Abstract
Introduction
The number of patients entering a heart failure program at the heart failure unit at St Vincent’s University Hospital (Dublin, Ireland) is increasing. However, the impact of a community direct access service on the workload pattern of a heart failure unit and its appropriateness remain poorly described. The workload of this hospital-based heart failure unit was analyzed over a 3-year period to assess changing workload patterns and to examine the appropriateness and outcome of patients’ direct access to the unit.
Methods
Clinical audits from the heart failure unit for the years 2002, 2003, and 2004 were reviewed, and the types of visits were classified and expressed as a percentage of total patient contact. A prospective, observational study was designed to examine the volume and nature of community direct access to the heart failure unit. Unscheduled contact was defined as a telephone call to the heart failure unit from a patient or carer seeking advice and/or reporting clinical deterioration. All unscheduled contact was triaged by a heart failure clinical nurse specialist, and advice was given on what to do, including immediate same-day referral to the heart failure clinic (termed an unscheduled visit).
Results
Twenty-eight percent of all unscheduled contacts resulted in an unscheduled visit to the unit. Eighty percent of unscheduled visits to the unit demonstrated evidence of clinical deterioration confirmed by physician examination. Eighty-nine percent of patients with clinical deterioration required an increase in oral medications, 10% required administration of an intravenous diuretic, and 1% required direct hospital admission. Unscheduled visits to the unit account for 20% of all clinical reviews annually. None of the unscheduled contacts that were resolved over the telephone (47%) or referred to the family physician or emergency department (25%) resulted in an admission with heart failure.
Conclusion
This study underlines the necessity for, and efficacy of, a community direct access service for heart failure patients in redirecting the course of clinical deterioration.
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References
Ellrodt G, Cook DJ, Lee J, et al. Evidence-based disease management. JAMA 1997; 278: 1687–92
Epstein WA, Sanchez M, Kechijian P. Conjunctivitis. Arch Dermatol 1985; 121: 838
Patients must be actively involved for asthma disease management programmes to be effective. Drug Ther Perspect 1999; 13 (12): 5-7
Capomolla S, Febo O, Ceresa M, et al. Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by dayhospital and usual care. J Am Coll Cardiol 2002; 40: 1259–66
Stewart S, Marley J, Horowitz J. Effects of a multidisciplinary home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999; 354: 1077–83
Fonarrow G, Stevenson L, Waiden J, et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol 1997; 30: 725–32
Rich M, Gray D, Beckham V, et al. Effect of a multidisciplinary intervention on medical compliance in medical patients with congestive heart failure. Am J Med 1996; 101: 270–6
Rich M, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190–5
Phillips C, Singa R, Rubin H, et al. Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics: a meta-regression analysis. Eur J Heart Fail 2005; 7: 333–41
Phillips C, Wright S, Kern D, et al. Comprehensive discharge planning plus postdischarge support for older patients with congestive heart failure: a metaanalysis. JAMA 2004; 291: 1358–67
McAlistar F, Stewart S, Ferrua S, et al. Multidisciplinary strategies of management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 2004; 44: 810–9
Atienza F, Anguita M, Martinez-Alzamora N, et al. Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. Eur J Heart Fail 2004; 6: 643–52
Gonseth J, Guallar-Castillon P, Banegas J, et al. The effectiveness of disease management programs in reducing hospital readmission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J 2004; 25: 1570–95
Lainscak M. Implementation of guidelines for management of heart failure in heart failure clinic: effects beyond pharmacological treatment. Int J Cardiol 2004; 97: 411–6
McDonald K, Ledwidge M, Cahill J, et al. Heart failure management: multidisciplinary care has intrinsic benefit above the optimization of medical care. J Card Fail 2002; 8: 142–8
McDonald K, Ledwidge M, Cahill J, et al. Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge. 2001; 3: 209–15
Ledwidge M, Barry M, Cahill J, et al. Is multidisciplinary care of heart failure cost effective when combined with optimal medical care? Eur J Heart Fail 2003; 5: 381–9
Jain A, Mills P, Nunn L, et al. Success of a multidisciplinary heart failure clinic for the initiation and up-titration of key therapeutic agents. Eur J Heart Fail. 2005; 7: 405–10
Ledwidge M, Travers B, Ryder, et al. Specialist care of heart failure improves appropriate pharmacotherapy at the expense of greater polypharmacy and drug interactions. Eur J Heart Fail 2004; 6: 235–43
Tsuyukl R, Fradette M, Johnson J, et al. A multicentre disease management program for hospitalized patients with heart failure. J Card Fail 2004; 10: 473–80
DeWalt DA, Pignone M, Malone R, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns 2004; 55: 78–86
McDonald K, Ledwidge M. Heart failure management programs: can we afford to ignore the inpatient phase of care? J Card Fail 2003; 9: 258–62
Krumholz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002; 39: 83–9
Capomolla S, Pinna G, La Rovere MT, et al. Heart failure disease management program: a pilot study of home telemonitoring versus usual care. Eur J Heart Fail 2004; 6 Suppl.: 91–8
De Lusignan S, Wells S, Johnson P, et al. Compliance and effectiveness of 1 year’s home telemonitoring: the report of a pilot study of patients with chronic heart failure. Eur J Heart Fail 2001; 3: 723–30
Blue L, Lang E, McMurray J, et al. Randomised controlled trial of a specialist nurse intervention in heart failure. BMJ 2001; 323: 715–8
Ledwidge M, Ryan E, O’Loughlin C, et al. Heart failure care in a hospital unit: a comparison of standard 3-month and extended 6-month programs. Eur J Heart Fail 2005; 7: 385–91
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No sources of funding were used to assist in the preparation of this study. The authors have no conflicts of interest that are directly relevant to the content of this study.
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Conlon, C., O’Loughlin, C., Ledwidge, M. et al. Community Direct Access Service for Early Detection and Treatment of Clinical Deterioration. Dis-Manage-Health-Outcomes 14, 185–190 (2006). https://doi.org/10.2165/00115677-200614030-00007
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DOI: https://doi.org/10.2165/00115677-200614030-00007