What the General Practitioner Needs to Know About Their Chronic Heart Failure Patient.
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ABSTRACT:
SUBMITTER: Rutten FH
PROVIDER: S-EPMC5490985 | biostudies-other | 2016 Nov
REPOSITORIES: biostudies-other
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Project description:BACKGROUND:Chronic heart failure (CHF) is the most common reason for hospital admissions in Germany. For the National Disease Management Guideline (NDMG) on CHF, a multidisciplinary expert panel revised the chapters on drug therapy, invasive therapy, and care coordination, following the methods of evidence-based medicine. METHODS:Recommendations are based on international guideline adaptations or systematic literature search. They were developed by a multidisciplinary expert panel, approved in a formal consensus procedure, and tested in open consultation, as specified by the requirements for S3 guidelines. RESULTS:The pharmacological treatment is based on ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists as well as diuretics to treat fluid retention, if present. Sacubitril/Valsartan and ivabradine showed positive effects on mortality in large but methodologically limited RCT. They are recommended if established combination therapy is not sufficient for symptom control, or if drugs are not tolerated/contraindicated. The indications for pacemakers or defibrillators have been confined to patient subgroups in which clinical trials have shown a clear benefit. Moreover, the goals of treatment and the patient's expectations should be aligned with each other. Structured care programs, specialized nurses, remote, or telephone monitoring showed moderate effects on patient related outcomes in RCT. CONCLUSION:All patients with heart failure are suggested to be enrolled in a structured program (e.g., a disease management program) including coordinated multidisciplinary care and continuous educational interventions. In patients with a poor prognosis, more intensive care is recommended, e.g. specialized nurses, or telephone support.
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Project description:The Care-Related Quality of Life survey for Chronic Heart Failure (CaReQoL CHF) is a newly developed patient-reported outcome measure (PROM) that measures care-related quality of life in patients diagnosed with chronic heart failure. This study describes the psychometric properties of the questionnaire and its relationship with disease severity and global rating of quality of care.Insurance companies selected patients with a recorded diagnosis of chronic heart failure and for whom the hospital submitted a billing statement in the last year. Exploratory factor analysis, Cronbach's alpha and item-rest correlation were used to construct the CaReQoL CHF. Construct validity was assessed by examining the mean values of the CaReQoL CHF scales for the categories of the widely-used New York Heart Association (NYHA) functional classification and by correlating the global rating of quality of care with the CaReQoL CHF scales.One thousand eighteen patients with chronic heart failure filled out the CaReQoL CHF (RR: 35.7%). The CaReQoL CHF consists of 20 items and three scales: social and emotional problems, physical limitations, and being in safe hands. The mean scores of the three scales differed significantly for the NYHA categories, particularly for the social-emotional problems and physical limitation scales. The 'being in safe hands' scale showed a moderate positive correlation with the global rating of quality of care.The CaReQoL CHF is a concise and valid PROM that matches patients' priorities in healthcare. It adds a new element to existing quality of life questionnaires for patients with chronic heart failure, that is 'being in safe hands' scale. This scale is relevant for patients because they experience anxiety and tension about their condition. Future research should determine whether the CaReQoL CHF can help healthcare providers in daily practice to focus treatment on outcomes of care that are relevant to individual patients.
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Project description:BACKGROUND: Knowledge of the extent to which patient characteristics are systematically associated with variation in patient evaluations will enable us to adjust for differences between practice populations and thereby compare GPs. Whether this is appropriate depends on the purpose for which the patient evaluation was conducted. Associations between evaluations and patient characteristics may reflect gaps in the quality of care or may be due to inherent characteristics of the patients. This study aimed to determine such associations in a setting with a comprehensive list system and gate-keeping. METHODS: A nationwide Danish patient evaluation survey among voluntarily participating GPs using the EUROPEP questionnaire, which produced 28,260 patient evaluations (response rate 77.3%) of 365 GPs. In our analyses we compared the prevalence of positive evaluations in groups of patients. RESULTS: We found a positive GP assessment to be strongly associated with increasing patient age and increasing frequency of attendance. Patients reporting a chronic condition were more positive, whereas a low self-rated health was strongly associated with less positive scores also after adjustment. The association between patient gender and assessment was weak and inconsistent and depended on the focus. We found no association either with the patients' educational level or with the duration of listing with the GP even after adjusting for patient characteristics. CONCLUSION: Adjustment for patient differences may produce a more fair comparison between GPs, but may also blur the assessment of GPs' ability to meet the needs of the populations actually served. On the other hand, adjusted results will enable us to describe the significance of specific patient characteristics to patients' experience of care.
| S-EPMC2533311 | biostudies-literature
Project description:Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are main causes of dyspnoea, and echocardiography and spirometry are essential investigations for these diagnoses. Our aim was to determine the prevalence of HF and COPD in a general population, also how the diseases may be identified, and to what extent their clinical characteristics differ. In the seventh survey of Tromsø study (2015-16), subjects aged 40 years or more were examined with echocardiography, spirometry, lung sound recordings, questionnaires, including the modified Medical Research Council (mMRC) questionnaire on dyspnoea, and N-terminal pro-brain natriuretic peptide analysis. A diagnosis of HF (HF with reduced ejection fraction, HF with mid-range ejection fraction, or HF with preserved ejection fraction) or COPD was established according to current guidelines. Predictors of HF and COPD were evaluated by logistic regression and receiver operating characteristic curve analysis. A total of 7110 participants could be evaluated for COPD, 1624 for HF, and 1538 for both diseases. Age-standardized prevalence of HF was 6.8% for women and 6.1% for men; the respective figures for COPD were 5.2% and 5.1%. Among the 1538 evaluated for both diseases, 139 subjects fulfilled the HF criteria, but only 17.1% reported to have the disease. Of those fulfilling the COPD criteria, 31.6% reported to have the disease. Shortness of breath at exertion was a frequent finding in HF; 59% of those with mMRC ≥2 had HF, while such shortness of breath was found in 24% among those with COPD. Reporting mMRC ≥2 had an odds ratio for HF of 19.5 (95% confidence interval 11.3-33.7), whereas the odds ratio for COPD was 6.3 (95% confidence interval 3.5-11.6). Current smoking was the strongest predictor of COPD but did not predict HF. Basal inspiratory crackles were significant predictors of HF in multivariable analysis. Among the subtypes of HF, an age <70 years was most frequently found in HF with reduced ejection fraction, in 51.7%. Clinical scores based on the predictive value in multivariable analysis of history, symptoms, and signs predicted HF and COPD with areas under the curve of 0.833 and 0.829, respectively. Study participants with HF and COPD were in most cases not aware of their condition. In general practice, when an elderly patient present with shortness of breath, both diseases should be considered. Previous cardiovascular disease points at HF, while a history of smoking points at COPD. The threshold should be low for ordering echocardiography or spirometry for verifying the suspected cause of dyspnoea.
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Project description:ObjectivesDiagnosing chronic heart failure (CHF) in general practice is challenging. Our aim was to investigate how general practitioners (GPs) diagnose CHF in real-world patients.DesignThink-aloud study.MethodsFourteen GPs were asked to reason about four real-world CHF cases from their own practices. The cases were selected through a clinical audit. This was followed by an interview to get a deeper insight in their reasoning. The Qualitative Analysis Guide of Leuven was used as a guide in data analysis.ResultsWe developed a conceptual diagnostic model based on three important reasoning steps. First, GPs assessed the likelihood of CHF based on the presence or absence of HF signs and symptoms. However, this approach had serious limitations since GPs experienced many barriers in their clinical assessment, especially in comorbid elderly. Second, if CHF was considered based on step 1, the main influencing factor to take further diagnostic steps was the GPs' perception of the added value of a validated CHF diagnosis in that specific case. Third, the choice and implications of these further diagnostic steps (N-terminal pro B-type natriuretic peptide, ECG and/or cardiac ultrasound) were influenced by the GPs' knowledge about these tests and the quality of the cardiologists' reports.ConclusionThis think-aloud study identified the factors that influenced the diagnostic reasoning about CHF in general practice. As a consequence, targets to improve this diagnostic reasoning were withheld: a paradigm shift towards an earlier and more comprehensive risk assessment with, among others, access to natriuretic peptide testing and convincing GPs of the added value of a validated HF diagnosis.
| S-EPMC6475198 | biostudies-literature
Project description:BackgroundGalectin-3 is a biomarker for prognostication and risk stratification of patients with heart failure (HF). It has been suggested that renal function strongly relates to galectin-3 levels. We aimed to describe galectin-3 renal handling in HF.Methods and resultsIn Sprague-Dawley rats, we infused galectin-3 and studied distribution and renal clearance. Furthermore, galectin-3 was measured in urine and plasma of healthy controls, HF patients and hemodialysis patients. To mimic the human situation, we measured galectin-3 before and after the artificial kidney. Infusion in rats resulted in a clear increase in plasma and urine galectin-3. Plasma galectin-3 in HF patients (n=101; mean age 64 years; 93% male) was significantly higher compared to control subjects (n=20; mean age 58 years; 75% male) (16.6 ng/mL versus 9.7 ng/mL, P<0.001), while urinary galectin-3 in HF patients was comparable (28.1 ng/mL versus 35.1 ng/mL, P=0.830). The calculated galectin-3 excretion rate was lower in HF patient (2.3 mL/min [1.5 to 3.4] versus 3.9 mL/min [2.3 to 6.4] in control subjects; P=0.005). This corresponded with a significantly lower fractional excretion of galectin-3 in HF patients (2.4% [1.7 to 3.7] versus 3.0% [1.9 to 5.5]; P=0.018). These differences, however, were no longer significant after correction for age, gender, diabetes, and smoking. HF patients who received diuretics (49%) showed significantly higher aldosterone and galectin-3 levels. Hemodialysis patients (n=105; mean age 63 years; 65% male), without urinary galectin-3 excretion, had strongly increased median plasma galectin-3 levels (70.6 ng/mL).ConclusionsIn this small cross-sectional study, we report that urine levels of galectin-3 are not increased in HF patients, despite substantially increased plasma galectin-3 levels. The impaired renal handling of galectin-3 in patients with HF may explain the described relation between renal function and galectin-3 and may account for the elevated plasma galectin-3 in HF.
| S-EPMC4323807 | biostudies-literature
Project description:Chronic heart failure (CHF) is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. CHF patients are encouraged to self-manage their illness, such as adhering to medical regimens and monitoring symptoms, to optimise health outcomes and quality of life. In so doing, patients are asked to collaborate with their health service providers with regard to their care. However, patients generally do not self-manage well, even with specialist support. Moreover, self-management interventions are yet to demonstrate morbidity or mortality benefits. Social network approaches to self-management consider the availability and mobilisation of all resources, beyond those of only the patient and healthcare providers. Used in conjunction with e-health platforms, social network approaches may offer a means by which to optimise self-management programmes of the future.
| S-EPMC5490946 | biostudies-other