Developing a global practice-based framework of person-centred care from primary data: a cross-national qualitative study with patients, caregivers and healthcare professionals.

INTRODUCTION: Person-centred care (PCC) is internationally recognised as a critical component of high-quality healthcare. However, PCC evolved in a few high-income countries and there are limited data exploring this concept across the vast majority of countries which are low- and middle-income. This study aimed to appraise and adapt a PCC model across three serious physical conditions in three middle-income countries and generate an evidence-based framework and recommendations for globally relevant PCC. METHODS: Cross-national, cross-sectional qualitative study. In depth, semistructured interviews conducted with: advanced cancer patients in Jordan (n=50), their caregivers (n=20) and healthcare professionals (HCPs) (n=20); chronic obstructive pulmonary disease patients in South Africa (n=22), their caregivers (n=19) and HCPs (n=22); heart failure patients in Thailand (n=14), their caregivers (n=10) and HCPs (n=12). Data were analysed using framework analysis. Santana et al's PCC model (2018) and Giusti et al's systematic review (2020) were used to construct an a priori coding frame for deductive analysis, with additional inductive coding for coding that did not fit the frame. RESULTS: The findings both reveal specific practical actions that contribute towards delivering PCC and highlight new cross-national domains of person-centredness: interdependency and collectivism; bringing care into the home and community; equity and non-discrimination; addressing health and illness within the context of limited resources; and workforce well-being. CONCLUSION: The data suggest that PCC requires particular structural features of the healthcare system to be in place, such as professional education in PCC values and partnerships with community-based workers. These structures may better enable PCC processes, including tailored information sharing and providing genuine opportunities for patients to do the things that matter to them, such as making informed care decisions and sustaining social relationships. PCC must also accommodate a collectivist perspective and support the well-being of the workforce.

National trend in heart failure hospitalization and outcome under public health insurance system in Thailand 2008-2013.

BACKGROUND: There are limited data on the burden, characteristics, and outcomes of hospitalized heart failure (HF) patients in Thailand. The aim of this study was to investigate national trend in HF hospitalization rate, in-hospital and 1-year mortality rate, and rehospitalization rate in Thailand. METHODS: We analyzed the claims data of hospitalized patients obtained from the three major Thailand public health reimbursement systems between 2008 and 2013. Patients aged ≥ 18 years with a principal diagnosis of HF by the International Classification of Diseases, Tenth Revision, Thai modification were included. Comorbidities were identified by secondary diagnosis codes. The annual rate of HF hospitalization was calculated per 100,000 beneficiaries. Records of subsequent hospitalization of discharged patients were retrieved. For 1-year mortality rate, vital status of each patient was obtained from Thai Civil Registration of Death database. All outcomes were tested for linear trends across calendar years. RESULTS: Between 2008 and 2013, 434,933 HF hospitalizations were identified. The mean age was 65.3 years (SD 14.6), and 58.1% were female. The HF hospitalization rate increased from 138 in 2008 to 168 per 100,000 beneficiaries in 2013 (P for trend < 0.001). Nearly half (47.4%) had had a prior HF admission within 1 year. A small proportion of patients (7.4%) received echocardiography during hospitalization. The median length of hospital stay was 3 days. In-hospital mortality declined from 4.4 to 3.8% (P for trend < 0.001). The overall 30-day and 1-year rehospitalization rates were 34 and 73%, respectively, without significant trends over the study period. Most common cause of 30-day rehospitalization was HF (42%). One-year mortality decreased from 31.8% in 2008 to 28.5% in 2012 (P for trend < 0.001). CONCLUSION: Between 2008 and 2013, HF hospitalization rate in Thailand increased. The in-hospital and 1-year mortality rates decreased slightly. However, the rehospitalization rate remained high mainly due to recurrent HF hospitalization.

Prognostic Value of Global Longitudinal Strain in Patients With Heart Failure With Improved Ejection Fraction.

OBJECTIVES: The authors sought to determine whether global longitudinal strain (GLS) is independently associated with the natural history of patients with heart failure (HF) with improved ejection fraction (HFimpEF). BACKGROUND: Left ventricular (LV) ejection fraction (EF) often improves in patients with reduced EF. The clinical course of patients with HFimpEF, however, is quite variable. GLS, a sensitive indicator of LV systolic function, could help predict risk of future events in this population. METHODS: Retrospective analysis of HF patients with LVEF >40% on index echocardiogram who had LVEF <40% on initial study and improvement of ≥10%. GLS was assessed by 2-dimensional speckle-tracking software on index echocardiography. Primary outcome was time to first occurrence of cardiovascular mortality or HF hospitalization/emergency treatment. RESULTS: Of the 289 patients with HFimpEF, median absolute values of GLS (aGLS) and LVEF from index echocardiography were 12.7% (IQR: 10.8%-14.7%) and 52% (IQR: 46%-58%), respectively. Over 53 months following index echocardiography, the primary endpoint occurred less frequently in patients with aGLS above the median than below it (21% vs 34%; P = 0.014); HR of 0.51; 95% CI: 0.33-0.81; P = 0.004. When assessed as a continuous variable, each 1% increase in aGLS on index echocardiogram was associated with a lower likelihood of the composite endpoint; HR of 0.86; 95% CI: 0.79-0.93; P < 0.001, an association that persisted after multivariable adjustment; HR 0.90; 95% CI: 0.82-0.97; P = 0.01. Lower aGLS was associated with increased likelihood of deterioration in LVEF. CONCLUSIONS: In patients with HFimpEF, GLS is a strong predictor for future HF events and deterioration in cardiac function.

Association of left ventricular ejection fraction with worsening renal function in patients with acute heart failure: insights from the RELAX-AHF-2 study.

AIMS: Whether risk of worsening renal function (WRF) during acute heart failure (AHF) hospitalization or the association between in-hospital WRF and post-discharge outcomes vary according to left ventricular ejection fraction (LVEF) is uncertain. We assessed incidence of WRF, factors related to its development and impact of WRF on post-discharge outcomes across the spectrum of LVEF in patients enrolled in RELAX-AHF-2. METHODS AND RESULTS: A total of 6112 patients who had LVEF measured on admission and renal function determined prospectively during hospitalization were included. WRF, defined as a rise in serum creatinine ≥0.3 mg/dL from baseline through day 5, occurred in 1722 patients (28.2%). Incidence increased progressively from lowest to highest LVEF quartile (P < 0.001). After baseline adjustment, WRF risk in Q4 (LVEF >50%) remained significantly greater than in Q1 (LVEF ≤29%; hazard ratio 1.2, 95% confidence interval 1-1.43; P = 0.050). Age and comorbidity burden including chronic kidney disease increased as LVEF increased. Neither admission haemodynamic abnormalities, extent of diuresis during hospitalization nor residual congestion explained the increased incidence of WRF in patients with higher LVEF. Serelaxin treatment and diuretic responsiveness were associated with reduced risk of WRF in all LVEF quartiles. WRF in patients in the upper three LVEF quartiles increased risk of post-discharge events. CONCLUSIONS: Worsening renal function incidence during AHF hospitalization increases progressively with LVEF. Greater susceptibility of patients with higher LVEF to WRF appears more related to their advanced age and worse underlying kidney function rather than haemodynamic or treatment effects. WRF is associated with increased risk of post-discharge events except in patients in the lowest LVEF quartile.

Relationship between left ventricular ejection fraction and cardiovascular outcomes following hospitalization for heart failure: insights from the RELAX-AHF-2 trial.

AIMS: Although left ventricular ejection fraction (LVEF) is routinely used to categorize patients with heart failure (HF), whether it predicts outcomes after hospitalization for acute heart failure (AHF) is uncertain. Consequently, we assessed the relationship between LVEF and cardiovascular (CV) outcomes in a large, well characterized cohort of patients hospitalized for AHF. METHODS AND RESULTS: The 6128 patients from the RELAX-AHF-2 trial who had LVEF measured during AHF hospitalization were separated into LVEF quartiles and the relationship between LVEF and a composite of CV mortality and rehospitalization for HF or renal failure through 180 days was assessed. We found progressively lower risk for this composite outcome as LVEF increased (hazard ratio 0.95, 95% confidence interval 0.93-0.98 per 5% LVEF increase, P < 0.001) that was driven predominantly by decreased risk for rehospitalization. The smoothed spline curve depicting risk remained stable as LVEF decreased until reaching approximately 40%, at which point risk increased progressively with further reductions in LVEF. Significant differences between LVEF quartiles for post-discharge CV risk were seen in patients with an ischaemic aetiology or with a history of HF preceding index hospitalization, but were less robust in patients with non-ischaemic aetiology and absent in those with de novo HF. CONCLUSION: In patients hospitalized with AHF, CV events over 180 days were more frequent in patients with lower LVEF. This was due predominantly to a significant increase in risk for HF/renal failure rehospitalization but not in either CV or all-cause mortality. LVEF had greater prognostic value in patients with ischaemic aetiology or pre-existing HF.

Heart failure around the world.

With increasingly large sample sizes required to demonstrate event reduction, heart failure outcome trials are no longer being performed in a small group of selected patients and countries, but at a global scale with worldwide contribution of patients from countries with considerable differences in background therapy, socioeconomic status and healthcare practices. Recent studies have highlighted how socioeconomic determinants rather than geographical factors may underlie the heterogeneity of patient populations across the globe. Therefore, in this review, we evaluated (i) regional differences in patient characteristics and outcomes in recent epidemiologic studies; (ii) regional differences in worldwide representativeness of clinical trial populations; and (iii) the role of socioeconomic determinants in driving country differences in heart failure trial enrolment and clinical outcomes.

Heart failure mortality compared between elderly and non-elderly Thai patients.

OBJECTIVE: To investigate heart failure mortality compared between elderly and non-elderly Thai patients. METHODS: This study included patients at least 18 years of age who were admitted to the hospital with a primary diagnosis of heart failure (ICD-10-TM code: 150.9) during 2008-2012 according to three major Thailand reimbursement systems (civil servant, social security, and universal coverage systems). Patients were categorized into either the elderly group (age > 65 years) or the non-elderly group (age ≤ 65 years). Mortality rate and survival analysis were compared between groups. Demographic, underlying disease and comorbid condition data were collected. Cardiovascular and non-cardiovascular death was also analyzed. RESULTS: A total of 201,709 patients were included. The average age of patients was 64.9 ± 14.8 years, and the gender proportion breakdown was 84,155 (41.7%) males and 117,554 (58.3%) females. Just over half of patients (107,325 patients; 53.2%) were elderly. Overall mortality rate was 50.8%. The mortality rate at one month, six months, one year, and three years was 11.0%, 24.5%, 32.5%, and 46.3%, respectively. Elderly patients had a higher rate of mortality compared to non-elderly patients with an adjusted odds ratio (OR) of 1.47 (95% CI: 1.46-1.49) for all-cause mortality, an OR of 1.25 (95% CI: 1.23-1.27) for cardiovascular death, and an OR of 1.72 (95% CI: 1.68-1.75) for non-cardiovascular death (all P < 0.001). After adjusting for potential confounders, elderly status remained the second strongest factor associated with increased risk of mortality after heart failure hospitalization following chronic kidney disease. CONCLUSIONS: The overall mortality rate after heart failure hospitalization was a very high 50.8%. Multivariate analysis revealed elderly status to be an independent predictor of mortality after hospitalization. This finding suggests that improvements are needed related to the quality of care and follow-up given to elderly Thai heart failure patients.

Correlation between aortic stiffness and left atrial volume index in hypertensive patients.

BACKGROUND: Both arterial stiffness and left atrial volume index are crucial predictors of cardiovascular outcomes in hypertensive patients. The correlation between these two factors has not been previously well established in hypertensive population. OBJECTIVES: To determine the correlation between arterial stiffness and left atrial volume index in hypertensive patients. METHODS AND RESULTS: The study was performed in 111 consecutive hypertensive patients (49.5% male, mean age 70.8 ± 10.3 years) undergoing cardiac magnetic resonance imaging (CMR). Arterial stiffness was determined by pulse wave velocity in the thoracic aorta by velocity-encoded imaging. Left atrial volume was assessed by biplane area-length method. Pulse wave velocity was significantly correlated with left atrial volume index in univariate analysis (r = 0.20, p = 0.032). In multivariate analysis, pulse wave velocity, coronary artery disease and left ventricular mass remain independent predictors (ß = 1.01, p = 0.02). CONCLUSION: Increased arterial stiffness correlates with left atrial enlargement in hypertensive patients. The prevention of left atrial enlargement and subsequent complications by specific antihypertensive drugs with positive effect on aortic stiffness warrants further studies.