Use of regional transmural agreements to support the right care in the right place for patients with chronic heart failure-a qualitative study.

BACKGROUND: Chronic heart failure (CHF) poses a major challenge for healthcare systems. As these patients' needs vary over time in intensity and complexity, the coordination of care between primary and secondary care is critical for them to receive the right care in the right place. To support the continuum of care needed, Dutch regional transmural agreements (RTAs) between healthcare providers have been developed. However, little is known about how the stakeholders have experienced the development and use of these RTAs. The aim of this study was to gain insight into how stakeholders have experienced the development and use of RTAs for CHF and explore which factors affected this. METHODS: We interviewed 25 stakeholders from 9 Dutch regions based on the Measurement Instrument for Determinants of Innovations framework. Interview recordings were transcribed verbatim and analysed through open thematic coding. RESULTS: In most cases, the RTA development was considered relatively easy. However, the participants noted that sustainable use of the RTAs faced different complexities and influencing factors. These barriers concerned the following themes: education of primary care providers, referral process, patients' willingness, relationships between healthcare providers, reimbursement by health insurance companies, electronic health record (EHR) systems and outcomes. CONCLUSION: Some complexities, such as reimbursement and EHR systems, are likely to benefit from specialised support or a national approach. On a regional level, interregional learning can improve stakeholders' experiences. Future research should focus on quantitative effects of RTAs on outcomes and potential financing models for projects that aim to transition care from one setting to another.

Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study.

OBJECTIVES: The purpose of this study was to assess whether management of heart failure (HF) guided by an individualized N-terminal pro-B-type natriuretic peptide (NT-proBNP) target would lead to improved outcome compared with HF management guided by clinical assessment alone. BACKGROUND: Natriuretic peptides may be attractive biomarkers to guide management of heart failure (HF) and help select patients in need of more aggressive therapy. The PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study is, to our knowledge, the first large, prospective randomized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome. METHODS: A total of 345 patients hospitalized for decompensated, symptomatic HF with elevated NT-proBNP levels at admission were included. After discharge, patients were randomized to either clinically-guided outpatient management (n = 171), or management guided by an individually set NT-proBNP (n = 174) defined by the lowest level at discharge or 2 weeks thereafter. The primary end point was defined as number of days alive outside the hospital after index admission. RESULTS: HF management guided by this individualized NT-proBNP target increased the use of HF medication (p = 0.006), and 64% of HF-related events were preceded by an increase in NT-proBNP. Nevertheless, HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point (685 vs. 664 days, p = 0.49), nor did it significantly improve any of the secondary end points. In the NT-proBNP-guided group mortality was lower, as 46 patients died (26.5%) versus 57 (33.3%) in the clinically-guided group, but this was not statistically significant (p = 0.206). CONCLUSIONS: Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy, but failed to provide significant clinical improvement in terms of mortality and morbidity. (Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [PRIMA]; NCT00149422).

Measuring body composition in chronic heart failure: a comparison of methods.

AIMS: Fat-free mass (FFM) is increasingly recognized as a systemic marker of disease severity in chronic organ failure and is an important target for physiologic and pharmacologic interventions to improve functional status. The aim of this study was therefore to evaluate two clinical methods to assess FFM in patients with chronic heart failure (CHF) using deuterium dilution (DEU) as reference and bromide dilution to assess the ratio between intracellular (ICW) and extracellular water (ECW) as potential confounder. METHODS: Body composition was measured with dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA) and DEU in 22 stable patients from our heart failure outpatient clinic and 24 healthy age matched controls. RESULTS: FFM values measured by DXA and DEU in patients (r = 0.92, SEE: 3.1 kg) and controls (r = 0.99, SEE: 1.3 kg) were strongly related. In both patients and controls, the inter method difference increased with higher values of FFM (DXA overestimating DEU). The ICW/ECW ratio was within the normal range and comparable between the groups. In patients, a highly significant correlation coefficient was found (r = 0.93, SEE 2.1 p = 0.01) between total body water (DEU) and height squared/resistance (Ht2/R). On multiple regression next to Ht2/R, body weight was an independent predictor of FFM(DEU) (r = 0.95, SEE 2.5 kg, p<0.001; TBWdeu = 0.528 Ht2/R + (0.182 weight) + 8.277). CONCLUSION: DXA and DEU are appropriate and interchangeable laboratory methods for assessment of FFM in clinically stable heart failure patients, however, overestimation of FFM(DXA) should be considered. BIA is a suitable clinical alternative for diagnostic purposes.

Predicting capacities required in cardiology units for heart failure patients via simulation.

The management of a department of cardiology has to plan the capacity of both elective and non-elective patients. Heart failure (HF) patients are admitted to the hospital in a non-elective way. The precision with which the capacity needed for non-elective patients can be predicted determines the degree of flexibility in planning the admission of elective patients. In this study we want to determine how accurately we can predict the bed occupancy of HF patients using a simulation model. Data of the year 2000 were used to obtain the necessary probability distribution functions. Data from the year 2001 were used for determining the prediction accuracy. The results show that the arrival of new HF patients can be adequately predicted. However, the bed occupancy by new and especially current patients is predicted less accurately. Still in 70% (90%) of the days of a 5-day-prediction interval the error is at most one (two) bed(s). The results may improve if the cardiologist is asked to predict the length of stay of the current patients.