Secular trends in the utility of SGLT-2 inhibitors in heart failure patients with type 2 diabetes mellitus across Metro South Health hospitals in South-East Queensland.

BACKGROUND: The 2018 Australian Heart Failure (HF) guidelines strongly recommended commencing sodium-glucose co-transporter-2 inhibitors (SGLT-2is) in HF patients with type 2 diabetes mellitus (T2DM). The uptake of SGLT-2is for HF patients with T2DM in our health service is unknown. AIMS: To determine the adoption of the 2018 HF guidelines by assessing the temporal trends of SGLT-2is' usage in HF patients with T2DM at Metro South Health (MSH) hospitals, in South-East Queensland. METHODS: Retrospective analysis of all HF patients (ejection fraction (EF) < 50%) with T2DM who were managed within MSH hospitals between June 2018 and June 2021. RESULTS: A total of 666 patients met the inclusion criteria with 918 HF encounters. Mean age was 72 years and 71% were male (473/666). Mean EF was 30% (SD ± 11%), and mean estimated glomerular filtration rate was 48 mL/min/1.73 m2 (SD ± 25). Fifty-four per cent (362/666) had contraindications to SGLT-2is. Among those without contraindications, there was a five-fold increase in the utility of SGLT-2is, 7% (2/29) before versus 38% (103/275) after implementation of the HF guidelines (P < 0.001). Patients on SGLT-2is were younger (64 years vs 69 years, P = 0.002) and had a lower number of HF hospitalisations (1.1 vs 2.1, P = 0.01). CONCLUSIONS: During the study period, 54% of our HF patients with T2DM were not on SGLT-2is due to prescribing guidelines/limitations in the Australian context. We observed a five-fold significant increase in the uptake of SGLT-2is before and after implementation of HF guidelines among patients without contraindications to SGLT-2is. There were significantly fewer HF hospitalisations among patients on SGLT-2is compared to those without.

Cardiotoxicity after cancer treatment: a process map of the patient treatment journey.

BACKGROUND/AIM: Cardiotoxicity is a potential complication of anticancer therapy. While guidelines have been developed to assist practitioners, an effective, evidence based clinical pathway for the treatment of cardiotoxicity has not yet been developed. The aim of this study was to describe the journey of patients who developed cardiotoxicity through the healthcare system in order to establish baseline data to inform the development and implementation of a patient-centred, evidence-based clinical pathway. METHODS: Mixed-methods design with quantitative and qualitative components using process mapping at 3 large medical centres in 2 states between 2010 and 2015. RESULTS: Fifty (50) confirmed cases of cardiotoxicity were reviewed (39 medical record reviews, 7 medical record review and interviews and 4 internview only). The mean age at cancer diagnosis of this group was 53.3 years (range 6-89 years); 50% female; 30% breast cancer, 23% non-Hodgkin's lymphoma; mean chemotherapy cycles 5.2 (median 6; range 1-18); 49 (89%) presented to chemotherapy with pre-existing cardiovascular risk factors; 39 (85%) had at least one modifiable risk factor and 11 (24%) had more than 4; 44 (96%) were diagnosed by echocardiogram and 27 (57%) were referred to a cardiologist (only 7 (15%) before chemotherapy). Post chemotherapy, 22 (48%) patients were referred to a multidisciplinary heart failure clinic; 8 (17%) to cardiac rehabilitation; 1 (2%) to cancer survivorship clinic and 10 (22%) to a palliative care service. There were 16 (34%) deaths during the timeframe of the study; 4 (25%) cardiac-related, 6 (38%) cancer-related, 4 (25%) due to sepsis and 2 (12%) other causes not recorded. The main concerns participants raised during the interviews were cancer professionals not discussing the potential for cardiotoxicity with them prior to treatment, nor risk modification strategies; a need for health education, particularly regarding risks for developing heart failure related to cancer treatment; and a lack of collaboration between oncologists and cardiologists. CONCLUSIONS: Our results demonstrate that the clinical management of cancer patients with cardiotoxicity was variable and fragmented and not patient centered. This audit establishes practice gaps that can be addressed through the design of an evidence-based clinical pathway for cancer patients with, or at risk, of cardiotoxicity.

Cost-Utility Analysis of Home-Based Telerehabilitation Compared With Centre-Based Rehabilitation in Patients With Heart Failure.

BACKGROUND: Whilst home-based telerehabilitation has been shown non-inferior to traditional centre-based rehabilitation in patients with chronic heart failure, its economic sustainability remains unknown. This study aimed to investigate the cost-utility of a home-based telerehabilitation program. METHODS: A comparative, trial-based, incremental cost-utility analysis was conducted from a health care provider's perspective. We collected data as part of a multi-centre, two-arm, non-inferiority, randomised controlled trial with 6 months follow-up. There were 53 participants randomised to either a telerehabilitation program (consisting of 12 weeks of group-based exercise and education delivered into the home via online videoconferencing) or a traditional centre-based program. Health care costs (including personnel, equipment and hospital readmissions due to heart failure) were extracted from health system records, and calculated in Australian dollars using 2013 as the base year. Health utilities were measured using the EuroQol five-dimensional (EQ-5D) questionnaire. Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and utility differences were plotted on a cost-effectiveness plane. RESULTS: Total health care costs per participant were significantly lower in the telerehabilitation group (-$1,590, 95% CI: -2,822, -359) during the 6 months. No significant differences in quality-adjusted life years (0, 95% CI: -0.06, 0.05) were seen between the two groups. CONCLUSIONS: Heart failure telerehabilitation appears to be less costly and as effective for the health care provider as traditional centre-based rehabilitation.

Patient preferences for the delivery of cardiac rehabilitation.

OBJECTIVE: To elicit patients' preferences for cardiac rehabilitation(CR). METHODS: A Discrete Choice Experiment was used to quantify patients' preferences for the delivery of CR. This survey-based method elicited the relative importance of different characteristics of a program. RESULTS: 200 in-patients eligible to attend CR completed the survey. Over half of the patients strongly preferred a centre-based compared to a home-based program. Many but not all preferred a program starting within two rather than six weeks of discharge and exercise delivered in a group rather than individual setting, with exercise via the internet using telehealth strongly disliked. Some respondents preferred lifestyle information delivered one-to-one by a health professional, and there was an overall preference against delivery by smart phone Apps. Some preferred a program out of rather than within working hours and a shorter program (four weeks compared to eight weeks). CONCLUSIONS: This study provides further insight into patient preferences for a CR program. Although the strongest preferences were for centre-based programs with healthcare professionals facilitating exercise classes and one-on-one education, it is important to offer flexible delivery as one approach will not suit everyone. PRACTICE IMPLICATIONS: There is the potential to improve CR programs by focusing on patient preferences.

Exploring patient experiences and perspectives of a heart failure telerehabilitation program: A mixed methods approach.

OBJECTIVES: To describe patient experiences and perspectives of a group-based heart failure (HF) telerehabilitation program delivered to the homes via online video-conferencing. BACKGROUND: Limited information currently exists on patient experiences of telerehabilitation for HF. Patient feedback and end-user perspectives provide important information regarding the acceptability of this new delivery model which may have a substantial impact on future uptake. METHODS: We used mixed-methods design with purposive sampling of patients with HF. We used self-report surveys and semi-structured interviews to measure patient experiences and perspectives following a 12-week telerehabilitation program. The telerehabilitation program encompassed group-based exercise and education, and were delivered in real-time via videoconferencing. Interviews were transcribed and coded, with thematic analysis undertaken. RESULTS: Seventeen participants with HF (mean age [SD] of 69 [12] years and 88% males) were recruited. Participants reported high visual clarity and ease of use for the monitoring equipment. Major themes included motivating and inhibiting influences related to telerehabilitation and improvement suggestions. Participants liked the health benefits, access to care and social support. Participants highlighted a need for improved audio clarity and connectivity as well computer training for those with limited computer experience. The majority of participants preferred a combined face-to-face and online delivery model. CONCLUSION: Participants in this study reported high visual clarity and ease-of-use, but provided suggestions for further improvements in group-based video telerehabilitation for HF.

Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure?

Introduction This study aimed to determine the validity and reliability of video-based telerehabilitation assessments in patients with heart failure. Methods Seventeen consecutive participants (mean age 69 years, SD 12 years and 88% males) undertook assessments of three functional tests via both telerehabilitation and face-to-face approaches, on the same day. The assessment order was randomised and conducted by independent assessors. Outcome measures included functional tests: timed up and go (time), six-minute walk (distance), grip strength (kilograms); system usability scale to rate participant experience with telerehabilitation assessment; and number of technical issues encountered. Validity and inter- and intra-rater reliability of telerehabilitation assessments were examined using limits of agreement, intra-class correlation coefficients (ICC), and paired t-tests. Results The limits of agreement for telerehabilitation assessments were within the clinically acceptable limits for timed up and go and grip strength. Telerehabilitation assessments for all functional tests were strongly associated with face-to-face assessments, with ICCs of between 0.85 and 0.96. Inter- and intra-rater reliability of telerehabilitation assessments for all functional tests were excellent (all ICC > 0.95). The mean (SD) system usability scale score was 85 (15)/100. Some incidences of Internet drop-outs, video freezing and auditory fading occurred. Discussion The use of telehealth for the assessment of functional exercise capacity appears to be valid and reliable in patients with heart failure.

The Self-care Educational Intervention for Patients With Heart Failure: A Study Protocol.

BACKGROUND: A variety of educational interventions have been implemented to assist patients with heart failure (HF) to maintain their own health, develop self-care behaviors, and decrease readmissions. The most effective approach to education has yet to be established. OBJECTIVE: The aim of this study is to determine the effectiveness of a multimedia educational intervention for patients with HF in reducing hospital readmissions. Secondary outcomes include changes in knowledge and self-care behaviors. METHODS: A randomized controlled trial in a large tertiary referral hospital in Australia has recruited 200 patients and will follow them for 12 months. Patients diagnosed with HF have been randomly allocated 1:1 to either usual education or a multimedia educational intervention. Framed by the principles of adult learning, this individualized intervention was delivered face to face by a specialized HF nurse, with a targeted educational assessment and subsequent development of an educational plan. The multimedia approach combined viewing a DVD and verbal discussion supported by a written manual. The teach-back strategy at the conclusion of the intervention evaluated the patient's learning through 5 key questions about self-management of HF. Readmissions are assessed at 28 days, 3 months, and 12 months. Knowledge and self-care behavior are assessed at baseline, 3 months, and 12 months. CONCLUSIONS: This study evaluates the effectiveness of a targeted multimedia educational intervention. Study results may inform the design of in-hospital education for HF patients.

Education material for heart failure patients: what works and what does not?

Patient education is an important element of care, but evidence with regard to education material is not always apparent, as it is intertwined with educational strategies as components of heart failure management programs. Difficulties have arisen in determining the effectiveness of particular education strategies, as multiple strategies are commonly bundled together and packaged within research protocols. To further complicate this issue, the bundles are diverse, lack precision in describing their components, and report different outcomes. Despite these difficulties, clinicians can utilise a number of proven commonalities to deliver effective education: assessment of learning needs and style, verbal interaction with a healthcare professional, and a selection of multimedia patient education materials.

Pilot testing of a self-care education intervention for patients with heart failure.

BACKGROUND: A key component of the structured approach to the management of chronic heart failure (CHF) is effective patient education. Patient education is a precursor to performing appropriate health-related behaviours that can decrease rehospitalizations. AIM: To pilot test an educational intervention and to determine the efficacy of a self-care manual combined with a DVD for patients with CHF. Outcomes of interest included heart failure-related knowledge and self-care behaviours. METHODS: This pilot study enrolled a sample of 38 patients with CHF. A pre-test/post-test design was conducted to assess changes in knowledge and self-care abilities. Knowledge was assessed with the Dutch Heart Failure Knowledge Scale and self-care behaviours were assessed using the Self-Care of Heart Failure Index. RESULTS: Of the 38 participants 71% were male, 50% were aged between 65 and 74 years, and 31.6% had not completed Year 10 education. There was a statistically significantly difference in the pre- and post-test scores for knowledge (p < 0.0001). Self-care showed positive improvement between pre- and post-test scores; maintenance (p = 0.027), management (p < 0.0001) and confidence (p = 0.051). CONCLUSION: This pilot study has indicated that a patient-centred self-care manual combined with a DVD is beneficial and is associated with an improvement in patients' knowledge and self-care abilities. PRACTICE IMPLICATIONS: Healthcare professionals should utilize multimedia educational resources specifically designed to meet the learning needs of patients with CHF.

Frequency of urinary incontinence in people with chronic heart failure.

OBJECTIVES: The purpose of the study was to examine the frequency and severity of urinary incontinence in people with heart failure (HF). Secondary aims were to determine the differences in known risk factors for those who were continent and incontinent, to investigate the correlates of urinary incontinence in people with HF, and to examine the relationship between urinary incontinence with medication adherence, in particular, diuretics, and quality of life. BACKGROUND: Urinary incontinence is a common condition affecting older adults. However, the frequency of incontinence in people with HF remains largely unknown. METHODS: This was a descriptive study. A convenience sample of 181 people with HF were surveyed to determine frequency, severity and presence of risk factors of urinary incontinence and dosages of prescribed HF medications. Instruments included the Revised Urinary Incontinence Scale, Medication Adherence Report Scale and Incontinence Impact Questionnaire Short Form. Regression analyses were used to examine relationships between variables and presence of urinary incontinence. RESULTS: Eighty-nine people responded (66% male, mean age 67 years), 44 (49%) self-reporting urinary incontinence. Of these, 30 (34%) respondents rated their incontinence severity as slight or moderate. More incontinent respondents took furosemide doses greater than 20 mg daily (P = 0.046) and low doses of beta-blockers compared with continent respondents (P = 0.002). Taking low doses of beta-blockers explained 23% of variance for urinary incontinence (r(2) = 0.23, P = 0.015). Incontinent respondents reported altering or missing a diuretic dose (P < 0.02) compared with those who were continent. CONCLUSIONS: Frequency of urinary incontinence in this group of people with HF appears high. It appears that screening for urinary incontinence may be important as part of routine care in HF management programmes. In addition, awareness of dosages of furosemide and beta-blockers and in particular, adherence to diuretics also should be monitored. Prospective studies investigating these issues and the effect of targeted interventions are required.

Learning for heart failure patients (The L-HF patient study).

AIM AND OBJECTIVE: To investigate the learning style and preferences for information delivery of heart failure patients for the purpose of informing the design of educational resources. BACKGROUND: Patient education is a vital component of heart failure management programmes however the content and delivery of education varies in each programme. Traditionally education programmes for patients have focussed on educational needs as identified by health care providers however research has shown there are discrepancies between patients' and nurses' perceptions of the learning needs of heart failure patients. There is no evidence that educational programmes for heart failure patients are based on identification of patients learning needs or their preferred learning style. DESIGN: Qualitative. METHOD: A purposive sample of 12 participants, diagnosed with heart failure and enrolled in a heart failure management programme, participated in semi-structured interviews. RESULTS: Four themes emerged: knowledge quest (L-loading), barriers to learning (L-inhibitors), facilitators for learning (L-agonists), and meeting educational needs (L-titration). Integral to these themes was the participant's relationship with health care professionals. CONCLUSION: This study provides unique information regarding the preferred learning modality of heart failure patients and, as such, serves to inform the development of appropriate education resources specifically tailored for this population. RELEVANCE TO CLINICAL PRACTICE: The development of effective modes of education is likely to further enhance heart failure management programmes service organisation and delivery and improve health outcomes for heart failure patients.

Learning style and learning needs of heart failure patients (The Need2Know-HF patient study).

BACKGROUND: Heart failure management programs which include education are the gold standard for management of patients with heart failure. Identifying the learning styles and learning needs of heart failure patients is an essential step in developing effective education strategies within these programs. AIM: To investigate the learning style and learning needs of heart failure patients. METHODS: Patients diagnosed with heart failure at a large tertiary referral hospital completed a Heart Failure Learning Style and Needs Inventory. RESULTS: From the total of 55 patients who completed the questionnaire 64% reported a preference for multimodal learning style, 18% preferred read/write, 11% preferred auditory, and 7% preferred kinesthetic. In relation to educational topics, signs and symptoms was ranked as the most important topic to learn about followed by prognosis. CONCLUSION: This study provides a poignant snap-shot into the world of chronic disease. In essence, the patients' educational needs for living with heart failure can be summed up as "Never better, getting worse, unpredictable". The results indicate that these groups of patients need to know (Need2Know) about information regarding their signs and symptoms as well as wanting to elicit the significance of their disease and whether it can be cured.

Improving survival after in-hospital cardiac arrest: the Australian experience.

BACKGROUND: Survival rates after in-hospital cardiac arrest have not improved markedly despite improvements in technology and resuscitation training. OBJECTIVES: To investigate clinical variables that influence return of spontaneous circulation and survival to discharge after in-hospital cardiac arrest. METHODS: An Utstein-style resuscitation template was implemented in a 750-bed hospital. Data on 158 events were collected from January 2004 through November 2004. Significant variables were analyzed by using a multiple logistic regression model. RESULTS: Of the 158 events, 128 were confirmed cardiac arrests. Return of spontaneous circulation occurred in 69 cases (54%), and the patient survived to discharge in 41 (32%). An initial shockable rhythm was present in 42 cases (33%), with a return of spontaneous circulation in 32 (76%) and survival to discharge in 24 (57%). An initial nonshockable rhythm was present in the remaining 86 cases (67%), with a return of spontaneous circulation in 37 (43%) and survival to discharge in 17 (20%). Witnessed or monitored arrests (P=.006), time to arrival of the cardiac arrest team (P=.002), afternoon shift (P=.02), and initial shockable rhythm (P=.005) were independently associated with return of spontaneous circulation. Location of patient in a critical care area (P=.002), initial shockable rhythm (P<.001), and length of resuscitation (P=.02) were independently associated with survival to hospital discharge. CONCLUSIONS: The high rate of survival to discharge after cardiac arrest is attributed to extensive education and the incorporation of semiautomatic external defibrillators into basic life support management.