Home Care NetWork
Home Care Literature Reviews 2005
Congestive Heart Failure:
Cleland JG, Louis AA, Rigby AS, Janssens U, Balk AH; TEN-HMS Investigators. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol. 2005;45:1654-64. Epub 2005 Apr 22.
This British randomized controlled trial compared a home telemonitoring program (HTM) with a nurse’s initiate a telephone support system (TS) and usual care (UC) in 426 patients with heart failure who were felt to be of high risk for hospitalization or death. While the number of patient-days lost due to hospitalization or death decrease progressively with more aggressive home care (i.e., UC 9.5%, TS 15.9%, and HTM 12.7%) these changes did not reach statistical significance. The mean duration of admissions for patients in the HTM group was reduced by six days (95% confidence interval 1 –11) and the usual care group had a significantly higher (p= 0.032) one-year mortality than the other two groups (45% versus 27% for TS or 29% for HTM). This very well done study supports the value of aggressive in-home monitoring of patients with heart failure. It also points to the need for careful selection of such patients.
Series F, Kimoff RJ, Morrison D, Leblanc MH, Smilovitch M, Howlett J, Logan AG, Floras JS, Bradley TD. Prospective evaluation of nocturnal oximetry for detection of sleep-related breathing disturbances in patients with chronic heart failure. Chest. 2005;127:1507-14.
This Canadian case series compared in-hospital and in-home oximetry and polysomnographic nocturnal recordings in 50 consecutive patients with congestive heart failure to evaluate the utility of in-home oximetry as a screening tool for sleep disordered breathing. Home oximetry had an 85% sensitivity and 93% specificity for detecting sleep disordered breathing confirmed by polysomnography. Oximetry was not able to differentiate obstructive sleep apnea from central sleep apnea. Overnight home oximetry appears to be a sensitive screening tool for patients with heart failure.
Feldman PH, Murtaugh CM, Pezzin LE, McDonald MV, Peng TR. Just-in-Time Evidence-Based E-mail "Reminders" in Home Health Care: Impact on Patient Outcomes. Health Serv Res. 2005;40:865-86.
This randomized controlled trial evaluated the effect of two interventions, an e-mail to a home care patient’s nurse with specific clinical recommendations for heart failure management and the same e-mail supplemented with reminders of resources to carry out these recommendations, with usual care in 628 home care patients with a primary diagnosis of heart failure. Both interventions showed improvement in disease-specific symptoms, 12.9 and15.3 %, with no difference (p<0.05), between the interventions. Both interventions had positive impacts on other clinical measures. Because there were no differences between the two interventions, however, the simpler and invention was felt to be more cost-effective. A very interesting study showing the usefulness a very simple computer-based program of targeted reminders.
Murtaugh CM, Pezzin LE, McDonald MV, Feldman PH, Peng TR. Just-in-Time Evidence-Based E-mail "Reminders" in Home Health Care: Impact on Nurse Practices. Health Serv Res. 2005;40:849-864.
This paper describes an analysis of the data contained in the above referenced study. Review of patient records indicated that both interventions were effective in influencing both patient assessment and education activities. This study is a companion of the study outlined above and further strengthens the utility of the simple intervention.
Home Care Literature Reviews 2004
Congestive Heart Failure:
DeBusk RF, Miller NH, Parker KM, Bandura A, Kraemer HC, Cher DJ, West JA, Fowler MB, Greenwald G. Care management for low-risk patients with heart failure: a randomized, controlled trial. Ann Intern Med. 2004;141:606-13.
This randomized clinical trial compared the outcomes of a nurse-managed, telephone based program for patients with congestive heart failure with usual care in a single HMO system. Following hospitalization for heart failure, 462 patients were randomized into the two treatment groups. At the end of one year there was no difference in the rate of rehospitalization between the two groups. The authors speculated that because all the patients were in a single healthcare system the level of care was generally high enough (or at least consistent enough) that this intervention wasn't necessary. Whether such a system might be effective in patients at higher risk remains to be seen certainly other nurse based programs to manage congestive heart failure have been shown to be effective.
Upadya SP, Sedrakyan A, Saldarriaga C, Nystrom K, Bozzo J, Lee FA, Katz SD. Comparative costs of home positive inotropic infusion versus in-hospital care in patients awaiting cardiac transplantation. J Card Fail. 2004;10:384-9.
This case series analyzed the cost savings associated with the use of home infusion of positive inotropic agents combined with implantation of an automatic implantable cardioverter defibrillator (AICD) to support patients with end-stage heart failure awaiting cardiac transplantation. The analysis included 3070 patient days and compared a strategy of immediate hospital discharge after implantation of the (AICD) versus ongoing in patient care and found that the outpatient strategy resulted in a savings of $71,300 to $120,500 per patient. In home infusion was both practical and cost-saving in these patients with heart failure waiting cardiac transplantation.
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-84.
This randomized clinical trial examined the effectiveness of a transitional care intervention consisting of discharge planning and a three month home follow-up protocol delivered by advanced practice nurses (APNs) in 239 elders hospitalized with heart failure. The intervention group had a longer time to first readmission or death was longer in intervention patients (log rank chi2=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40), fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002) but only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). While the improvements in symptomatic measures were short lived, the overall results were excellent.
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