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 1 ⁰ and 2 ⁰ 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% BNP 58% Chest X-ray 38% ECG 31% Echo 26% None identified

Baseline findings - prescriptions 81% Diuretic 14% Aldosterone antagonist 67% ACE inhibitor 52% Beta blocker 11% 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 followed- up 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 –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 Weigh regularly Check legs for swelling Take note of breathing Do none of the above Know much about heart failure

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 nurse- led 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.