Evaluation of a Community Health Service Center-Based Intervention Program for Managing Chronic Heart Failure

Abstract

Background: Although the role of primary care for the management of patients with chronic heart failure (CHF) has been highly recommended, structural involvement of primary care in heart failure (HF) management programs is extremely limited Aims: To examine the feasibility and applicability of two most recommended forms of care delivery mode, home visit and telephone support, for CHF management in the setting of community health service center (CHSC). Study Design: Prospective study. Methods: This study was conducted in two CHSCs in Beijing, China. Care delivery was led by trained general practitioners or community nurses via home visits in one CHSC and telephone support in the other. Data regarding the change in mortality and hospitalization rate during 12 months and self-care level at 6 months were prospectively collected and compared across the intervention groups. Results: A total of 329 patients were included, with 142 in the home visit group and 187 in the telephone support group. Patients in both groups had frequent visits to CHSC (8.1±5.9 in the home visit and 7.7±4.1 in the telephone support group, p=0.45) during the follow-up period. Compared to the telephone support group, patients in the home visit group showed a reduction in all-cause mortality (14.1% versus 20.3%, p=0.14), one or more hospitalizations due to any cause (33.8% versus 44.2%, p=0.12) and one or more hospitalizations due to cardiac cause (17.6% versus 24.6%, p=0.13) in the home visit group. The absolute differences were 6.2% (95% CI: 1.9%, 14.3%), 8.4% (95% CI: 2.1%, 18.9%) and 7.3% (95% CI: 1.5%, 16.1%), respectively, although the results were not statistically significant. After 6 months of intervention, patients in both groups achieved marked improvement in self-care with reference to their own baseline values. Conclusion: Although no statistical difference was observed between the two care delivery approaches regarding the clinical outcomes of interest, given the high participation rates, the acceptable rate of adverse events, frequent CHSC visits and patients’ preferences in the current study, it was concluded that CHSC might be the optimal setting for delivering care to CHF patients in China.

Keywords

• Chronic heart failure, home visit, mortality rate, primary care, telephone support

References

1. 1. Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008. JAMA 2011;306:1669-78. [CrossRef]
2. 2. Parissis J, Athanasakis K, Farmakis D, Boubouchairopoulou N, Mareti C, Bistola V, et al. Determinants of the direct cost of heart failure hospitalization in a public tertiary hospital. Int J Cardiol 2014;180C:46-9.
3. 3. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 2013;127:e6-e245. [CrossRef]
4. 4. Dai G. Heart failure in China: review and prospect. Zhonghua Xin Xue Guan Bing Za Zhi 2015;43:104-7.
5. 5. Maeder MT, Rickli H, Pfisterer ME, Muzzarelli S, Ammann P, Fehr T, et al. Incidence, clinical predictors, and prognostic impact of worsening renal function in elderly patients with chronic heart failure on intensive medical therapy. Am Heart J 2012;163:407-14, 14 e1.
6. 6. Curtis LH, Whellan DJ, Hammill BG, Hernandez AF, Anstrom KJ, Shea AM, et al. Incidence and prevalence of heart failure in elderly persons, 1994-2003. Arch Intern Med 2008;168:418-24. [CrossRef]
7. 7. Vuorinen AL, Leppanen J, Kaijanranta H, Kulju M, Helio T, van Gils M, et al. Use of home telemonitoring to support multidisciplinary care of heart failure patients in Finland: randomized controlled trial. J Med Internet Res 2014;16:e282. [CrossRef]
8. 8. Smith CE, Piamjariyakul U, Wick JA, Spertus JA, Russell C, Dalton KM, et al. Multidisciplinary Group Clinic Appointments: The Self-Management and Care of Heart Failure (SMAC-HF) Trial. Circ Heart Fail 2014;7:888-94. [CrossRef]

9. 9. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 2004;44:810-9. [CrossRef]
10. 10. Kasper EK, Gerstenblith G, Hefter G, Van Anden E, Brinker JA, Thiemann DR, et al. A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol 2002;39:471-80. [CrossRef]
11. 11. Azad NA, Molnar FJ, Byszewski AM. Multidisciplinary congestive heart failure clinic for older women: a randomized, controlled trial. J Am Geriatr Soc 2006;54:874-5. [CrossRef]
12. 12. Wijeysundera HC, Trubiani G, Wang X, Mitsakakis N, Austin PC, Ko DT, et al. A population-based study to evaluate the effectiveness of multidisciplinary heart failure clinics and identify important service components. Circ Heart Fail 2013;6:68-75. [CrossRef]
13. 13. Koh C. Chronic heart failure management in Australia--time for general practice centred models of care? Aust Fam Physician 2013;42:521.
14. 14. Vilaseca J, Dedeu T, de Graaf P, Hobbs R, Muth C, Martensson J, et al. Chronic heart failure: the role of primary care - position paper of the European Forum for Primary Care. Qual Prim Care 2008;16:351-62.
15. 15. Ahmedov M, Green J, Azimov R, Avezova G, Inakov S, Mamatkulov B. Addressing the challenges of improving primary care quality in Uzbekistan: a qualitative study of chronic heart failure management. Health Policy Plan 2013;28:458-66. [CrossRef]
16. 16. Chao J, Wang Y, Xu H, Yu Q, Jiang L, Tian L, et al. The effect of community-based health management on the health of the elderly: a randomized controlled trial from China. BMC Health Serv Res 2012;12:449. [CrossRef]
17. 17. Zhao F, Zheng JZ, Chen BW, Xie XH. Analyses on the effect of community-based intervention on hypertension. Zhonghua Liu Xing Bing Xue Za Zhi 2003;24:897-900.
18. 18. Stewart S, Carrington MJ, Marwick T, Davidson PM, Macdonald P, Horowitz J, et al. The WHICH? trial: rationale and design of a pragmatic randomized, multicentre comparison of homevs. clinic-based management of chronic heart failure patients. Eur J Heart Fail 2011;13:909-16. [CrossRef]
19. 19. Riegel B, Lee CS, Dickson VV, Carlson B. An update on the self-care of heart failure index. J Cardiovasc Nurs 2009;24:485- 97. [CrossRef]
20. 20. Riegel B, Carlson B, Moser DK, Sebern M, Hicks FD, Roland V. Psychometric testing of the self-care of heart failure index. J Card Fail 2004;10:350-60. [CrossRef]
21. 21. Tung HH, Chen SC, Yin WH, Cheng CH, Wang TJ, Wu SF. Self care behavior in patients with heart failure in Taiwan. Eur J Cardiovasc Nurs 2012;11:175-82.
22. 22. Stewart S, Carrington MJ, Marwick TH, Davidson PM, Macdonald P, Horowitz JD, et al. Impact of home versus clinic-based management of chronic heart failure: the WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care) multicenter, randomized trial. J Am Coll Cardiol 2012;60:1239-48. [CrossRef]
23. 23. Jaarsma T, van der Wal MH, Lesman-Leegte I, Luttik ML, Hogenhuis J, Veeger NJ, et al. Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Arch Intern Med 2008;168:316-24. [CrossRef]
24. 24. Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002;105:2861-6. [CrossRef]
25. 25. Ekman I, Andersson B, Ehnfors M, Matejka G, Persson B, Fagerberg B. Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure. Eur Heart J 1998;19:1254-60. [CrossRef]
26. 26. Whitty JA, Stewart S, Carrington MJ, Calderone A, Marwick T, Horowitz JD, et al. Patient preferences and willingness-topay for a home or clinic based program of chronic heart failure management: findings from the Which? trial. PLoS One 2013;8:e58347. [CrossRef]
27. 27. Ritzema J, Troughton R, Melton I, Crozier I, Doughty R, Krum H, et al. Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure. Circulation 2010;121:1086-95. [CrossRef]
28. 28. Chen XJ, Gao XL, You GY, Jiang J, Sun XL, Li X, et al. Higher blood pressure control rate in a real life management program provided by the community health service center in China. BMC Public Health 2014;14:801. [CrossRef]
29. 29. Liu LJ, Li Y, Sha K, Wang Y, He X. Patient assessment of chronic illness care, glycemic control and the utilization of community health care among the patients with type 2 diabetes in Shanghai, China. PLoS One 2013;8:e73010.[CrossRef