Sokoreli, I. et al. (2016) Depression as an independent prognostic factor for all-cause mortality after a hospital admission for worsening heart failure. International Journal of Cardiology, 220, pp. 202-207. (doi:10.1016Cardiology, 220, pp. 202-207. (doi:10. /j.ijcard.2016 This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/129512/ This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT1 Depression as an independent prognostic factor for all-cause mortality after a hospital admission for worsening heart failure I. Sokoreli 1,2, , J.J.G. E-mail address: ioanna.sokoreli@philips.com (I. Sokoreli). A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT 2 AbstractBackground: Depression is associated with increased mortality among patients with chronic

The management of long-term conditions such as chronic heart failure (CHF) will need to change due to a growing ageing population and the need to deliver health care within finite resources. Telehealth (or remote patient monitoring) is being introduced as a possible solution to meet these demands and has implications for the way nursing care is delivered and how services are reorganised. This paper guides nurses and their managers on how to meet the challenges of implementing a telehealth service for CHF management by exploring the possible barriers and pitfalls to its introduction, and comparing the advantages and disadvantages of different nursing telehealth service models in use in the UK.

BackgroundHome telemonitoring (HTM) of chronic heart failure (HF) promises to improve care by timely indications when a patient’s condition is worsening. Simple rules of sudden weight change have been demonstrated to generate many alerts with poor sensitivity. Trend alert algorithms and bio-impedance (a more sensitive marker of fluid change), should produce fewer false alerts and reduce workload. However, comparisons between such approaches on the decisions made and the time spent reviewing alerts has not been studied.MethodsUsing HTM data from an observational trial of 91 HF patients, a simulated telemonitoring station was created and used to present virtual caseloads to clinicians experienced with HF HTM systems. Clinicians were randomised to either a simple (i.e. an increase of 2 kg in the past 3 days) or advanced alert method (either a moving average weight algorithm or bio-impedance cumulative sum algorithm).ResultsIn total 16 clinicians reviewed the caseloads, 8 randomised to a simple alert method and 8 to the advanced alert methods. Total time to review the caseloads was lower in the advanced arms than the simple arm (80 ± 42 vs. 149 ± 82 min) but agreements on actions between clinicians were low (Fleiss kappa 0.33 and 0.31) and despite having high sensitivity many alerts in the bio-impedance arm were not considered to need further action.ConclusionAdvanced alerting algorithms with higher specificity are likely to reduce the time spent by clinicians and increase the percentage of time spent on changes rated as most meaningful. Work is needed to present bio-impedance alerts in a manner which is intuitive for clinicians.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0398-9) contains supplementary material, which is available to authorized users.

Background General practitioners in the UK are financially incentivised, via the Quality Outcomes Framework, to maintain a record of all patients at their practice with heart failure and manage them appropriately. The prevalence of heart failure recorded in primary care registers (0.7–1.0%) is less than reported in epidemiological studies (3–5%). Using an audit of clinical practice, we set out to investigate if there are patients ‘missing’ from primary care heart failure registers and what the underlying mechanisms might be. Design The design of this study was as an audit of clinical practice at a UK general practice ( n = 9390). Methods Audit software (ENHANCE-HF) was used to identify patients who may have heart failure via a series of hierarchical searches of electronic records. Heart failure was then confirmed or excluded based on the electronic records by a heart failure specialist nurse and patients added to the register. Outcome data for patients without heart failure was collected after two years. Results Heart failure prevalence was 0.63% at baseline and 1.12% after the audit. Inaccurate coding accounted for the majority of missing patients. Amongst patients without heart failure who were taking a loop diuretic, the rate of incident heart failure was 13% and the rate of death or hospitalization with heart failure was 25% respectively during two-year follow-up. Conclusion There are many patients missing from community heart failure registers which may detriment patient outcome and practice income. Patients without heart failure who take loop diuretics are at high risk of heart failure-related events.

By establishing which factors influence a patient's decision to refuse or withdraw early from HTM, it may be possible to redesign HTM referral processes. It may be that patients with CHF who also have depression, anxiety, low control and poor technology skills should not be referred until they receive appropriate support or that they should be managed differently when they do receive HTM. The results of ADAPT-HF may provide a way of making more efficient and cost-effective use of HTM services.

As home telemonitoring (HTM) moves away from randomised controlled trials and towards the mainstreaming of services, a clear set of guidance on how to evaluate them is needed. Without appropriate and systematic evaluations, the healthcare sector and those who commission its services will not be able to learn important lessons about which aspects of HTM work best. This article will discuss the advantages and disadvantages of different strategies that can be employed by commissioners and service providers in the evaluation of HTM services.

Purpose: To assess the effect of routine use of home telemonitoring on the risk of re-admission to hospital amongst patients with heart failure.Context: Heart failure is a common reason for hospitalizations, which often recur. Telemonitoring might detect early decompensation allowing intervention to prevent re-admission. A systematic review concluded that telehealth reduced heart failure related hospitalizations by almost 30 % [1]. In Europe, the use of telehealth has primarily been limited to studies, pilots and small programs; it has not yet become routine in clinical practice. Accordingly, we assessed the effects of a telemonitoring service on unplanned re-admissions to hospital at 90 days and one year.Methods: OPERA-HF is an ongoing prospective observational study, enrolling patients hospitalized with worsening heart failure to the Hull & East Yorkshire Hospitals NHS Trust, UK. All patients enrolled in the study are followed subsequent to discharge. The primary outcome for this analysis was unplanned all-cause readmission. Patients were referred to telehealth by the hospital discharge team if aged >18 years and registered with a Hull-based primary care physician. To remove imbalances in baseline characteristics between patients on telehealth and those not, propensity matching was used to estimate effectiveness. A logistic regression model was used to determine the propensity score (probability of being selected for telehealth) for each patient. The calculated propensity scores were applied to a weighted logistic regression to account for selection assignment differences between patients on telehealth and on standard care. Propensity scores were calculated by controlling for age, number of severe comorbidities, New York Heart Association (NYHA) class at admission, emergency heart failure hospitalizations in prior 6 months, total daily pill count, heart rate and NT-proBNP at discharge.Results and discussion: Of 546 patients enrolled, 89 received telehealth. Table 1 shows their baseline characteristics. Patients selected for telehealth had fewer unplanned readmissions at both 90 days (OR: 0.66; 95% CI: 0.45 to 0.97; P < 0.05) and one year (OR: 0.68; 95% CI: 0.46 to 0.99; P < 0.05) than those who were not. In a routine care setting, patients with heart failure receiving telehealth after discharge have fewer unplanned readmissions compared with those without telehealth.