Evaluation of a
community based heart
failure programme.
Authors.
Anita Bell, Public Health Physician
Veronique Gibbons, Research Fellow in Primary Care
Gerry Devlin, Consultant Cardiologist
Raewyn Fisher, Consultant Cardiologist
Keith Buswell, General Practitioner
Ross Lawrenson, Professor in Primary Care
Background
•
•
•
•
Heart failure (HF) is a
significant cause of
hospitalisation and has a poor
prognosis
There can be differences in
utilisation of HF services
between urban and rural
populations (e.g. Clark, MJA,
2007)
There are significant difference
in investigations and
prescribing for cardiovascular
disease between urban and
rural populations (Fraser, NZ
Rural Lit Review, 2009, Gibbons
NZMJ 2006)
Previous NZ research has
shown inequalities in HF
outcomes for indigenous Māori
(Bramley, NZMJ, 2004; Riddell,
NZMJ, 2005)
Aims
• To improve jointly with primary and secondary
care, the diagnosis and management of HF in
the community
• To improve communication between 1⁰ and 2⁰
care
• To support general practice teams
• To reduce admissions or re-admissions for HF
Participants
• Identified two rural communities with high needs
populations – Te Kuiti
• Clients were identified from GP computerised records
with a coded diagnosis of heart failure
• All clients were assigned a pathway regarding his or her
care
Participants
• Identified two rural communities with high needs
populations – Te Kuiti and Tokoroa
• Clients were identified from GP computerised records
with a coded diagnosis of heart failure
• All clients were assigned a pathway regarding his or her
care
Baseline Findings
• 404 patients
• Age at dx: mean 65.6 yrs
(NZ Euro 69.1,Māori 59.9)
• Gender: Male 51%
• Ethnicity: NZ European
53%, Māori 31%, Pacific
9.2%
• Smokers: 33% NZ Euro,
54% Māori, 11% Pacific
Baseline Findings – Symptoms
• 57% SOE on exertion
• 20% Orthopnoea
• 19% Paroxysmal Nocturnal
Dyspnoea
• 31% Peripheral Oedema
(ankles)
Baseline Findings – Comorbidities
•
•
•
•
38% Diabetes
67.5% Obesity (BMI >30)
18% COPD
12% End Stage Renal
Failure
Baseline Findings – use of
investigations
•
•
•
•
•
27%
58%
38%
31%
26%
BNP
Chest X-ray
ECG
Echo
None identified
Baseline findings - prescriptions
•
•
•
•
•
81%
14%
67%
52%
11%
Diuretic
Aldosterone antagonist
ACE inhibitor
Beta blocker
Angiotensin Receptor Blocker
Participants - Clinic
• Prioritisation to HF clinic was
based on:
–
–
–
–
HF history,
Investigations,
Medication
The number of GP and/or
hospital admissions over the
previous two years
• 131/404 patients were
invited to attend HF clinic
(intervention)
Intervention
• Client seen by Cardiologist or Registrar and HF
nurse at clinic
• Clients needing medication titration followedup by HF nurse in the community
• All clinic clients followed-up by HF nurse by
either phone or home visit
• Contact made with GP to inform the outcome
of clinic visit before clinic letter arrives
(particularly where there are medication
changes)
Evaluating the service
• A formal evaluation of the service was carried out at the
end of the first year of the service at both pilot sites
• The evaluation involved quantitative and qualitative
aspects in the design
• Quantitative - Baseline data included demographic
information, risk factors, investigations and medications
• Qualitative - Key stakeholders were invited to
participate in face-to-face interviews; clients and GPs
were invited to complete an anonymous survey
regarding the service.
After 12 months
•
126/131 had an echo at clinic:
–
–
–
–
57.9% EF >50 (mostly normal)
20.6% EF 41-50
21.4% EF <40
46% had diastolic dysfunction
• 60% of clients required medication altered or started:
– 15% had beta blocker altered,
– 1 in 5 had ACEI dose altered,
– less than 10% had an ARB or angiotensin altered.
• 10% were referred to main hospital for further
investigations such as angiography
Key stakeholder interviews
• Related to development,
initiation and
implementation of the
service
• Key areas:
 Management
 Administration
 Clinical structure and process
 Cardiologist position
 Communication – Service
 Communication – Patients
 Other issues
Google images
GP survey
• 70% response rate
• 60% GPs from Te Kuiti and 40% from
Tokoroa
• All respondents aware of the service
and 90% had referred into the service
• 70% reported a marked improvement
in their clients condition
• 90% felt the information regarding
their client had improved
• The input of the heart failure
specialist nurse was well received
• The positive feedback for the
availability of echocardiography
locally was unanimous
Client Satisfaction Survey
• Sixty percent of clients completed
the survey - 44% male, 40% female,
16% blank
• 58% European, 22% Māori, 6%
other, 14% blank
• Factors such as the locality of the
service, consideration of the staff,
cultural and health needs at the clinic
all scored highly
• Almost 40% felt their heart failure
had improved, 50% felt the same
• 30% reported doing a lot more since
attending the service
Changes observed after service intervention
Before %
After %
% Change
Knowledge of medications
74
84
+13.5
Weigh regularly
46
76
+65
Check legs for swelling
70
84
+20
Take note of breathing
60
72
+20
Do none of the above
12
2
-83.3
Know much about heart failure
36
48
+ 33
Added input from the nurse
• Nurse had motivated clients to
make lifestyle changes (42%) .
• Approx 50% reported nurse had
helped with other problematic
health issues
• 90% were happy to have the nurse
visit them at home
• Telephone contact was reported as
the most common means of
communication with the nurse
followed by rural hospital follow up
visits
• 60% felt attendance at the clinic
had been of benefit to their families
Summary of main outcomes
• The service was acceptable
to clients, GPs and
secondary care
• The service was successful
in achieving all initial
indicators
• Self-management improved
as a result of the service
• The service worked well to
support the management of
HF clients in primary care
• Greater access to echo and
to a community cardiologist
was well received by GPs
Recommendations
• GP should be encouraged to use BNP as
a screening tool to assess in the first
instance whether a patient has heart
failure.
• Continue to move towards a more nurseled service especially in the two areas of
Te Kuiti and Tokoroa.
• The use of electronic aids should be
developed.
• Work should be carried out to look at the
need for development of psychosocial
input which is recommended for heart
failure management and a range of other
chronic diseases.