to compare the MedSentry remote medication monitoring system versus usual care in older HF adult patients who recently completed a HF telemonitoring program .  We hypothesized that remote medication monitoring would be associated with fewer unplanned hospitalizations and emergency department ( ED ) visits , increased medication adherence , and improved health-related quality of life ( HRQoL ) compared to usual care . Methods Participants were r and omized to usual care or use of the remote medication monitoring system for 90 days . Twenty-nine participants were enrolled and the final analytic sample consisted of 25 participants . Participants completed question naires at enrollment and closeout to gather data on medication adherence , health status , and HRQoL. Electronic medical records were review ed for data on baseline classification of heart function and the number of unplanned hospitalizations and ED visits during the study period . Results Use of the medication monitoring system was associated with an 80 % reduction in the risk of all-cause hospitalization and a significant decrease in the number of all-cause hospitalization length of stay in the intervention arm compared to usual care . Objective device data indicated high adherence rates ( 95%-99 % ) among intervention group participants despite finding no significant difference in self-reported adherence between study arms . The intervention group had poorer heart function and HRQoL at baseline , and HRQoL declined significantly in the intervention group compared to controls . Conclusions The MedSentry medication monitoring system is a promising technology that merits continued development and evaluation . The MedSentry medication monitoring system may be useful both as a st and alone system for patients with complex medication regimens or used to complement existing HF telemonitoring interventions . We found significant reductions in risk of all-cause hospitalization and the number of all-cause length of stay in the intervention group compared to controls . Although HRQoL deteriorated significantly in the intervention group , this may have been due to the poorer HF-functioning at baseline in the intervention group compared to controls . Telehealth medication adherence technologies , such as the MedSentry medication monitoring system , are a promising method to improve patient self-management , the quality of patient care , and reduce health care utilization and expenditure for patients with HF and other chronic diseases that require complex medication regimens . Trial Registration Clinical Trials.gov NCT01814696 ; https:// clinical trials.gov/ct2/show/ study /NCT01814696 ( Archived by WebCite ® at http://www.webcitation.org/6giqAVhno Background —No treatment strategies have been demonstrated to be beneficial for the population for patients with heart failure ( HF ) and preserved ejection fraction ( EF ) . Methods and Results —The CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients ( CHAMPION ) trial was a prospect i ve , single-blinded , r and omized controlled clinical trial testing the hypothesis that hemodynamically guided HF management decreases decompensation leading to hospitalization . Of the 550 patients enrolled in the study , 119 had left ventricular EF ≥40 % ( average , 50.6 % ) , 430 patients had low left ventricular EF ( < 40 % ; average , 23.3 % ) , and 1 patient had no documented left ventricular EF .  A microelectromechanical system pressure sensor was permanently implanted in all participants during right heart catheterization . After implant , subjects were r and omly assigned in single-blind fashion to a treatment group in whom daily uploaded pressures were used in a treatment strategy for HF management or to a control group in whom st and ard HF management included weight-monitoring , and pressures were uploaded but not available for investigator use . The primary efficacy end point of HF hospitalization rate > 6 months for preserved EF patients was 46 % lower in the treatment group compared with control ( incidence rate ratio , 0.54 ; 95 % confidence interval , 0.38–0.70 ; P<0.0001 ) . After an average of 17.6 months of blinded follow-up , the hospitalization rate was 50 % lower ( incidence rate ratio , 0.50 ; 95 % confidence interval , 0.35–0.70 ; P<0.0001 ) . In response to pulmonary artery pressure information , more changes in diuretic and vasodilator therapies were made in the treatment group . Conclusions —Hemodynamically guided management of patients with HF with preserved EF reduced decompensation leading to hospitalization compared with st and ard HF management strategies . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00531661 Ambulatory care by physicians especially devoted to the management of heart failure ( HF ) has been reported to have beneficial effects . The aim of this work was to assess the effect of outpatient management at a HF clinic , as compared with care by the usual assistant physician , on prognosis of HF patients . In this non-r and omised study , we prospect ively followed 339 patients after a hospitalisation index for HF , in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting : either a specific outpatient clinic ( n=157 ) or the usual assistant physician ( n=182 ) . The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term . The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic ( adjusted odds ratio 0.23 ; 95 % CI 0.12 - 0.46 ) . Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days ( adjusted hazard ratio 0.52 ; 95 % CI 0.34 - 0.81 ) . The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients Meta‐analyses of cell therapy trials for heart disease have yielded discrepant results . To resolve limitations associated with meta‐analyses , such as imprecision and accumulation of r and om errors , we conducted trial sequential analysis ( TSA ) . R and omized controlled trials that administered autologous bone marrow‐derived cells to patients who suffered acute myocardial infa rct ion ( AMI ) or heart failure ( HF ) were included . TSA has been applied to two clinical outcomes , all‐cause mortality and hospitalization for HF , and to left ventricular ejection fraction ( LVEF ) , as a surrogate of heart function . The results suggest that there is evidence of reduction of the risk of mortality and hospitalization in HF , but insufficient evidence to determine treatment effect in AMI . Moreover , the treatment does not improve LVEF by more than a mean difference of 4 % when administered to either AMI or HF patients . The required number of participants to include in a meta‐ analysis to detect treatment effect was also estimated Objective Heart failure ( HF ) is a major health problem result ing in a high financial burden for the healthcare system . Many previous HF management programmes reduced adverse clinical outcomes and costs , but they usually involved several professional figures as well as huge investments , requiring re sources and budgets not often available in our healthcare system . We evaluated the effects of our HF management programme , which included patient education and regular outpatient contact with the HF team , on re-hospitalisation and death , optimising the few re sources already available at our hospital . Methods Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were r and omised to the intervention group ( nurse-led education programme , facilitated telephone communication and follow-up visits with an internist at 15 days , 1 and 6 months ) or to the usual care group ( follow-up by their primary care physician ) . The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period . Results There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group ( P = NS ) . Fourteen patients ( 14 % ) in the intervention group and eight patients ( 8 % ) in the control group died during the study period ( P = NS ) . Unplanned outpatient visits were less frequent in the intervention group than in the control group ( 39 [ 28 % ] versus 99 [ 72 % ] , P < 0.001 ) . Conclusions The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status . More intense follow-up monitoring and more re sources are needed to achieve better results Background : Heart failure ( HF ) is a chronic and costly condition that affects approximately 5.8 million people in the United States , with an additional 670 000 diagnosed yearly . With high 30-day hospital readmission rates , the importance of determining effective means of preventing readmissions is imperative . Despite published guidelines emphasizing the importance of education in preventing readmissions , the most effective means of educating hospitalized patients with HF about their self-care remains unknown . Objective : The aim of this study was to determine if hospitalized HF patients educated with the teach-back method retain self-care educational information and whether it is associated with fewer hospital readmissions . Methods : A prospect i ve cohort study design included 276 patients older than 65 years hospitalized with HF over a 13-month period . Patients were educated and evaluated using the teach-back method as part of usual care . Data on ability to recall educational information while hospitalized and during follow-up approximately 7 days after hospital discharge were collected . Readmissions were confirmed through follow-up telephone calls and review of medical records . Results : Patients correctly answered 3 of 4 , or 75 % , of self-care teach-back questions 84.4 % of the time while hospitalized and 77.1 % of the time during follow-up telephone call . Greater time spent teaching was significantly associated with correctly answered questions ( P < .001 ) . Patients who answered teach-back questions correctly while hospitalized and during follow-up had nonsignificant ( P = .775 and .609 ) reductions in all-cause 30-day hospital readmission rates , but a trend toward significance ( P = .15 ) was found in patients who had readmissions for HF . Conclusions : The teach-back method is an effective method used to educate and assess learning . Patients educated longer retained significantly more information than did patients with briefer teaching . Correctly answered HF-specific teach-back questions were not associated with reductions in 30-day hospital readmission rates . Future studies that include patients r and omized to receive usual care or teach-back education to compare readmissions and knowledge acquisition would provide further comparison of teach-back effectiveness Anemia is common in patients with chronic heart failure ( HF ) , with a prevalence ranging from 10 % to 56 % , and may be a risk factor for poor outcomes . Anemia in HF remains poorly understood , with significant gaps in its impact on health-related quality of life ( HRQoL ) , with most studies in HF being retrospective or from registries . The purpose of this study was to explore the relation of hemoglobin ( Hgb ) with HRQoL and training-induced changes in HRQoL in a cohort of patients in Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training ( HF-ACTION ) . Using data from HF-ACTION , a r and omized controlled trial of exercise training in patients with HF and low left ventricular ejection fractions , HRQoL was measured using the Kansas City Cardiomyopathy Question naire ( KCCQ ) at baseline , 3 and 12 months , and annually up to 4 years . Treatment group effects on HRQoL were estimated using linear mixed models according to the intention-to-treat principle . It was hypothesized that baseline Hgb would be correlated with baseline KCCQ scales and that Hgb would moderate the beneficial effect of exercise training on HRQoL. Hgb level was not significantly correlated with baseline HRQoL. Baseline Hgb did not moderate the beneficial effect of exercise training on KCCQ overall or subscales relative to usual care . In conclusion , in the HF-ACTION cohort , there was no correlation with baseline Hgb and baseline HRQoL as measured by the KCCQ . In addition , the beneficial effects of HRQoL from exercise training were not modulated by baseline Hgb BACKGROUND & AIMS Hypoalbuminemia is common in acute heart failure ( HF ) patients and has been associated with increased hospital mortality and long-term mortality . Undernutrition is a factor causing hypoalbuminemia . The PICNIC study results show that a nutritional intervention in undernourished acute HF patients reduces the risks of all-cause death and of readmission for HF . We aim ed to investigate whether the efficacy of a nutritional intervention is consistent among the subgroups of patients with and without hypoalbuminemia . METHODS In PICNIC study , a total of 120 malnourished hospitalized patients due to acute HF were r and omized to conventional HF treatment or conventional HF treatment combined with an individualized nutritional intervention . The primary endpoint was a composite of all-cause death or readmission for worsening of HF , with a maximum follow-up of 12 months . In this post-hoc sub- analysis we assessed the interaction of the effects of a nutritional intervention among patients with and without hypoalbuminemia . Analysis was by intention to treat . RESULTS 59 ( 49,2 % ) patients demonstrated hypoalbuminemia and 61 ( 50,8 % ) had normalbuminemia  . At 12 months , the number of events for the primary endpoint in the intervention group compared with the control group was consistent among patients with hypoalbuminemia ( 28.6 % intervention vs 61.3 % control , HR 0,35 , 95 % CI 0,15 - 0,81 ) and those without ( 25.8 % intervention vs 60 % control , HR 0,35 , 95 % CI 0,15 - 0,79 ; interaction p = 0,86 ) . CONCLUSION There was no evidence that the relative efficacy of a nutritional intervention in undernourished acute HF patients was different between patients with normalbuminemia and those with hypoalbuminemia BACKGROUND Nearly half of all patients with chronic heart failure ( HF ) have a normal ejection fraction ( EF ) , and abnormal diastolic function ( ie , diastolic heart failure [ DHF ] ) . However , appropriate management of DHF patients remains a difficult and uncertain challenge . METHODS AND RESULTS The Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure ( COMPASS-HF ) trial was design ed to evaluate whether an implantable hemodynamic monitor ( IHM ) was safe and effective in reducing the number of heart failure-related events ( HFRE ) in patients with chronic HF . The current study presents data on a prespecified and planned subgroup analysis from the COMPASS-HF trial : 70 patients with an EF > or = 50 % ( ie , DHF ) . As such , this represents a subgroup analysis of the COMPASS-HF Trial . DHF patients were r and omized  to IHM-guided care ( treatment ) vs. st and ard care ( control ) for 6 months . All 70 patients received optimal medical therapy , but the hemodynamic information from the IHM was used to guide patient management only in the treatment group . The HFRE rate in DHF patients r and omized to treatment was 0.58 events/6 months compared with DHF patients r and omized to control , which was 0.73 events/6 months ; this represented a 20 % nonsignificant reduction in the overall HFRE rate in the treatment group ( 95 % CI = -46 , 56 , P = .66 ) . There was a 29 % nonsignificant reduction in the relative risk of a HF hospitalization in the DHF patients r and omized to treatment compared with DHF patients r and omized to control ( 95 % CI = -69 , 70 , P = .43 ) . CONCLUSIONS The IHM was shown to be safe and was associated with a very low system-related and procedure-related complication rate in DHF patients . However , in this subgroup analysis limited to 70 DHF patients , the addition IHM-guided care did not significantly lower the rate of HFR events . The results of this subgroup analysis in DHF patients , for whom there are currently no proven , effective management strategies , will be used to design future studies defining the effects of IHM-guided care in patients with DHF OBJECTIVES This study was design ed to investigate whether the addition of N-terminal pro-B-type natriuretic peptide-guided , intensive patient management ( BM ) to multidisciplinary care ( MC ) improves outcome in patients following hospitalization due to heart failure ( HF ) . BACKGROUND Patients hospitalized due to HF experience frequent rehospitalizations and high mortality . METHODS Patients hospitalized due to HF were r and omized to BM , MC , or usual care ( UC ) . Multidisciplinary care included 2 consultations from an HF specialist who provided therapeutic recommendations and home care by a specialized HF nurse . In addition , BM included intensified up-titration of medication by HF specialists in high-risk patients . NT-proBNP was used to define the level of risk and to monitor wall stress . This monitoring allowed for anticipation of cardiac decompensation and adjustment of medication in advance . RESULTS A total of 278 patients were r and omized in 8 Viennese hospitals . After 12 months , the BM group had the highest proportion of  antineurohormonal triple-therapy  ( difference among all groups ) . Accordingly , BM  reduced days of HF hospitalization ( 488 days ) compared with the hospitalization for the MC ( 1,254 days ) and UC ( 1,588 days ) groups ( p < 0.0001 ; significant differences among all groups ) . Using Kaplan-Meier analysis , the first HF rehospitalization ( 28 % ) was lower in the BM versus MC groups ( 40 % ; p = 0.06 ) and the MC versus UC groups ( 61 % ; p = 0.01 ) . Moreover , the combined end point of death or HF rehospitalization was lower in the BM ( 37 % ) than in the MC group ( 50 % ; p < 0.05 ) and in the MC than in the UC group ( 65 % ; p = 0.04 ) . Death rate was similar between the BM ( 22 % ) and MC groups ( 22 % ) , but was lower compared with the UC group ( 39 % ; vs. BM : p < 0.02 ; vs. MC : p < 0.02 ) . CONCLUSIONS Compared with MC alone , additional BM improves clinical outcome in patients after HF hospitalization . ( BNP Guided Care in Addition to Multidisciplinary Care ; NCT00355017 ) BACKGROUND Telemonitoring , the use of communication technology to monitor clinical status , is gaining attention as a strategy to improve the care of patients with heart failure . A system of frequent monitoring could alert clinicians to early heart failure decompensation , providing the opportunity for intervention before patients become severely ill and require hospitalization . Moreover , patients ' participation in a daily monitoring program could have a favorable effect on their health behaviors . The literature on telemonitoring for heart failure , however , is quite limited . METHODS AND MATERIAL S Telemonitoring to Improve Heart Failure Outcomes ( Tele-HF ) is a r and omized , controlled , trial design ed to compare an automated , daily symptom , and self-reported weight monitoring intervention with usual care in reducing ( all-cause ) hospital readmissions and mortality among patients recently hospitalized with decompensated heart failure . The intervention will be implemented and all outcomes will be assessed over a 6-month period . The purpose of the intervention is to collect information about symptoms , clinical status and weight and to engage participants in their own self-care .  Participants are recruited from general cardiology , heart failure specialty , and primary care practice s across the United States . CONCLUSIONS The results of this study may inform future policy decisions regarding implementation of telemonitoring in treatment of heart failure OBJECTIVES To determine whether 30-day readmissions were associated with presence of cognitive impairment more in elderly adults with heart failure ( HF ) than in those with other diagnoses and whether medical teams recognized cognitive impairment . DESIGN One-year prospect i ve cohort quality improvement program of cognitive screening and retrospective chart review of documentation and outcomes . SETTING Academic tertiary care hospital medical unit with a cardiovascular focus and an enhanced discharge program of individualized patient education . PARTICIPANTS Individuals aged 70 and older screened before home discharge ( 241 admission encounters ; 121 with HF as a primary diagnosis , 120 without ) . The HF cohort included individuals with preserved and reduced ejection fraction . Individuals who had undergone transplantation , ventricular assist device implantation , or hemodialysis or who had a primary oncology diagnosis or hospice referral were excluded . MEASUREMENTS  Mini-Cog  administered 48 hours or less before discharge , 30-day all-cause readmission rates , documentation of dementia or cognitive impairment , and caregiver education . RESULTS Mini-Cog scores were less than 4 ( indicating cognitive impairment ) in 157 encounters ( 82 ( 67.7 % ) with HF , 75 ( 62.5 % ) without ) . Mini-Cog scores were similar in rate and distribution between groups . Individuals with HF and cognitive impairment had a significantly higher 30-day readmission rate than did the other groups ( 26.8 % vs 13.2 % ; P = .01 ; HF , no cognitive impairment , 12.8 % ; no HF , no cognitive impairment , 13.3 % ; cognitive impairment , no HF , 13.3 % ) . In individuals with HF and cognitive impairment , those with documented caregiver education had lower readmission rates than those without ( 14.3 % vs 36.2 % ; P = .03 ) . Fewer than 9 % had documentation of cognitive impairment in the medical record . CONCLUSION Cognitive impairment , which is frequently undocumented , may indicate greater risk of readmission for individuals with HF than those without . Screening for cognitive impairment , adapting discharge for it , and involving family and caregivers in discharge education may help reduce readmissions Background : The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure ( HF ) patients . Objective : The purpose of this article is to ( 1 ) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies , ( 2 ) describe re sources and material s used in the group clinic appointment , and ( 3 ) present results supporting this patient-centered group intervention . Methods : This clinical trial included 198 HF patients ( r and omized to either group clinical appointments or to st and ard care ) . Data were collected from 72 group clinic appointments via patients ’ ( 1 ) group clinic session evaluations , ( 2 ) HF self-care behaviors skills , ( 3 ) HF-related discouragement and quality of life scores , and ( 4 ) HF-related reshopitalizations during the 12-month follow-up . Also , the costs of delivery of the group clinical appointments were tabulated . Results : Overall , patients rated group appointments as 4.8 of 5 on the “ helpfulness ” in managing HF score . The statistical model showed a 33 % decrease in the rate of rehospitalizations ( incidence rate ratio , 0.67 ) associated with the intervention over the 12-month follow-up period when compared with control patients ( & khgr;21 = 3.9 , P = .04 ) . The total cost for implementing 5 group appointments was $ 243.58 per patient . Conclusion : The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care . In turn , better self-care was associated with reductions in HF-related hospitalizations BACKGROUND Serial measurements of N-terminal pro-B type natriuretic peptide ( NT-proBNP ) provide prognostic information in patients with chronic heart failure ( HF ) . Changes in NT-proBNP concentrations parallel prognosis ; however , it remains unclear whether HF care with a goal to maximize medical therapy and also lower NT-proBNP concentrations is superior to st and ard HF care alone . AIMS The aim of the study was to evaluate the hypothesis that an HF strategy guided by NT-proBNP reduces cardiovascular events compared to st and ard of care HF management . METHODS In a prospect i ve r and omized single-center trial , subjects with New York Heart Association class II to IV systolic HF ( left ventricular ejection fraction < or = 40 % ) will be enrolled . Both groups will receive st and ard HF management ( with a goal for minimizing HF symptoms and achieving maximal dosages of therapies with proven mortality benefit in HF ) , whereas one group ( " NT-proBNP " ) will also have treatment adjustments to reduce NT-proBNP concentrations < or = 1,000 pg/mL. The primary end point of the trial is total cardiovascular events for a 1-year period ; secondary end points will include effects of NT-proBNP-guided care on cardiac structure and function , quality of life , and total costs of care .  RESULTS Enrollment began in 2006 ; of the original 300 planned , thus far , 151 subjects have been r and omized . Interim analysis in November 2009 indicated significant reduction of events in the NT-proBNP arm . Full results are expected in 2010 . CONCLUSIONS The Pro-B Type Natriuretic Peptide Outpatient Tailored Chronic Heart Failure Therapy ( PROTECT ) Study will test the hypothesis that therapy guided by NT-proBNP concentrations will be superior to st and ard of care HF management ( www . clinical trials.gov identifier NCT00351390 ) Background Recent increasing prevalence of heart failure ( HF ) patients leads to an increasing burden to the health care system . Consequently , there is a need for innovative strategies to reduce HF hospitalizations . Methods We performed a multicentre r and omized controlled trial to test the hypothesis that telemonitoring in patients with HF , by means of the Health Buddy ® system ( HB ) , will reduce HF hospitalizations and number of contacts with caregivers as compared to care as usual ( CAU ) during 1 year follow-up , from October 1 , 2007 , through December 31 , 2008 . Results Among 382 patients —197 in the HB and 185 in the CAU-group—226 ( 59 % ) were male , mean age was 71.5 ( SD 11.2 ) , 45.5 % being ≥75 years of age ; 57 % of the patients were in NYHA HF class 2 , 40 % in class 3 and 3 % in class 4 . Both study groups were similar for demographic and clinical characteristics . Mean time to first heart failure related hospitalization was 161 days for the intervention group and 139 days for the usual-care group ; hospitalizations occurred in 18 ( 9.1 % ) compared to 25 patients ( 13.5 % ) respectively ( Kaplan – Meier p=0.151 , hazard ratio 0.65 , CI 0.35–1.17 ) . Combined endpoint of heart failure admission and all cause mortality was similar for both groups ( Kaplan – Meier p=0.641 hazard ratio 0.89 , CI 0.69–1.83 ) . Cox regression analysis disclosed an important interaction between group assignment and heart failure duration , p=0.007 , OR=0.983 , CI 0.970–0.995 indicating a significant decrease in heart failure hospitalizations in the intervention group if heart failure duration was < 18 months , p=0.026 , hazard ratio 0.26 , CI 0.07–0.94 . Contacts with the heart-failure-nurse were mean 1.36 ( range 0–11 ) in the intervention group vs. 1.74 ( 0–8 ) in the usual-care group ( Mann-Whitney p<0.001 ) . Mortality was 18 ( 9.1 % ) in the intervention-group and 12 ( 6.5 % ) in the usual-care-group ( Mann – Whitney p=0.34 , Cox-regression analysis p=0.82 ) . Conclusion Telemonitoring tends to reduce heart failure admissions and decreases contacts with specialized nurses . If heart failure duration is < 18 months heart failure admissions and readmissions are significantly reduced OBJECTIVE The purpose of this study was to determine the effect of a tailored message intervention on heart failure readmission rates , quality of life , and health beliefs in persons with heart failure ( HF ) . DESIGN This r and omized control trial provided a tailored message intervention during hospitalization and 1 week and 1 month after discharge . Theoretic framework The organizing framework was the Health Belief Model . SUBJECTS Seventy persons with a primary diagnosis of chronic HF were included in the study . RESULTS HF readmission rates and quality of life did not significantly differ between the treatment and control groups . Health beliefs , except for benefits of medications , significantly changed from baseline in the treatment group in directions posited by the Health Belief Model . CONCLUSIONS A tailored message intervention changed the beliefs of the person with HF in regard to the benefits and barriers of taking medications , following a sodium-restricted diet , and self-monitoring for signs of fluid overload . Future research is needed to explore the effect of health belief changes on actual self-care behaviors BACKGROUND Hyperuricemia is associated with reduced survival among patients with heart failure ( HF ) , but the effect of gout on HF outcomes is unknown . A recent r and omized trial suggested that allopurinol may reduce adverse outcomes among patients with hyperuricemia and HF . Our objective was to determine whether gout and allopurinol use are associated with HF outcomes . METHODS Time-matched , nested case-control analysis of a retrospective cohort of patients with HF who were 66 years or older using health care data bases in Quebec , Canada . The primary outcome measure was a composite measure of HF readmission and all-cause mortality . The secondary outcome measure was all-cause mortality . Rate ratios were calculated using conditional logistic regression and adjusted for known prognostic factors . RESULTS Of the 25,090 patients in this cohort , 14,327 experienced the primary outcome . Both a remote history of gout and an acute episode of gout ( within 60 days of the event date ) were associated with an increased risk of HF readmission or death ( adjusted rate ratio , 1.63 ; 95 % confidence interval , 1.48 - 1.80 ; P<.001 and 2.06 ; 1.39 - 3.06 ; P<.001 , respectively ) . Continuous allopurinol use ( > 30 days of continuous use ) was not associated with the primary outcome among the overall population with HF ( adjusted rate ratio , 1.02 ; 95 % confidence interval , 0.95 - 1.10 ; P=.55 ) but was associated with reduced HF readmissions or death ( 0.69 ; 0.60 - 0.79 ; P<.001 ) and all-cause mortality ( 0.74 ; 0.61 - 0.90 ; P<.001 ) among patients with a history of gout . CONCLUSIONS Patients with HF and a history of gout represent a high-risk population . Among such patients , the use of allopurinol is associated with improved outcomes OBJECTIVES We determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure ( HF ) . BACKGROUND Disease management programs for patients with HF including medical components may reduce readmissions by 40 % or more , but the value of an intervention focused on education and support is not known . METHODS We conducted a prospect i ve , r and omized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF . RESULTS Among the 88 patients ( 44 intervention and 44 control ) in the study , 25 patients ( 56.8 % ) in the intervention group and 36 patients ( 81.8 % ) in the control group had at least one readmission or died during one-year follow-up ( relative risk = 0.69 , 95 % confidence interval [ CI ] : 0.52 , 0.92 ; p = 0.01 ) . The intervention was associated with a 39 % decrease in the total number of readmissions ( intervention group : 49 readmissions ; control group : 80 readmissions , p = 0.06 ) . After adjusting for clinical and demographic characteristics , the intervention group had a significantly lower risk of readmission compared with the control group ( hazard ratio = 0.56 , 95 % CI : 0.32 , 0.96 ; p = 0.03 ) and hospital readmission costs of $ 7,515 less per patient . CONCLUSIONS A formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF BACKGROUND Decompensated heart failure ( HF ) is associated with unacceptable morbidity and mortality risks . Recent implantable technology advancements allow frequent filling pressure monitoring and provide insight into HF pathophysiology and a new tool for HF management . METHODS The CHAMPION trial is a prospect i ve , multicenter , r and omized , single-blind clinical trial testing the hypothesis that HF management guided by frequently assessed pulmonary artery pressures is superior to traditional methods . A total of 550 subjects with New York Heart Association ( NYHA ) functional class III HF were enrolled at 64 sites in the United States . All subjects received the CardioMEMS HF sensor as a permanent pulmonary artery implant and were r and omized to the treatment or the control group before discharge . The treatment group received traditional HF management guided by hemodynamic information from the sensor . The control group received traditional HF disease management . Safety endpoints include freedom from device/system-related complications and freedom from HF sensor failure at 6 months . The efficacy endpoint is a reduction in the rate of HF-related hospitalizations in the treatment group versus the control group at 6 months . CONCLUSIONS The CHAMPION trial will investigate the safety and clinical efficacy of the CardioMEMS hemodynamic monitoring system and may establish this management strategy as a new paradigm for the medical management of patients with symptomatic HF Abstract Aims Haemodynamic‐guided  heart failure ( HF ) management effectively reduces decompensation events and need for hospitalizations . The economic benefit of clinical improvement requires further study . Methods and results An estimate of the cost‐effectiveness of haemodynamic‐guided HF management was made based on observations published in the r and omized , prospect i ve single‐blinded CHAMPION trial . A comprehensive analysis was performed including healthcare utilization event rates , survival , and quality of life demonstrated in the r and omized portion of the trial ( 18 months ) . Markov modelling with Monte Carlo simulation was used to approximate comprehensive costs and quality ‐adjusted life years ( QALYs ) from a payer perspective . Unit costs were estimated using the Truven Health MarketScan data base from April 2008 to March 2013 . Over a 5‐year horizon , patients in the Treatment group had average QALYs of 2.56 with a total cost of US$ 56 974 ; patients in the Control group had QALYs of 2.16 with a total cost of US$ 52 149 . The incremental cost‐effectiveness ratio ( ICER ) was US$ 12 262 per QALY . Using comprehensive cost modelling , including all anticipated costs of HF and non‐HF hospitalizations , physician visits , prescription drugs , long‐term care , and outpatient hospital visits over 5 years , the Treatment group had a total cost of US$ 212 004 and the Control group had a total cost of US$ 200 360 . The ICER was US$ 29 593 per QALY . Conclusions St and ard economic modelling suggests that pulmonary artery pressure‐guided management of HF using the CardioMEMS ™ HF System is cost‐effective from the US‐payer perspective . This analysis provides the background for further modelling in specific country healthcare systems and cost structures BACKGROUND Heart failure ( HF )  treatment guided by amino-terminal pro-B type natriuretic peptide ( NT-proBNP ) may reduce cardiovascular event rates compared to st and ard-of-care ( SOC ) management . Comprehensive underst and ing regarding effect of NT-proBNP guided care on patient-reported quality of life ( QOL ) remains unknown . METHODS One hundred fifty-one subjects with HF due to left ventricular systolic dysfunction were r and omized to either SOC HF management or care with a goal to reduce NT-proBNP values ≤1000 pg/mL. Effects of HF on QOL were assessed using the  Minnesota Living with HF Question naire ( MLHFQ ) quarterly , with change ( Δ ) in score assessed across study procedures and as a function of outcome . RESULTS Overall , baseline MLHFQ score was 30 . Across study visits , QOL improved in both arms , but was more improved and sustained in the NT-proBNP arm ( repeated measures P = .01 ) ; NT-proBNP patients showing greater reduction in MLHFQ score ( -10.0 vs -5.0 ; P = .05 ) , particularly in the physical scale of the question naire . Baseline MLHFQ scores did not correlate with NT-proBNP ; in contrast , ∆MLHFQ scores modestly correlated with ∆NT-proBNP values ( ρ = .234 ; P = .006 ) as did relative ∆ in MLHFQ score and NT-proBNP ( ρ = .253 ; P = .003 ) . Considered in tertiles , less improvement in MLHFQ scores was associated with a higher rate of HF hospitalization , worsening HF , and cardiovascular death ( P = .001 ) . CONCLUSIONS We describe novel associations between NT-proBNP concentrations and QOL scores among patients treated with biomarker guided care .  Compared to SOC HF management , NT-proBNP guided care was associated with greater and more sustained improvement in QOL ( Clinical Trial Registration : www . clinical trials.govNCT00351390 ) AIMS To assess the effects of an NT-proBNP-guided medical management on 18-month outcomes in patients with heart failure ( HF ) and preserved LVEF ( HFpEF ) . METHODS AND RESULTS Patients with HFpEF ( LVEF > 45 % ; n = 123 ) and HF with reduced LVEF ( HFrEF ; LVEF ≤45 % ; n = 499 ) with age ≥60 years , NYHA class ≥ II , and elevated NT-proBNP ( > 400 ng/L or > 800 ng/L depending on age ) were r and omized to medical therapy titrated only to reduce symptoms to NYHA ≤II ( symptom-guided ) or also to reduce NT-proBNP below the inclusion threshold ( NT-proBNP-guided ) during a 6-month period . Patients were followed for an additional 12 months . Despite similar treatment escalation , NT-proBNP reduction and symptom relief were less in HFpEF than in HFrEF . Hospitalization-free survival at 18 months was worse in HFpEF than in HFrEF ( P = 0.02 ) , while survival and HF hospitalization-free survival did not differ . Among HFpEF patients , NT-proBNP reduction and symptom relief were similar in the symptom-guided ( n = 59 ) and NT-proBNP-guided ( n = 64 ) group despite more aggressive treatment in the NT-proBNP-guided group . In contrast to effects in HFrEF , NT-proBNP-guided management tended to worsen 18-month outcomes in HFpEF , with P-values for the interactions between LVEF stratum and management strategy of 0.2 for hospitalization-free survival , 0.03 for survival , and 0.01 for HF hospitalization-free survival . CONCLUSIONS Outcomes in HFpEF were not better than in HFrEF , and opposite effects of NT-proBNP-guided management were observed in HFpEF compared with HFrEF . These preliminary findings suggest that , in contrast to HFrEF , NT-proBNP-guided therapy may not be beneficial in HFpEF . Trial registration IS RCT N43596477 BACKGROUND Many approaches have been considered to reduce  heart failure ( HF )  readmissions . The Joint Commission on Accreditation of Health Care Organizations ( JC ) requires hospitals to provide  patients admitted for HF with discharge instructions that address 6 topics related to HF management : diet , exercise , weight monitoring , worsening symptoms , medications , and follow-up appointments . These guidelines were developed based on expert opinion , but no one has tested whether patients ' underst and ing of these instructions affects 30-day readmission rates . METHODS AND RESULTS We conducted a prospect i ve cohort study of patients admitted for decompensated HF . Patients completed an underst and ing survey immediately after their nurse read their discharge papers . The survey contained 1 question for each of the 6 JC topics . Of the 145 patients in the study , only 14 ( 10 % ) understood all 6 discharge instructions . Patients with complete comprehension of their discharge instructions were significantly less likely to be readmitted within 30 days than those with nonperfect underst and ing ( P = .044 ) , but this association was no longer significant after controlling for level of education and use of English as a primary language . CONCLUSIONS HF patients ' comprehension of discharge instructions is inadequate . Patients with limited education and those that do not speak English as a primary language are more likely to have poorer discharge underst and ing and higher rates of 30-day readmissions BACKGROUND Multidisciplinary care ( MDC ) of heart failure ( HF ) can significantly reduce rates of unplanned hospitalisation , the major cost component of HF care . AIMS This prospect i ve , r and omised , controlled study examines the cost- benefits of MDC of HF in the setting of optimal medical care . METHODS 98 NYHA class IV HF patients ( mean age 70.8+/-10.5 years ) were r and omised to MDC ( n=51 ) or routine care ( RC ; n=47 ) of HF . A  direct intervention cost was calculated from contact time ( scheduled and unscheduled ) spent by the MDC team . Unplanned hospitalisation costs for HF were calculated at a daily rate of 242 . Outcomes were determined in monetary terms , i.e. the cost of the service per hospitalisation prevented and net costs/savings at 3 months . RESULTS The direct intervention cost of the MDC team was 5860 , with an average cost per patient of 113 ( 95 % Cl : 97 - 128 ) . At 3 months , there were a total of 12 unplanned HF readmissions in the RC group ( 25.5 % rate , 195 days ) compared to 2 in the MDC group ( 3.9 % rate , 17 days ) . The number needed to treat to prevent one hospitalisation for HF was 6 over 3 months . The cost of the service per hospitalisation prevented was 586 . The intervention produced a net cost saving of 37,216 for 51 patients treated over 3 months . Sensitivity analyses using 50 % variation in costs and lower relative risk reductions confirmed the cost- benefits of the intervention . CONCLUSION MDC of HF remains cost-beneficial when combined with optimal , medical care . The significant clinical and cost- benefits suggest that this intensive approach to MDC and medical management should become the st and ard of care for HF OBJECTIVE This study compared the effectiveness and cost/utility ratio between a heart failure ( HF ) management program delivered by day-hospital ( DH ) and usual care in chronic heart failure ( CHF ) out patients . BACKGROUND Previous studies showed that about 50 % of readmissions for CHF can be prevented by a multidisciplinary approach . However , the performance , effectiveness , and cost/utility ratio of a process of HF outpatient management related to evidence -based medicine have not been considered . METHODS A total of 234 prospect i ve patients discharged by a HF Unit were r and omized to two management strategies : 122 patients to usual community care and 112 patients to a HF management program delivered by the DH .  Management ( rate of readmissions , therapeutic interventions ) , functional parameters ( New York Heart Association [ NYHA ] functional class , left ventricular diameters , and ejection fraction , deceleration time of early diastolic mitral flow , peak oxygen uptake , and mitral regurgitation ) and hard outcomes ( cardiac death and urgent cardiac transplantation ) were evaluated . The cost/utility ratios of the two strategies were compared . RESULTS After 12 + /- 3 months of follow-up , the individual rate access in DH was 5.5 + /- 3.8 days . The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients ( 13 vs. 78 , p < 0.00001 ) . Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class ( 13 % improved and 16 % worsened p = NS ) ; In contrast , the DH group showed significant changes in NYHA functional class ( 23 % improved and 11 % worsened , p < 0.009 ) . Hard cardiac events in the one-year follow-up occurred in 25/234 ( 10.6 % ) patients ; cardiac death occurred in 21/122 ( 17.2 % ) of the community group and in 3/112 ( 2.7 % ) in the DH group ( p < 0.0007 ) . One DH patient underwent urgent transplantation . Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events ( relative risk [ RR ] 0.17 ; confidence interval [ CI ] 0.06 to 0.66 ) . The cost/utility ratio of the two management strategies was similar ( usual care $ 2,409 vs. DH $ 2,244 ) . The incremental analysis revealed a cost savings of $ 1,068 for each quality -adjusted life year gained . The cost/utility ratio for the integration of DH management of CHF was $ 19,462 ( CI $ 13,904 to $ 34,048 ) . CONCLUSIONS A heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients . This management strategy is cost-effective and has an equitable value from a societal point of view BACKGROUND The postdischarge rehospitalization and death rates are high in patients with acute heart failure ( HF ) syndromes despite optimization of st and ard therapy for chronic HF . To the best of our knowledge , there has been no systematic analysis of the causes of death and rehospitalization in this patient population . METHODS This was a prespecified analysis of adjudicated cause-specific all-cause mortality and  cardiovascular ( CV ) hospitalization in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan ( EVEREST ) trial , a r and omized , double-blind , placebo-controlled study in patients hospitalized with worsening HF and left ventricular ejection fraction < or = 40 % comparing tolvaptan  , an oral vasopressin receptor antagonist to placebo , in addition to st and ard care . RESULTS Of the 4,133 r and omized , there were 5,239 rehospitalizations  and 1,080  deaths during a median of 9.9 months . Of all deaths , 41.0 % were due to HF , 26.0 % due to sudden cardiac death ( SCD ) , 2.6 % due to acute myocardial infa rct ion ( MI ) , 2.2 % due to stroke , and 13.2 % due to non-CV causes . Of all hospitalizations , 39.2 % were non-CV , whereas 46.3 % were for HF , and a minority of hospitalizations was due to stroke , MI , arrhythmia , or other CV causes . CONCLUSIONS Despite close follow-up and evidence -based therapy within a clinical trial , rehospitalization and death remain high . Although most deaths were from HF , one quarter of patients had SCD . In addition , there were almost as many non-CV hospitalizations as HF hospitalizations . Knowledge of the causes of death and rehospitalization may be essential for proper management and early initiation of therapy Background / Objective : Few studies have examined whether chronic heart failure ( HF ) outcomes can be improved by increasing patient engagement ( known as activation ) in care and capabilities for self-care management . The objective was to determine the efficacy of a patient activation intervention compared with usual care on  activation , self-care management , hospitalizations , and emergency department visits in patients with HF . Methods : This study used a r and omized , 2-group , repeated- measures design . After consent was given , 84 participants were stratified by activation level and r and omly assigned to usual care ( n = 41 ) or usual care plus the intervention ( n = 43 ) . The primary outcomes and measures were patient activation using the Patient Activation Measure ( PAM ) , self-management using the Self-Care of Heart Failure Index ( SCHFI ) and the Medical Outcomes Study ( MOS ) Specific Adherence Scale , and hospitalizations and emergency department visits . The intervention was a 6-month program to increase activation  and improve HF self-management behaviors , such as adhering to medications and implementing health behavior goals . Results : Participants were primarily male ( 99 % ) , were white ( 77 % ) , and had New York Heart Association III stage ( 52 % ) . The mean ( SD ) age was 66 ( 11 ) years , and 71 % reported 3 or more comorbidities . The intervention group compared with the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months . No significant group-by-time interactions were found for the SCHFI scales . Although the baseline MOS Specific Adherence Scale mean was lower in the intervention group , results showed a significant group-by-time effect with the intervention group improving more over time . Participants in the intervention group had fewer hospitalizations compared with the usual care group when the baseline activation/PAM level was low or high . Conclusion : This study supports the importance of targeted interventions to improve patient activation or engagement in HF care . Further work is needed related to HF self-management measurement and outcomes BACKGROUND We sought to examine the relationship between health-related quality of life ( HRQL ) and a first emergency rehospitalization and mortality in patients with heart failure ( HF ) having a wide variation in ventricular ejection fraction and functional status . METHODS Prospect i ve study conducted with 394 patients admitted for HF-related emergencies at 4 Spanish hospitals . Baseline HRQL was measured with a generic question naire , the Medical Outcomes Study 36-item Short Form Survey ( SF-36 ) , and with an HF-specific instrument , the Minnesota Living With Heart Failure ( MLWHF ) question naire . Cox proportional hazards models were used to calculate hazard ratios ( HRs ) for hospitalization and death on the basis of HRQL scores . RESULTS During a median follow-up of approximately 6 months , 138 patients ( 35.0 % ) underwent a first emergency rehospitalization and 70 ( 17.8 % ) died . After adjustment for biomedical , psychosocial , and health care variables , the frequency of hospital readmission was higher in patients with worse scores on the SF-36 physical functioning ( HR , 1.65 ; 95 % confidence interval [ CI ] , 1.11 - 2.44 ; P = .01 ) , general health ( HR , 1.73 ; 95 % CI , 1.19 - 2.52 ; P = .003 ) , and mental health ( HR , 1.65 ; 95 % CI , 1.10 - 2.47 ; P = .02 ) subscales . Results were similar for the mortality end point . For the MLWHF question naire , worse overall and worse physical and emotional summary scores were associated with higher mortality . CONCLUSIONS Worse HRQL is associated with hospital readmission and death in patients with HF . The magnitude of this association , for both physical and mental HRQL components , is comparable to that for other well-known predictors of hospital readmission and death , such as personal history of diabetes , previous hospitalizations , and treatment with angiotensin-converting enzyme inhibitors Background Chronic heart failure ( HF ) disease management programs have reported inconsistent results and have not included comorbid depression management or specifically focused on improving patient-reported outcomes . The Patient Centered Disease Management ( PCDM ) trial was design ed to test the effectiveness of collaborative care disease management in improving health status ( symptoms , functioning , and quality of life ) in patients with HF who reported poor HF-specific health status . Methods / design Patients with a HF diagnosis at four VA Medical Centers were identified through population -based sampling . Patients with a Kansas City Cardiomyopathy Question naire ( KCCQ , a measure of HF-specific health status ) score of < 60 ( heavy symptom burden and impaired quality of life ) were invited to enroll in the PCDM trial . Enrolled patients were r and omized to receive usual care or the PCDM intervention , which included : ( 1 ) collaborative care management by VA clinicians including a nurse , cardiologist , internist , and psychiatrist , who worked with patients and their primary care providers to provide guideline -concordant care management , ( 2 ) home telemonitoring and guided patient self-management support , and ( 3 ) screening and treatment for comorbid depression . The primary study outcome is change in overall KCCQ score . Secondary outcomes include depression , medication adherence , guideline -based care , hospitalizations , and mortality . Discussion The PCDM trial builds on previous studies of HF disease management by prioritizing patient health status , implementing a collaborative care model of health care delivery , and addressing depression , a key barrier to optimal disease management . The study has been design ed as an ‘ effectiveness trial ’ to support broader implementation in the healthcare system if it is successful . Trial registration Unique identifier : Background : Heart failure ( HF ) has clinical ly significant psychological and physical consequences for older persons , and hospitalization for HF is frequent and costly to the Medicare program . As HF is the most common primary Medicare home care diagnosis , there is a critical need to develop home care services that improve heath-related outcomes for this population . The primary aim of this pilot study was to develop , implement , and test the initial feasibility and potential efficacy of the Home-Care Education , Assessment , Remote-Monitoring , and Therapeutic Activities ( HEART ) trial , a nurse-directed multicomponent home care intervention . Observed outcomes were quality of life ( QOL ) , depressive symptoms , and 90-day hospitalization . Methods : Twenty-four patients with a primary diagnosis of HF were assigned to the intervention ( n = 12 ) or control group ( n = 12 ) according to geographical location in a large multibranch Medicare-certified home health agency . Intervention group patients received 8 structured nurse education visits using evidence -based protocol s design ed in previous trials to teach HF self-management and to prevent/reduce depression , as well as a telemonitoring system . Control group patients received usual care and telemonitoring .  Quality of life was assessed using the Minnesota Living With Heart Failure question naire . Depressive symptoms were assed using the Patient Health Question naire 9 at baseline and 90-day study end point . Results : Study protocol s and instrumentation were found to be feasible and effective . Examination of enrollment data led to a reevaluation of eligibility criteria . Patients participating in the HEART intervention demonstrated significantly improved QOL ( F = 8.99 , P = .007 ) and significantly reduced depressive symptoms ( F = 35.10 , P = .001 ) in comparison to control group patients at the study end point . There was a trend toward lower hospital readmission rates in the intervention group ( 16 % vs 25 % ) , but this was not statistically significant . Conclusion : This pilot study suggests that a full-scale trial of the HEART intervention is feasible BACKGROUND Multidisciplinary heart failure ( HF ) programs reduce hospital readmission and improve clinical outcomes . Although dietitians are often members of such teams , no r and omized studies have demonstrated the independent benefit of dietitian-administered dietary counseling for patients with HF . The purpose of this study was to evaluate the effect of dietitian education on adherence to a sodium-restricted diet  in ambulatory patients with stable HF . METHODS Patients with HF ( left ventricular ejection fraction < 35 % ) were r and omized into a dietitian education group ( n = 23 ) or a usual care group ( n = 24 ) , then observed for 3 months . Both groups received a 2 g/d dietary sodium prescription . The usual care group received nutrition advice by way of self-help literature , whereas the dietitian education group returned for 2 counseling sessions with a dietitian . RESULTS Dietitian education result ed in a significant decrease in sodium intake at 3 months ( 2.80 + /- 0.30 to 2.14 + /- 0.23 g/d , P < .05 ) . In contrast , there was no change in sodium intake in the usual care group ( 3.00 + /- 0.31 to 2.74 + /- 0.35 g/d , P = ns ) . CONCLUSIONS Dietitian-administered counseling was more effective than providing literature in reducing dietary sodium intake in patients with stable HF Background Heart failure ( HF ) patients discharged from rural hospitals have higher 30-day readmission rates .  Self-management ( SM ) reduces readmissions , but adherence to SM guidelines is low in the rural HF population . We tested a home-based intervention to enhance patient activation and lead to improved SM adherence . Methods In this two-group , repeated measures r and omized control trial , the main outcomes were patient reported and clinical outcomes associated with SM adherence , and all-cause readmission at 30 , 90 and 180 days . Results The study included 100 HF patients discharged from a rural critical access hospital . The intervention group received a 12-week SM training and coaching program delivered by telephone and tailored on subjects ’ activation levels . At α = .10 , the PATCH intervention showed significantly greater improvement compared to usual care in patient-reported SM adherence : weighing themselves , following a low-sodium diet , taking prescribed medication , and exercising daily ( all p < .0005 ) at 3 and 6 months after discharge . In contrast , groups did not differ in physical activity assessed by actigraphy or in clinical biomarkers . Contrary to expectation , the 30-day readmission rate was significantly higher ( p = .088 ) in the intervention group ( 19.6 % ) than in the control group ( 6.1 % ) , with no differences at 90 or 180 days . Conclusion It is feasible to conduct a r and omized controlled trial in HF patients discharged from rural critical access hospitals . Significantly higher patient-reported SM adherence was not accompanied by lower clinical biomarkers or readmission rates . Further research is needed to underst and mechanisms that influence outcomes and healthcare utilization in this population .Trial registration Clinical Trial Registration Information : Clinical Trials.gov ; NCT01964053 PRINCIPLES International guidelines for heart failure ( HF ) care recommend the implementation of inter-professional disease management programmes . To date , no such programme has been tested in Switzerl and . The aim of this r and omised controlled trial ( RCT ) was to test the effect on hospitalisation , mortality and quality of life of an adult ambulatory disease management programme for patients with HF in Switzerl and . METHODS Consecutive patients admitted to internal medicine in a Swiss university hospital were screened for decompensated HF . A total of 42 eligible patients were r and omised to an intervention ( n = 22 ) or usual care group ( n = 20 ) . Medical treatment was optimised and lifestyle recommendations were given to all patients . Intervention patients additionally received a home visit by a HF-nurse , followed by 17 telephone calls of decreasing frequency over 12 months , focusing on self-care . Calls from the HF nurse to primary care physicians communicated health concerns and identified goals of care . Data were collected at baseline , 3 , 6 , 9 and 12 months . Mixed regression analysis ( quality of life ) was used . Outcome assessment was conducted by research ers blinded to group assignment . RESULTS After 12 months , 22 ( 52 % ) patients had an all-cause re-admission or died . Only 3 patients were hospitalised with HF decompensation . No significant effect of the intervention was found on HF related to quality of life . CONCLUSIONS An inter-professional disease management programme is possible in the Swiss healthcare setting but effects on outcomes need to be confirmed in larger studies OBJECTIVES The purpose of this study was to assess whether management of heart failure ( HF ) guided by an individualized N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) target would lead to improved outcome compared with HF management guided by clinical assessment alone . BACKGROUND Natriuretic peptides may be attractive biomarkers to guide management of heart failure ( HF ) and help select patients in need of more aggressive therapy . The PRIMA ( Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality ? ) study is , to our knowledge , the first large , prospect i ve r and omized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome . METHODS A total of 345 patients hospitalized for decompensated , symptomatic HF with elevated NT-proBNP levels at admission were included . After discharge , patients were r and omized to either  clinical ly-guided outpatient management ( n = 171 ) , or management guided by an individually set NT-proBNP  ( n = 174 ) defined by the lowest level at discharge or 2 weeks thereafter . The primary end point was defined as number of days alive outside the hospital after index admission . RESULTS HF management guided by this individualized NT-proBNP target increased the use of HF medication ( p = 0.006 ) , and 64 % of HF-related events were preceded by an increase in NT-proBNP . Nevertheless , HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point ( 685 vs. 664 days , p = 0.49 ) , nor did it significantly improve any of the secondary end points . In the NT-proBNP-guided group mortality was lower , as 46 patients died ( 26.5 % ) versus 57 ( 33.3 % ) in the clinical ly-guided group , but this was not statistically significant ( p = 0.206 ) . CONCLUSIONS Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy , but failed to provide significant clinical improvement in terms of mortality and morbidity . ( Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [ PRIMA ] ; NCT00149422 ) Patients admitted with heart failure have disproportionately high readmission rates , most recently ranging from 17.5 % to 30.3 % nationally.1 The Affordable Care Act penalizes hospitals with higher than average readmission rates after admissions for heart failure . However , clinicians remain uncertain , which strategies are associated with reducing readmissions in this population .2 Experts have proposed that the creation and transmission of a high- quality discharge summary to outpatient clinicians may improve the transition from hospital to home . Discharge summaries may facilitate safer transitions in care by informing outpatient clinicians about the course of hospitalization , identifying pending studies requiring follow-up , suggesting further follow-up testing , and clarifying changes in medications and treatments after discharge . Nonetheless , despite widespread enthusiasm for improving the quality of discharge summaries , there have been few studies of the effectiveness of discharge summaries in helping to avoid readmissions , and those few have found no association of timeliness,3,4 transmission,5,6 or content5 with readmission . To determine the association of discharge quality and readmission in a large national sample , we examined discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes ( Tele-HF ) r and omized controlled trial . # # # Study Cohort and Setting The  Tele-HF study included patients living at home and hospitalized for heart failure in the previous 30 days.7 Patients in Tele-HF were recruited from 33 cardiology practice s in 21 states and the District of Columbia . We obtained discharge summaries for the index hospitalization . Wherever possible , we obtained Background Heart failure ( HF ) is a prevalent chronic disease in older adults that requires extensive self-care to prevent decompensation and hospitalization . Cognitive impairment may impact the ability to perform HF self-care activities . We examined the association between cognitive impairment and adherence to self-care in patients hospitalized for acute HF . Design Prospect i ve cohort study . Setting and participants A total of 577 patients ( mean age = 71 years , 44 % female ) hospitalized for HF at five medical centers in the United States and Canada . Measurements and methods Participants were interviewed for information on self-reported adherence to self-care using the European Heart Failure Self-care Behaviour Scale . We assessed cognitive impairment in three domains ( memory , processing speed , and executive function ) using st and ardized measures . Patients ’ demographic and clinical characteristics were obtained through medical record review . Multivariable linear regression was used to examine the association between cognitive impairment and self-care practice s adjusting for demographic and clinical factors . Results A total of 453 patients ( 79 % ) were impaired in at least one cognitive domain . Average adherence to self-care activities among patients with global cognitive impairment did not differ significantly from those without cognitive impairment ( 30.5 versus 29.6 ; 45-point scale ) . However , impaired memory was associated with lower self-care scores ( P = 0.006 ) in multivariable models . Conclusion Cognitive impairment is highly prevalent among older patients hospitalized for HF .  Memory impairment is associated with poorer adherence to self-care practice s. Screening for memory impairment in patients with HF may help to identify patients at risk for poor self-care who may benefit from tailored disease management programs OBJECTIVES The GUIDE-IT ( Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure ) study is design ed to determine the safety , efficacy , and cost-effectiveness of a strategy of adjusting therapy with the goal of achieving and maintaining a target N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) level of < 1,000 pg/ml compared with usual care in high-risk patients with systolic heart failure ( HF ) . BACKGROUND Elevations in natriuretic peptide ( NP ) levels provide key prognostic information in patients with HF . Therapies proven to improve outcomes in patients with HF are generally associated with decreasing levels of NPs , and observational data show that decreases in NP levels over time are associated with favorable outcomes . Results from smaller prospect i ve , r and omized studies of this strategy thus far have been mixed , and current guidelines do not recommend serial measurement of NP levels to guide therapy in patients with HF . METHODS GUIDE-IT is a prospect i ve , r and omized , controlled , unblinded , multicenter clinical trial design ed to r and omize approximately 1,100 high-risk subjects with systolic HF ( left ventricular ejection fraction ≤40 % ) to either usual care ( optimized guideline -recommended therapy ) or a strategy of adjusting therapy with the goal of achieving and maintaining a target NT-proBNP level of < 1,000 pg/ml . Patients in either arm of the study are followed up at regular intervals and after treatment adjustments for a minimum of 12 months . The primary endpoint of the study is time to cardiovascular death or first hospitalization for HF . Secondary endpoints include time to cardiovascular death and all-cause mortality , cumulative mortality , health-related quality of life , re source use , cost-effectiveness , and safety . CONCLUSIONS The GUIDE-IT study is design ed to definitively assess the effects of an NP-guided strategy in high-risk patients with systolic HF on clinical ly relevant endpoints of mortality , hospitalization , quality of life , and medical re source use . ( Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [ GUIDE-IT ] ; NCT01685840 ) Background Cognitive impairment is seen in up to three quarters of heart failure ( HF ) patients and has a significant negative impact on patients ’ health outcomes . Prospect i ve memory , which is defined as memory to carry out future intentions , is important for functional independence in older adults and involves application of multiple cognitive processes that are often impaired in HF patients . The objective of this study is to examine the effects of prospect i ve memory training on patients ’ engagement in HF self-care and health outcomes , carer strain and quality of life . Methods / design The proposed study is a r and omised , controlled trial in which 200 patients diagnosed with HF , and their carers will be recruited from 3 major hospitals across Melbourne . Eligible patients with HF will be r and omised to receive either : 1 ) The Virtual Week Training Program - a computerised prospect i ve memory ( PM ) training program ( intervention ) or 2 ) non-adaptive computer-based word puzzles ( active control ) .  HF patients ’ baseline cognitive function will be compared to a healthy control group ( n = 60 ) living independently in the community . Patients will undergo a comprehensive assessment of PM , neuropsychological functioning , self-care , physical , and emotional functioning . Assessment s will take place at baseline , 4 weeks and 12 months following intervention . Carers will complete measures assessing quality of life , strain , perceived control in the management of the patients ’ HF symptoms , and ratings of the patients ’ level of engagement in HF self-care behaviours . Discussion If the Virtual Week Training Program is effective in improving : 1 ) prospect i ve memory ; 2 ) self-care behaviours , and 3 ) wellbeing in HF patients , this study will enhance our underst and ing of impaired cognitive processes in HF and potentially is a mechanism to reduce healthcare costs . Trial registration Australian New Zeal and Clinical Trials Registry # 366376 ; 27 May 2014 . https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=366376&is Clinical Trial = False Background Acute decompensated heart failure ( ADHF ) is a leading cause of hospitalization in older persons in the United States . Reduced physical function and frailty are major determinants of adverse outcomes in older patients with hospitalized ADHF . However , these are not addressed by current heart failure ( HF ) management strategies and there has been little study of exercise training in older , frail HF patients with recent ADHF . Hypothesis Targeting physical frailty with a multi‐domain structured physical rehabilitation intervention will improve physical function and reduce adverse outcomes among older patients experiencing a HF hospitalization . Study design REHAB‐HF is a multi‐center clinical trial in which 360 patients ≥60 years hospitalized with ADHF will be r and omized either to a novel 12‐week multi‐domain physical rehabilitation intervention or to attention control . The goal of the intervention is to improve balance , mobility , strength and endurance utilizing reproducible , targeted exercises administered by a multi‐disciplinary team with specific milestones for progression . The primary study aim is to assess the efficacy of the REHAB‐HF intervention on physical function measured by total Short Physical Performance Battery score . The secondary outcome is 6‐month all‐cause rehospitalization . Additional outcome measures include quality of life and costs . Conclusions REHAB‐HF is the first r and omized trial of a physical function intervention in older patients with hospitalized ADHF design ed to determine if addressing deficits in balance , mobility , strength and endurance improves physical function and reduces rehospitalizations . It will address key evidence gaps concerning the role of physical rehabilitation in the care of older patients , those with ADHF , frailty , and multiple comorbidities BACKGROUND New strategies are required to optimize care in increasing numbers of chronic heart failure patients . The aim of this r and omised trial was to evaluate a remote guidance system . METHODS Intervention group patients received a home TV-channel providing educational material s. Tele-guidance was performed by a Medical Service Centre . Control group patients were followed by cardiologists and HF-nurses . Primary endpoints were total days in hospital for all causes and days alive and out of hospital . Secondary endpoints were : quality of life and knowledge of disease and self care . RESULTS 214 patients were enrolled , median age was 66 years , 89 % had systolic LV dysfunction , and 90 % were in NYHA class II or III . The mean LVEF was 31 % . Over a mean follow-up duration of 288 days , there were 199 hospital admissions in 105 patients . Comparison of the groups revealed no differences for the primary outcomes or for QoL or self care behaviour . Knowledge about heart failure however , increased significantly more in the Intervention group ( p<0.001 ) . CONCLUSION Tele-guidance may play a role in the management of heart failure patients since it takes over some of the tasks of HF-nurses . This may facilitate delivery of optimal care to more patients with the same level of experienced staff BACKGROUND Hospital admissions for acute decompensated heart failure ( ADHF ) are frequent and are accompanied by high percentages of mortality and readmissions . Brain natriuretic peptide ( BNP ) and the inactive N-terminal fragment of its precursor proBNP ( NT-proBNP ) are currently the best predictors of prognosis in heart failure ( HF ) patients . In the setting of chronic HF , studies that performed guidance of therapy by NT-proBNP have had only limited success . For patients with ADHF , retrospective studies have shown that a reduction in NT-proBNP of ≤30 % during admission is a significant predictor of HF readmissions and mortality . These data suggest a role for NT-proBNP guidance in the setting of ADHF admissions . STUDY DESIGN The PRIMA II is an investigator-initiated , multicenter , r and omized , controlled , prospect i ve 2-arm trial that investigates the impact of inhospital guidance for ADHF treatment by a predefined NT-proBNP target ( > 30 % reduction during admission ) on the reduction of readmission and mortality rates within 180 days . Consenting ADHF patients with NT-proBNP levels of > 1,700 ng/L are eligible . After achieving clinical stability , a total of 340 patients are r and omized to either NT-proBNP-guided or conventional treatment ( 1:1 ) . The primary end point is dual , that is , a composite of all-cause mortality and readmission for HF in 180 days and the number of days alive out of hospital in 180 days . Secondary end points are readmissions and /or mortality in 180 days , cost effectiveness of hospitalization days in 180 days , readmissions and mortality in 90 days , and quality of life . CONCLUSION The PRIMA II trial aims at providing scientific evidence for the use of NT-proBNP-guided therapy compared with conventional treatment in patients admitted for ADHF OBJECTIVE The purpose of this study was to test the efficacy of a heart failure ( HF ) training program on patients ' ability to recognize and respond to changes in HF symptoms . The primary aim was to compare event-free survival at 90 days . METHODS A total of 99 HF patients r and omized to the HF symptom training intervention or usual care completed instruments about self-care ( Self-Care of HF Index ) and at baseline and 3 months . Demographic , clinical , and comorbidity data were collected by interview and chart review . Time to first event ( death or a HF-related hospitalization ) was tracked by electronic records and patient interview . RESULTS The sample was predominately male ( 67.7 % ) , elderly ( 67.7 yrs ± 12.1 ) and Caucasian ( 88.9 % ) . The intervention group reported more events but the difference was not significantly different ( χ(2 ) = 1.18 , p = 0.26 ) . There was no difference in survival time between groups ( χ(2 ) = 1.53 , p = 0.216 ) . In paired t-tests , the intervention group had significantly improved self-care maintenance , management and confidence scores ( all p < 0.01 ) . The usual care group had significantly improved self-care maintenance and management ( both p < 0.01 ) . Improvements in self-care maintenance and confidence were higher in the intervention group compared with usual care ( 18.0 vs. 12.9 points ) . CONCLUSIONS HF symptom awareness training appeared to have an early but not sustained benefit result ing in no difference in 90-day event-free survival . However , larger improvement in self-care maintenance and confidence scores in the intervention group compared to usual care is promising . Embedding meaningful symptom monitoring strategies in self-care maintenance interventions requires further investigation Remote monitoring ( RM ) of homebound heart failure ( HF ) patients has previously been shown to reduce hospital admissions . We conducted a pilot trial of ambulatory , non-homebound patients recently hospitalized for HF to determine whether RM could be successfully implemented in the ambulatory setting . Eligible patients from Massachusetts General Hospital ( n = 150 ) were r and omized to a control group ( n = 68 ) or to a group that was offered RM ( n = 82 ) . The participants transmitted vital signs data to a nurse who coordinated care with the physician over the course of the 6-month study . Participants in the RM program had a lower all-cause per person readmission rate ( mean = 0.64 , SD ± 0.87 ) compared to the usual care group ( mean = 0.73 , SD ± 1.51 ; P-value = .75 ) although the difference was not statistically significant . HF-related readmission rate was similarly reduced in participants . This pilot study demonstrates that RM can be successfully implemented in non-homebound HF patients and may reduce readmission rates PURPOSE This work addresses the unanswered question of whether multidisciplinary care ( MDC ) of heart failure ( HF ) can reduce readmissions when optimal medical care is applied in both intervention and control groups . METHODS In a r and omized , controlled study , 98 patients ( mean age , 70.8 + /- 10.5 years ) admitted to hospital with left ventricular failure ( New York Heart Association Class IV ) were assigned to routine care ( RC , n = 47 ) or MDC ( n = 51 ) . All patients received the same components of inpatient , optimal medical care of HF : specialist-led inpatient care ; titration to maximum tolerated dose of angiotensin-converting enzyme inhibitor before discharge ; attainment of predetermined discharge criteria ( weight stable , off all intravenous therapy , and no change in oral regimen for 2 days ) . Only those in the MDC group received inpatient and outpatient education and close telephone and clinic follow-up . The primary study endpoint was rehospitalization or death for a HF-related issue at 3 months . MAIN FINDINGS At 3 months , four people had events in the MDC group ( 7.8 % rate over 3 months ) compared with 12 people ( 25.5 % rate over 3 months ) in the RC group ( P = 0.04 ) . CONCLUSION These data demonstrate for the first time the intrinsic benefit of MDC in the setting of protocol -driven , optimal medical management of HF . Moreover , the event rate of 7.8 % at 3 months , as the lowest reported rate for such a high-risk group , underlines the value of this approach to the management of heart failure Background . Hospitalization accounts for 70 % of heart failure ( HF ) costs ; readmission rates at 30 days are 24 % and rise to 50 % by 90 days . Agencies anticipate that telehomecare will provide the close monitoring necessary to prevent HF readmissions . Methods and Results . R and omized controlled trial to compare a telehomecare intervention for patients 55 and older following hospital discharge for HF to usual skilled home care .  Primary endpoints were 30- and 60-day all-cause and HF readmission , hospital days , and time to readmission or death . Secondary outcomes were access to care , emergency department ( ED ) use , and satisfaction with care . All-cause readmissions at 30 days ( 16 % versus 19 % ) and over six months ( 46 % versus 52 % ) were lower in the telehomecare group but were not statistically significant . Access to care and satisfaction were significantly higher for the telehomecare patients , including the number of in-person visits and days in home care . Conclusions . Patient acceptance of the technology and current home care policies and processes of care were barriers to gaining clinical effectiveness and efficiency Background : Hospital treatment of heart failure ( HF ) frequently does not follow published guidelines , potentially contributing to HF high morbidity , mortality and economic cost . The Experimental Prospect i ve Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was undertaken to determine how clinical pathways ( CP ) for hospital treatment of HF affected care variability , guidelines adherence , in-hospital mortality and outcomes at discharge . Methods / design : Two-arm , cluster-r and omised trial . Fourteen community hospitals were r and omised either to the experimental arm ( CP : appropriate therapeutic guidelines use , new organisation and procedures , patient education ) or to the control arm ( usual care ) . The main outcome was in-hospital mortality ; secondary outcomes were length and appropriateness of the stay , rate of unscheduled readmissions , customer satisfaction , usage of diagnostic and therapeutic procedures during hospital stay and quality indicators at discharge . All outcomes were measured using vali date d instruments available in literature . Results : In-hospital mortality was 5.6 % in the experimental arm ( n = 12 ) ; 15.4 % in controls ( n = 33 , p = 0.001 ) . In CP and usual care groups , the mean rates of unscheduled readmissions were 7.9 % and 13.9 % , respectively . Adjusting for age , smoking , New York Heart Association score , hypertension and source of referral , patients in the CP group , as compared to controls , had a significantly lower risk of in-hospital death ( OR 0.18 ; 95 % CI 0.07 to 0.46 ) and unscheduled readmissions ( OR 0.42 ; 95 % CI 0.20 to 0.87 ) . No differences were found between CP and control with respect to the appropriateness of the stay , costs and patient ’s satisfaction . Except for electrocardiography , all recommended diagnostic procedures were used more in the CP group . Similarly , pharmaceuticals use was significantly greater in CP , with the exception of diuretics and anti-platelets agents . Discussion : The introduction of a specifically tailored CP for the hospital treatment of HF was effective in reducing in-hospital mortality and unscheduled readmissions . This study adds to previous knowledge indicating that CP should be used to improve the quality of hospital treatment of HF . Trial registration number : AIMS Treatment of chronic heart failure ( CHF ) guided by natriuretic peptides has been studied in clinical trials with conflicting results . The aim of this study was to investigate if N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided therapy in symptomatic heart failure patients in primary care would improve clinical outcomes over and above treatment according to guidelines . METHODS AND RESULTS SIGNAL-HF was a 9 month , r and omized , single-blind , parallel group study in patients with CHF in NYHA class II-IV , ejection fraction (EF)<50 % and elevated NT-proBNP levels ( males>800 , females>1000 ng/L ) . All investigators underwent a pre- study educational programme about current CHF guidelines . A control group managed by non-trained investigators was considered not possible for ethical and practical reasons . Patients were r and omized to  structured treatment of CHF according to guidelines with or without NT-proBNP monitoring . The choice and dose of therapy for CHF was at the investigator 's discretion . The primary outcome variable was the composite endpoint of days alive , days out of hospital , and symptom score from the Kansas City Cardiomyopathy Question naire . In all , 252 patients were r and omized . The allocation groups were well balanced with regards to age , NT-proBNP , and EF . Treatment doses of beta-blockers and blockers of the renin-angiotensin-aldosterone system were markedly increased towards target doses and to a similar degree in both groups . There were no differences between the groups concerning either the primary endpoint ( P=0.28 ) or its components [ cardiovascular ( CV ) death , P=0.93 ; CV hospitalization , P=0.88 ; or symptom score , P=0.28 ] . CONCLUSION NT-proBNP-guided CHF treatment did not result in important improvements in clinical outcomes in patients with CHF in primary care above and beyond what could be achieved by education and structured CHF treatment according to guidelines INTRODUCTION Recent trials have demonstrated the effectiveness of multidisciplinary care ( MDC ) for patients with chronic heart failure ( CHF ) . However , results of the assessment of different programmes in individual countries could be different because of local specificities of health care systems . AIM We sought to determine whether MDC for patients with CHF has an influence on mortality , rate of rehospitalisation , quality of life ( QoL ) and self-care ( SC ) during a one-year study period . METHODS 160 patients with CHF treated in our unit were r and omly assigned to receive either MDC or routine care ( RC ) .  Patients from the MDC group ( n=80 ; mean age 67+/-10.2 years ) attended follow-up visits at the heart failure clinic after 14 days and 3 , 6 , 9 and 12 months after discharge . They were cared for by a team which consisted of a cardiologist , a heart failure nurse ( HF nurse ) , a psychologist and a physiotherapist . This group of patients received comprehensive education from the HF nurse and the cardiologist . Telephone counselling and home-based interventions by the HF nurse were also available daily . Patients from the RC group ( n=80 , mean age 69.5+/-10.7 years ) were cared for by their primary care physician only . In both groups QoL and SC scores were calculated based on a 21 and 12-item question naire completed by the patients at discharge and after one year . RESULTS After one-year follow-up the two groups did not differ in terms of either total and HF mortality or number of sudden deaths . In the MDC group when compared to the RC group we observed a significant decrease in the total number of hospital readmissions ( by 37 % , p < 0.05 ) , a decrease in hospital admissions due to HF ( by 48 % ; p < 0.05 ) and decreased length of stay during both all-cause readmissions and those due to HF ( p < 0.05 ) . After one year of follow-up both QoL and SC scores were significantly lower in the MDC group than in the RC group ( p < 0.001 ) , indicating improved QoL in the MDC group . CONCLUSIONS The one-year multidisciplinary care programme for patients with chronic heart failure in Poznań demonstrated significant improvement of treatment results in terms of frequency of readmissions and length of hospital stay as well as improved Qol . A tendency to decreased total and heart failure related mortality and decreased number of sudden deaths was also observed Background  Readmission rates for patients with heart failure are a major concern for hospitals worldwide . The importance of patient education and a structured care plan to ease the transition from hospital to home has been the focus of many intervention strategies to reduce readmission rates . The use of transitioning of care plans is believed to improve medication reconciliation , communication , patient education , and follow‐up . To date , the evidence has not been systematic ally evaluated to support the effectiveness of a nurse coordinated transitioning of care for patients with heart failure in reducing readmission rates . Objective The objective of the systematic review was to identify the best available evidence on the effectiveness of nurse coordinated transitioning of care between hospital and home on hospital readmission rates for all causes in adult patients hospitalised with heart failure . Search strategy The search strategy aim ed to find both published and unpublished studies in the English language from January 1975 through July 2010 . A search of MEDLINE , CINAHL , PsycINFO , Health source Nursing/academic edition , EMBASE , the Cochrane Library , and the Joanna Briggs Institute Library of Systematic Review s was conducted followed by a reference search of relevant studies . The initial key words search ed were : heart failure , readmission , and transitional care . Inclusion criteria R and omised controlled trials that evaluated the effect of nurse coordinated transitioning of care from hospital to home in adult patients with heart failure on  readmission  rates were selected . The outcome was defined as hospital readmissions for all causes following an initial admission for heart failure . Data collection and analysis Studies selected for retrieval were critically evaluated by two independent review ers for method ological validity using st and ardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument ( JBI‐MAStARI ) . Data were extracted and analysed using the JBI‐MAStARI program . Results A total of 16 r and omised controlled studies were included . Ten of the 16 studies included in the review show that a nurse led transitioning of care intervention can reduce the rate of readmission for patients with heart failure . Interventions utilising home visits , or home visits coupled with telephone follow‐up , show a more favourable reduction in readmission rates . Conclusions Reduced readmissions occur when transitioning of care interventions are carried out by a heart failure trained nurse who conducts at least one home visit and follows the patient at least weekly for a minimum of 30 days post discharge with either additional home visits or telephone contact . Implication s for practice This review supports the development of a nurse coordinated transitioning of care plan which will require improvements in communication , in addition to changes in health policy and payment systems that align incentives and performance measures in caring for patients with heart failure . Implication s for research Future research should evaluate the effect of the intensity and duration of the transitioning of care intervention on readmission rates in a large r and omised control trial on an adult population with heart failure to determine the ideal frequency and duration of the post discharge interventions AIMS Electronic health support ( e-health ) may improve self-care of patients with heart failure ( HF ) . We aim to assess whether an adjusted care pathway with replacement of routine consultations by e-health improves self-care as compared with usual care . In addition , we will determine whether the ESC/HFA ( European Society of Cardiology/Heart Failure Association ) website heartfailurematters.org ( HFM website ) improves self-care when added to usual care . Finally , we aim to evaluate the cost-effectiveness of these interventions . METHODS A three-arm parallel r and omized trial will be conducted . Arm 1 consists of usual care ; arm 2 consists of usual care plus the HFM website ; and arm 3 is the adjusted care pathway with an interactive platform for disease management ( e-Vita platform ) , with a link to the HFM website , which replaces routine consultations with HF nurses at the outpatient clinic . In total , 414 patients managed in 10 Dutch HF outpatient clinics or in general practice will be included and followed for 12 months . Participants are included if they have had an established diagnosis of HF for at least 3 months . The primary outcome is self-care as measured by the European Heart Failure Self-care Behaviour scale ( EHFScB scale ) . Secondary outcomes are quality of life , cardiovascular- and HF-related mortality , hospitalization , and its duration as captured by hospital and general practitioner registries , use of and user satisfaction with the HFM website , and cost-effectiveness . PERSPECTIVE This study will provide important prospect i ve data on the impact and cost-effectiveness of an interactive platform for disease management and the HFM website . CLINICAL TRIAL REGISTRATION unique identifier : NCT01755988 Background Heart failure is a prevalent health problem associated with costly hospital readmissions . Transitional care programs have been shown to reduce readmissions but are costly to implement . Evidence regarding the effectiveness of telemonitoring in managing the care of this chronic condition is mixed . The objective of this r and omized controlled comparative effectiveness study is to evaluate the effectiveness of a care transition intervention that includes pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight , blood pressure , heart rate , and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure . Methods / Design A multi-center , r and omized controlled trial is being conducted at six academic health systems in California . A total of 1,500 patients aged 50 years and older will be enrolled during a hospitalization for treatment of heart failure . Patients in the intervention group will receive intensive patient education using the ‘ teach-back ’ method and receive instruction in using the telemonitoring equipment . Following hospital discharge , they will receive a series of nine scheduled health coaching telephone calls over 6 months from nurses located in a central ized call center . The nurses also will call patients and patients ’ physicians in response to alerts generated by the telemonitoring system , based on predetermined parameters . The primary outcome is readmission for any cause within 180 days . Secondary outcomes include 30-day readmission , mortality , hospital days , emergency department ( ED ) visits , hospital cost , and health-related quality of life . Discussion BEAT-HF is one of the largest r and omized controlled trials of telemonitoring in patients with heart failure , and the first explicitly to adapt the care transition approach and combine it with remote telemonitoring . The study population also includes patients with a wide range of demographic and socioeconomic characteristics . Once completed , the study will be a rich re source of information on how best to use remote technology in the care management of patients with chronic heart failure . Trial registration Clinical Trials.gov # NCT01360203 Background — Therapy guided by N-terminal-pro-B-type natriuretic peptide ( NT-proBNP ) levels may improve outcomes in patients with chronic heart failure ( HF ) , especially in younger patients with reduced left ventricular ejection fraction . It remains unclear whether treatment effects persist after discontinuation of the NT-proBNP – guided treatment strategy . Methods and Results — Trial of Intensified versus st and ard Medical therapy in Elderly patients with Congestive Heart Failure r and omized 499 patients with HF aged ≥60 years with left ventricular ejection fraction ⩽45 % to intensified , NT-proBNP – guided versus st and ard , symptom-guided therapy into prespecified age groups ( 60–74 and ≥75 years ) during 18 months . A total of 329 patients ( 92 % ) alive at 18 months agreed to long-term follow-up . HF medication was intensified to a larger extent in the NT-proBNP – guided group . During long-term , NT-proBNP – guided therapy did not improve hospital-free ( primary end point : hazard ratio , 0.87 ; 95 % confidence interval , 0.71–1.06 ; P=0.16 ) or overall survival ( hazard ratio , 0.85 ; 95 % confidence interval , 0.64–1.13 ; P=0.25 ) but did improve HF hospitalization-free survival ( hazard ratio , 0.70 ; 95 % confidence interval , 0.55–0.90 ; P=0.005 ) . Patients aged 60 to 74 years had benefit from NT-proBNP – guided therapy on the primary end point and HF hospitalization-free survival , whereas patients aged ≥75 years did not ( P<0.10 for interaction ) . In l and mark analysis , there was no regression to the mean after cessation of the NT-proBNP – guided strategy . More intensified HF medication at month 12 was associated with better long-term HF hospitalization-free and overall survival . Conclusions — Intensified , NT-proBNP – guided therapy did not improve the primary end point compared with symptom-guided therapy but did improve HF hospitalization-free survival . Within the subgroup of patients aged 60 to 74 years , it improved clinical outcome including the primary end point . These effects did not disappear after cessation of the NT-proBNP – guided strategy on the long-term . This is possibly attributable to a more intensified HF medical therapy in the NT-proBNP – guided group . Clinical Trial Registration — URL : http://www.is rct n.org . Unique identifier : IS RCT N43596477 Aims Exercise is known to be beneficial for patients with heart failure ( HF ) , and these patients should therefore be routinely advised to exercise and to be or to become physically active . Despite the beneficial effects of exercise such as improved functional capacity and favourable clinical outcomes , the level of daily physical activity in most patients with HF is low . Exergaming may be a promising new approach to increase the physical activity of patients with HF at home . The aim of this study is to determine the effectiveness of the structured introduction and access to a Wii game computer in patients with HF to improve exercise capacity and level of daily physical activity , to decrease healthcare re source use , and to improve self‐care and health‐related quality of life . Methods and results A multicentre r and omized controlled study with two treatment groups will include 600 patients with HF . In each centre , patients will be r and omized to either motivational support only ( control ) or structured access to a Wii game computer ( Wii ) . Patients in the  control  group will receive advice on physical activity and will be contacted by four telephone calls . Patients in the Wii group also will receive advice on physical activity along with a Wii game computer , with instructions and training . The primary endpoint will be exercise capacity at 3 months as measured by the 6 min walk test . Secondary endpoints include exercise capacity at 6 and 12 months , level of daily physical activity , muscle function , health‐related quality of life , and hospitalization or death during the 12 months follow‐up . Conclusion The HF‐Wii study is a r and omized study that will evaluate the effect of exergaming in patients with HF . The findings can be useful to healthcare professionals and improve our underst and ing of the potential role of exergaming in the treatment and management of patients with HF . Trial registration OBJECTIVE To assess the impact and cost-effectiveness of two information-based provider reminder interventions design ed to improve self-care management and outcomes of heart failure ( HF ) patients . DATA SOURCES / STUDY SETTING Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF . STUDY DESIGN Patients were treated by nurses r and omly assigned to usual care or one of two intervention groups . The basic intervention was an e-mail to the patient 's nurse highlighting six HF-specific clinical recommendations . The augmented intervention supplemented the initial nurse reminder with additional clinician and patient re sources . DATA COLLECTION Patient interviews were conducted 45 days post admission to measure self-management behaviors , HF-specific outcomes ( Kansas City Cardiomyopathy Question naire-KCCQ ) , health-related quality of life ( EuroQoL ) , and service use . PRINCIPAL FINDINGS Both interventions improved the mean KCCQ summary score ( 15.3 and 12.9 percent , respectively ) relative to usual care ( p < or = .05 ) . The basic intervention also yielded a higher EuroQoL score relative to usual care ( p < or = .05 ) . In addition , the interventions had a positive impact on medication knowledge , diet , and weight monitoring . The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes . CONCLUSIONS This study demonstrates the positive impact of targeting evidence -based computer reminders to home health nurses to improve patient self-care behaviors , knowledge , and clinical outcomes . It also advances the field 's limited underst and ing of the cost-effectiveness of selected strategies for translating research into practice BACKGROUND Heart failure ( HF ) is common in long-term care facilities ( LTCs ) . This study compared mortality and hospitalization rates and examined predictors of these outcomes among new LTC residents with and without HF . METHODS AND RESULTS This prospect i ve cohort study followed 546 newly admitted residents from 42 LTCs for up to 1 year . Health information was collected from participant and caregiver interviews , physicians ' records , diagnostic procedures , and hospitalization records . Multivariate logistic regression modeling determined predictors of hospitalization among residents , and Cox proportional hazards regression determined predictors for time to mortality . HF prevalence was 21.4 % . The sample was predominantly ( > 70 % ) female , and individuals with HF were significantly older with higher prevalence of reduced left ventricular ejection fraction . Overall annual mortality and hospitalization rates were 24 % and 27 % , respectively . Among residents with HF , 42 % died and 31 % were hospitalized within 1 year . Among residents with HF , use of major tranquilizers was the strongest predictor of sooner mortality ; use of anticoagulants and major tranquilizers also increased mortality risk , whereas higher baseline function was associated with longer time to mortality . History of peripheral vascular disease was the strongest predictor of hospitalizations among residents with HF , and use of antiplatelet agents and history of any smoking exposure increased this risk . CONCLUSIONS Among LTC residents , HF is associated with high mortality and hospitalization rates . Many factors contribute to mortality and hospitalizations among residents with HF , and comprehensive HF management programs are needed to improve outcomes Background We aim ed to establish the support needs of people with heart failure and their caregivers and develop an intervention to improve their health-related quality of life . Methods We used intervention mapping to guide the development of our intervention . We identified “ targets for change ” by synthesis ing research evidence and international guidelines and consulting with patients , caregivers and health service providers . We then used behaviour change theory , expert opinion and a taxonomy of behaviour change techniques , to identify barriers to and facilitators of change and to match intervention strategies to each target . A patient and public involvement group helped to identify patient and caregiver needs , refine the intervention objectives and strategies and deliver training to the intervention facilitators . A feasibility study ( IS RCT N25032672 ) involving 23 patients , 12 caregivers and seven trained facilitators at four sites assessed the feasibility and acceptability of the intervention and quality of delivery and generated ideas to help refine the intervention . Results The Rehabilitation Enablement in Chronic Heart Failure ( REACH-HF ) intervention is a comprehensive self-care support programme comprising the “ Heart Failure Manual ” , a choice of two exercise programmes for patients , a “ Family and Friends Re source ” for caregivers , a “ Progress Tracker ” tool and a facilitator training course . The main targets for change are engaging in exercise training , monitoring for symptom deterioration , managing stress and anxiety , managing medications and underst and ing heart failure . Secondary targets include managing low mood and smoking cessation . The intervention is facilitated by trained healthcare professionals with specialist cardiac experience over 12 weeks , via home and telephone contacts . The feasibility study found high levels of satisfaction and engagement with the intervention from facilitators , patients and caregivers . Intervention fidelity analysis and stakeholder feedback suggested that there was room for improvement in several areas , especially in terms of addressing caregivers ’ needs . The REACH-HF material s were revised accordingly . Conclusions We have developed a comprehensive , evidence -informed , theoretically driven self-care and rehabilitation intervention that is grounded in the needs of patients and caregivers . A r and omised controlled trial is underway to assess the effectiveness and cost-effectiveness of the REACH-HF intervention in people with heart failure and their caregivers ABSTRACT BACKGROUND Low literacy increases the risk for many adverse health outcomes , but the relationship between literacy and adverse outcomes in heart failure ( HF ) has not been well studied . METHODS We studied a cohort of ambulatory patients with symptomatic HF ( NYHA Class II-IV within the past 6 months ) who were enrolled in a r and omized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US . The primary outcome was combined all-cause hospitalization or death , with a secondary outcome of hospitalization for HF . Outcomes were assessed through blinded interviews and subsequent chart review s , with adjudication of cause by a panel of masked assessors . Literacy was measured using the short Test of Functional Health Literacy in Adults . We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy . RESULTS Of the 595 study participants , 37 % had low literacy . Mean age was 61 , 31 % were NYHA class III/IV at baseline , 16 % were Latino , and 38 % were African-American . Those with low literacy were older , had a higher NYHA class , and were more likely to be Latino ( all p < 0.001 ) . Adjusting for site only , participants with low literacy had an incidence rate ratio ( IRR ) of 1.39 ( 95 % CI : 0.99 , 1.94 ) for all-cause hospitalization or death and 1.36 ( 1.11 , 1.66 ) for HF-related hospitalization . After adjusting for demographic , clinical , and self-management factors , the IRRs were 1.31 ( 1.06 , 1.63 ) for all-cause hospitalization and death and 1.46 ( 1.20 , 1.78 ) for HF-related hospitalization . CONCLUSIONS Low literacy increased the risk of hospitalization for ambulatory patients with heart failure . Interventions design ed to mitigate literacy-related disparities in outcomes are warranted Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients Abstract Objectives . To evaluate whether a new home intervention system ( HIS , OPTILOGG ® ) consisting of a specialised software , a tablet computer ( tablet ) wirelessly connected to a weight scale may improve self-care behaviour , health-related quality of life ( HRQoL ) , knowledge about heart failure ( HF ) and reduce hospital days due to HF . Design . 82 patients ( 32 % females ) with mean age : 75 ± 8 years hospitalised with HF were r and omised at discharge to an intervention group ( IG ) equipped with the HIS or to a control group ( CG ) receiving st and ard HF information only . The tablet contained information about HF and lifestyle advice according to current guidelines . It also showed present dose of diuretic , changes in patient-measured weight and HRQoL over time . Results . After 3 months the IG displayed a dramatic improvement in self-care with p < 0.05 ( median IG : 17 [ IQR : 13 , 22 ] and CG : 21 [ IQR : 17 , 25 ] ) . The disease-specific HRQoL was measured by Kansas City Cardiomyopathy Question naire . The IG had significantly higher score ( median IG : 65.1 [ IQR : 38.5 , 83.3 ] vs. CG : 52.1 [ IQR : 41.1 , 64.1 ] p < 0.05 ) and an improved physical limitation ( median IG : 54.2 [ IQR : 37.7 , 83.3 ] vs. CG : 45.8 [ IQR : 25.0 , 54.2 ] p < 0.05 ) There was no difference in knowledge . IG showed fewer HF-related days in the hospital , with 1.3 HF-related hospital days/patient versus 3.5 in CG ( risk ratio : 0.38 ; 95 % confidence interval : 0.31–0.46 ; p < 0.05 ) . Conclusion . HF patients with a HIS tablet computer and scale improved in self-care and HRQoL. Days in hospital due to HF were reduced . A medical device that is easy to use can be a valuable tool for improving self-care and outcome in patients with HF Objective To test a multidisciplinary approach to reduce heart failure ( HF ) readmissions that tailors the intensity of care transition intervention to the risk of the patient using a suite of electronic medical record (EMR)-enabled programmes . Methods A prospect i ve controlled before and after study of adult in patients admitted with HF and two concurrent control conditions ( acute myocardial infa rct ion ( AMI ) and pneumonia ( PNA ) ) was performed between 1 December 2008 and 1 December 2010 at a large urban public teaching hospital . An EMR-based software platform stratified all patients admitted with HF on a daily basis by their 30-day readmission risk using a published electronic predictive model . Patients at highest risk received an intensive set of evidence -based interventions design ed to reduce readmission using existing re sources . The main outcome measure was readmission for any cause and to any hospital within 30 days of discharge . Results There were 834 HF admissions in the pre-intervention period and 913 in the post-intervention period . The unadjusted readmission rate declined from 26.2 % in the pre-intervention period to 21.2 % in the post-intervention period ( p=0.01 ) , a decline that persisted in adjusted analyses ( adjusted OR (AOR)=0.73 ; 95 % CI 0.58 to 0.93 , p=0.01 ) . In contrast , there was no significant change in the unadjusted and adjusted readmission rates for PNA and AMI over the same period . There were 45 fewer readmissions with 913 patients enrolled and 228 patients receiving intervention , result ing in a number needed to treat ( NNT ) ratio of 20 . Conclusions An EMR-enabled strategy that targeted scarce care transition re sources to high-risk HF patients significantly reduced the risk-adjusted odds of readmission
Main Findings : The results indicate that an intervention involving any human factor principles may nearly double an individual ’s probability of not being readmitted .
Principal Conclusions : Interventions with human factor principles reduce readmissions among HF patients .
Background : Human factors play an important role in health-care outcomes of heart failure ( HF ) patients .
A systematic review and meta- analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies .
Purpose : To investigate how the 8 guiding principles of choice , rest , environment , activity , trust , interpersonal relationships , outlook , and nutrition reduce HF readmissions .