Home care for heart failure: can caregiver education prevent hospital admissions? A randomized trial in primary care

Abstract

Aim To assess the feasibility and effectiveness of a low-complexity, low-cost model of caregiver education in primary care, targeted to reduce hospitalizations of heart failure patients. Methods A cluster-randomized, controlled, open trial was proposed to general practitioners, who were invited to identify patients with heart failure, exclusively managed at home and continuously attended by a caregiver. Participating general practitioners were then randomized to: usual treatment; caregiver education (educational session for recognizing early symptoms/signs of heart failure, with recording in a diary of a series of patient parameters, including body weight, blood pressure, heart rate). The patients were observed at baseline and during a 12-month follow-up. Results Three hundred and thirteen patients were enrolled (163 in the intervention, 150 in the usual care group), 63% women, mean age 85.3 ± 7.7 years. At the end of the 12-month follow-up, a trend towards a lower incidence of hospitalizations was observed in the intervention group (hazard ratio 0.73; 95% CI 0.53–1.01 P = 0.061). Subgroup analysis showed that for patients with persistent/permanent atrial fibrillation, age less than 90 years or Barthel score equal to or greater than 50 a significant lower hospital admission rate occurred in the intervention group (hazard ratio 0.63; 95% CI 0.39–0.99; P = 0.048, hazard ratio 0.66; 95% CI 0.45–0.97; P = 0.036 and hazard ratio 0.61; 95% CI 0.41–0.89; P = 0.011, respectively). Conclusion Caregivers training for early recognition of symptoms/signs of worsening heart failure may be effective in reducing hospitalizations, although the benefit was evident only in specific patient subgroups (with persistent/permanent atrial fibrillation, age <90 years or Barthel score ≥ 50), with only a positive trend in the whole cohort. Trial registration ClinicalTrials.gov Identifier: NCT03389841.

Sociodemographic Characteristics Predicting Digital Health Intervention Use After Acute Myocardial Infarction

“…Although the confidence interval was relatively wide (1.02–4.39), our results suggest that caregivers may encourage patients to engage more frequently with a given DHI and ultimately adhere to their care plan. These results are in agreement with the current body of literature, which suggest that DHIs that involve caregivers improve cardiac medication adherence and may be effective in reducing re-hospitalizations [ 30 – 32 ]. Further investigation with a larger sample size and direct assessment of the presence/absence of a caregiver is needed to confirm these findings.…”

Empowered But Isolated

“…Patients with HF and caregivers coped with HF exacerbation in the pattern they used in the past, instead of trying new methods 34 . Training family caregivers in detecting and coping with early symptoms of HF exacerbation is promising in helping patients reduce hospitalizations 35 . Different from conflicts in symptom appraisals in other studies, 36,37 we highlighted family caregivers felt isolated about communication barriers as patients refused or were unable to discuss their discomfort in this study.…”

Clinical implications of assessing frailty in elderly patients treated with permanent cardiac pacing

“…The study is original and underscores the possibility for more accurate assessments of elderly patients undergoing pacemaker implantation, from the perspective of a holistic approach to patient care, targeted to evaluate not only patient complexity and comorbidities but also frailty, with a specific focus on physical impairment. In patients who were alive at 1 year, physical performance did not differ at follow-up versus baseline, suggesting that initiatives dedicated to patients and caregivers, also in collaboration with general practitioners 7 should be considered for promoting physical activity, with the potential for improving the patient's quality of life and outcome.…”

“…The findings are of great interest and should promote further investigation on the best management practices for these vulnerable subjects, according to dedicated programmes. 7 However, it remains to be assessed the extent of association between frailty and not only outcome but also quality of life and improvement of disability, as potential targets of our interventions.…”

“…The data presented by Balla et al 6 together with those reported in the literature 13 suggest that frailty may be a reliable factor for predicting outcome. The consequent clinical assessment, combining the evaluation of underlying cardiac status, the degree of cognitive impairment, as well as the availability of caregiver assistance and the extent of comorbidities 7 may guide cardiac pacing strategies in elderly patients, with regard to choice of the type of device, patient surveillance and monitoring (Fig. 1).…”