Effectiveness and Factors Determining the Success of Management Programs for Patients With Heart Failure: A Systematic Review and Meta-analysis.

INTRODUCTION AND OBJECTIVES: Heart failure management programs reduce hospitalizations. Some studies also show reduced mortality. The determinants of program success are unknown. The aim of the present study was to update our understanding of the reductions in mortality and readmissions produced by these programs, elucidate their components, and identify the factors determining program success. METHODS: Systematic literature review (1990-2014; PubMed, EMBASE, CINAHL, Cochrane Library) and manual search of relevant journals. The studies were selected by 3 independent reviewers. Methodological quality was evaluated in a blinded manner by an external researcher (Jadad scale). These results were pooled using random effects models. Heterogeneity was evaluated with the I2 statistic, and its explanatory factors were determined using metaregression analysis. RESULTS: Of the 3914 studies identified, 66 randomized controlled clinical trials were selected (18 countries, 13 535 patients). We determined the relative risks to be 0.88 for death (95% confidence interval [95%CI], 0.81-0.96; P < .002; I2, 6.1%), 0.92 for all-cause readmissions (95%CI, 0.86-0.98; P < .011; I2, 58.7%), and 0.80 for heart failure readmissions (95%CI, 0.71-0.90; P < .0001; I2, 52.7%). Factors associated with program success were implementation after 2001, program location outside the United States, greater baseline use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, a higher number of intervention team members and components, specialized heart failure cardiologists and nurses, protocol-driven education and its assessment, self-monitoring of signs and symptoms, detection of deterioration, flexible diuretic regimen, early care-seeking among patients and prompt health care response, psychosocial intervention, professional coordination, and program duration. CONCLUSIONS: We confirm the reductions in mortality and readmissions with heart failure management programs. Their success is associated with various structural and intervention variables.

Efectividad y determinantes del éxito de los programas de atención a pacientes con insuficiencia cardiaca: revisión sistemática y metanálisis / Effectiveness and factors determining the success of management programs for patients with heart failure: a systematic review and meta-analysis

Introducción y objetivos: Los programas de atención a pacientes de insuficiencia cardiaca reducen ingresos hospitalarios. Algunos estudios reducen mortalidad. Se desconocen los determinantes del éxito. El objetivo es actualizar el conocimiento sobre la reducción de mortalidad y reingresos de estos programas, describir sus componentes e identificar factores condicionantes de resultados. Métodos: Revisión sistemática de la bibliografía (1990-2014) (PubMed, EMBASE, CINAHL, Cochrane Library) y búsqueda manual en revistas relevantes. Tres revisores independientes seleccionaron los estudios. La calidad metodológica fue evaluada a ciegas por una investigadora externa (escala Jadad). Los resultados se combinaron mediante modelos de efectos aleatorios. La heterogeneidad se evaluó con el estadístico I2, y se determinaron sus factores explicativos mediante análisis de metarregresión. Resultados: Se identificaron 3.914 estudios. Se seleccionaron 66 ensayos clínicos controlados y aleatorizados (18 países, 13.535 pacientes), y se observaron riesgos relativos de muerte de 0,88 (intervalo de confianza del 95% [IC95%], 0,81-0,96; p < 0,002; I2, 6,1%), reingresos por todas las causas de 0,92 (IC95%, 0,86-0,98; p < 0,011; I2, 58,7%) y reingresos por insuficiencia cardiaca de 0,80 (IC95% 0,71-0,90; p < 0,0001; I2, 52,7%). Factores asociados al éxito: programas posteriores a 2001, no realizados en Estados Unidos, mayor uso basal de inhibidores de la enzima de conversión de la angiotensina/antagonistas del receptor de la angiotensina II, mayor número de profesionales y componentes de la intervención, especialización del cardiólogo y la enfermera, educación protocolizada y evaluada, automonitorización de signos y síntomas, reconocimiento de descompensación, pauta flexible de diuréticos, aviso y atención precoz, intervención psicosocial, coordinación de profesionales y duración del programa. Conclusiones: Se confirma la reducción de mortalidad y reingresos con los programas de insuficiencia cardiaca, cuyo éxito se asoció con diferentes variables de estructura e intervención (AU)

Introduction and objectives: Heart failure management programs reduce hospitalizations. Some studies also show reduced mortality. The determinants of program success are unknown. The aim of the present study was to update our understanding of the reductions in mortality and readmissions produced by these programs, elucidate their components, and identify the factors determining program success. Methods: Systematic literature review (1990-2014; PubMed, EMBASE, CINAHL, Cochrane Library) and manual search of relevant journals. The studies were selected by 3 independent reviewers. Methodological quality was evaluated in a blinded manner by an external researcher (Jadad scale). These results were pooled using random effects models. Heterogeneity was evaluated with the I2 statistic, and its explanatory factors were determined using metaregression analysis. Results: Of the 3914 studies identified, 66 randomized controlled clinical trials were selected (18 countries, 13 535 patients). We determined the relative risks to be 0.88 for death (95% confidence interval [95%CI], 0.81-0.96; P < .002; I2, 6.1%), 0.92 for all-cause readmissions (95%CI, 0.86-0.98; P < .011; I2, 58.7%), and 0.80 for heart failure readmissions (95%CI, 0.71-0.90; P < .0001; I2, 52.7%). Factors associated with program success were implementation after 2001, program location outside the United States, greater baseline use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, a higher number of intervention team members and components, specialized heart failure cardiologists and nurses, protocol-driven education and its assessment, self-monitoring of signs and symptoms, detection of deterioration, flexible diuretic regimen, early care-seeking among patients and prompt health care response, psychosocial intervention, professional coordination, and program duration. Conclusions: We confirm the reductions in mortality and readmissions with heart failure management programs. Their success is associated with various structural and intervention variables (AU)

Extubaciones no programadas en pacientes sometidos a fase de destete en cuidados intensivos: incidencia y factores de riesgo / Unplanned extubations in patients in the ventilator weaning phase in the intensive care unit: Incidence and risk factors

Objetivos. Cuantificar la incidencia de extubaciones no programadas (ENP) en una unidad de cuidados intensivos (UCI) polivalente y determinar los factores de riesgo. Método. Estudio observacional, prospectivo y analítico realizado en una UCI polivalente de 8 camas durante un período de 6 meses. Los 79 participantes se eligieron por orden consecutivo de ingreso. Los criterios de inclusión fueron que estuviesen sometidos a ventilación mecánica (VM) durante al menos durante 12h y que pasaran por la fase de destete de VM. Se valoró edad, días con tubo endotraqueal (TET), días de estancia en la UCI, fase de destete de VM y nivel de sedación y/o agitación mediante la escala sedación agitación de Riker y el índice pronóstico APACHE II. Se calculó la densidad de incidencia para ENP y se compararon las variables medidas en el grupo de pacientes extubados y no extubados mediante el test de comparación de la U de Mann-Whitney. Resultados. De los 79 casos que constituyeron la muestra, se constataron 15 casos (18,9%) de ENP, de los que el 76,9% ocurrió durante la fase de destete. Un 73,3% (11 casos) se debió a autoextubación, un 20% (3 casos) por causa accidental y un 6,6% (un caso) por obstrucción del TET. La edad menor o igual a 60 años fue un factor de riesgo, no objetivándose relación con otros factores a estudio: días de estancia, días con TET y APACHE. Conclusiones. Los pacientes en riesgo de ENP se caracterizan por una edad más joven y un estado de agitación según la escala Riker. Las ENP ocurren, generalmente, cuando el paciente se encuentra durante la fase de destete del ventilador(AU)

Objectives. To identify the incidence of unplanned extubations (UE) in a general intensive care unit (ICU) and associated risk factors. Methods. An analytical, observational and prospective study was performed in an eight-bed general ICU over a 6-month period. The participants consisted of 79 consecutive patients who underwent mechanical ventilation for 12h or more and who were under the ventilator weaning phase. The variables studied were age, days of endotracheal intubation, length of stay in the ICU, weaning phase and the APACHE II prognostic score; the degree of sedation and/or agitation was evaluated using Riker's Sedation-Agitation Scale. The incidence density of UEs was calculated and the variables measured in the extubated and non-extubated groups were compared using the Mann Whitney U-test. Results. Among the 79 patients studied, UE occurred in 15 (18.9%). Of these events, 76.9% occurred during the ventilator weaning phase. There were 11 cases (73.3%) of self-extubations, three cases (20%) of accidental removal and one case (6.6%) of endotracheal tube obstruction. Age equal to or less than 60 years was a risk factor. No relationship was found with the remaining factors studied: days of hospital stay, days of endotracheal intubation or APACHE score. Conclusions. Patients at risk for UE were younger and showed agitation on the Riker scale. UEs usually occurred during the ventilator weaning phase(AU)

[Unplanned extubations in patients in the ventilator weaning phase in the intensive care unit: Incidence and risk factors]. / Extubaciones no programadas en pacientes sometidos a fase de destete en cuidados intensivos: incidencia y factores de riesgo.

OBJECTIVES: To identify the incidence of unplanned extubations (UE) in a general intensive care unit (ICU) and associated risk factors. METHODS: An analytical, observational and prospective study was performed in an eight-bed general ICU over a 6-month period. The participants consisted of 79 consecutive patients who underwent mechanical ventilation for 12 h or more and who were under the ventilator weaning phase. The variables studied were age, days of endotracheal intubation, length of stay in the ICU, weaning phase and the APACHE II prognostic score; the degree of sedation and/or agitation was evaluated using Riker's Sedation-Agitation Scale. The incidence density of UEs was calculated and the variables measured in the extubated and non-extubated groups were compared using the Mann Whitney U-test. RESULTS: Among the 79 patients studied, UE occurred in 15 (18.9%). Of these events, 76.9% occurred during the ventilator weaning phase. There were 11 cases (73.3%) of self-extubations, three cases (20%) of accidental removal and one case (6.6%) of endotracheal tube obstruction. Age equal to or less than 60 years was a risk factor. No relationship was found with the remaining factors studied: days of hospital stay, days of endotracheal intubation or APACHE score. CONCLUSIONS: Patients at risk for UE were younger and showed agitation on the Riker scale. UEs usually occurred during the ventilator weaning phase.