Failure of an Educational Program: Experiences of the Vienna Heart School

Abstract

Patients' nonadherence is an important problem in the management of heart failure and seems to be one of the factors leading to a high rate of readmissions. Previous studies to improve adherence in several countries were successful regarding quality of therapy and reduction of readmissions. In these studies, heart failure patients underwent lessons during hospitalization 1-4 after discharge from the hospital, 5,6 were treated by an out-patient clinic specializing in heart failure, 7 -9 or by multidisciplinary interventions. 10,11 Hypothesizing that improving the knowledge of the disease would lead to better adherence, 12 reduce readmission, mortality, and thus probably reduce health costs, 13,14 we established the Vienna Heart School (VHS). In a pilot phase including hospitalized heart failure patients, we have observed that the sickness impedes the success of the VHS lessons. Therefore we hypothesized that VHS lessons after discharge, when the patients' condition is stabilized, would be more appropriate.The aim of the prospective study in patients hospitalized because of heart failure was to evaluate whether VHS after discharge would reduce readmissions and mortality.Consecutive patients admitted with heart failure were invited to take part in a study after hospital discharge, randomizing them to conventional care or to attending VHS plus conventional therapy. From the included patients, the following characteristics were registered: history of arterial hypertension, diabetes mellitus, myocardial infarction documented by electrocardiography and typical enzyme kinetics, diagnosis of coronary heart disease documented by coronary angiography, and electrocardiographic documentation of atrial fibrillation. Dilated cardiomyopathy was diagnosed if the patient showed an enlarged left ventricle, systolic dysfunction, and normal coronary arteries. Valvular heart disease was diagnosed if the physician in charge of the patient estimated that valvular heart disease contributed to the development of heart failure. Reasons for exclusion were planned readmissions, cardiac interventions, surgery, dementia,life-expectancy<1 year, or living outside of Vienna.The VHS consisted of 3 lessons, performed in the hospital within 2 weeks after discharge. At the time of discharge, appointments for the lessons were made for the patients randomized to VHS. The VHS was based on a co-teaching concept and was performed by nurses and doctors. One lesson concentrated on the pathophysiology of heart failure, one on medication, and one on lifestyle. For each lesson the patients received a script. For immigrant patients, we offered lessons in Serbo-Croatian and Turkish.Follow-up visits were scheduled after 2, 6, and 12 months. These follow-up visits took place in the hospital. The lessons, including the scripts, were free of charge, however, transportation to the hospital had to be organized and financed by the patient. End points were death and readmission for any reason. The plan was to recruit 200 patients within 1 year.Group comparisons for dif...