IMPLEMENTATION OF INTEGRATED CARE FOR HEART FAILURE PATIENTS: THE AUCKLAND HEART FAILURE MANAGEMENT STUDY
H.J Walsh*. S Muncaster, G.A Whalley, N Sharpe, R.N Doughty.
Department of Medicine, University of Auckland School of Medicine, Auckland, New Zealand
Background: Congestive heart failure (CHF) remains a major public health problem despite significant advances in medical management. Many patients (pts) with CHF are elderly and are under-represented in the clinical trials of therapeutic agents. Hospital admissions and readmissions are common as is polypharmacy. It is unclear how the benefits of modern management can be maximised for all pts with CHF.
Aims. The aims of this randomised controlled trial were to assess the benefits of a comprehensive approach to CHF, specifically, an integrated, holistic and participatory management approach, involving primary and secondary care, pts and their families.
Methods and Results: Pts with an exacerbation of CHF were recruited at Auckland Hospital from June 1996 to April 1998. Prior to randomisation and before discharge an echo was performed and pts completed 2 quality of life (QOL) questionnaires. Pts were randomised to either a management group (MG, n=l00) or usual care (UC, n=97) and followed up for 12 months.
197 pts were recruited, mean age 73yrs, 40% were female, 80% Caucasian, 55% had >= 1 prior admission for CHF. These pts were high risk with 117(60%) readmitted to hospital and 42 (22%) dead within 12 months.
MG pts attended a specialist CHF clinic within 2 weeks of discharge and thereafter alternating visits between the clinic and GP every 6 weeks. In addition, pts attended education and counseling sessions, were given a diary to record daily weight, medications and symptoms. Integrated care for MG pts was time and resource intensive. The pts attended clinics on average 3.8 times (range 0-10) and received an average of 6.2 phone calls (range 0-26) from a specialist heart failure nurse over the 12 months. 10% of pts declined to attend one or more of the clinic visits due to transport or personal reasons. 3 education sessions were offered: 71%, 61% and 47% attended the 1st (1 month), 2nd (6 weeks) and 3rd (6 months) sessions respectively.
Conclusion: Despite initial motivation from this high risk group of patients, and in the setting of a clinical trial, attendance at the clinic was variable and waned over the course of follow-up. Attendance at the education sessions was less than anticipated, and in particular the later sessions were poorly attended. There are multiple reasons accounting for poor attendance which influence the application of comprehensive management approaches in chronic disease.
