Result card

  • ORG2: What kind of patient/participant flow is associated with structured telephone support (STS) for adult patients with chronic heart failure?
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What kind of patient/participant flow is associated with structured telephone support (STS) for adult patients with chronic heart failure?

Authors: Valentina Prevolnik Rupel, Taja Čokl, Eleftheria Karampli

Internal reviewers: Ulla Saalasti - Koskinen, Elle Kisk, Ricardo Ramos

To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain).The results are provided in descriptive way.

STS replaced historical program of doctor’s visits for HF patients after discharge. In interventions utilizing STS, the patient is monitored remotely while being at home (including a relative’s home, nursing home or residential care home). The patients are contacted in regular time intervals via telephone by either healthcare personnel (e.g. specialized HF nurses) or an automated telephone-based interactive response system. The STS support starts being planned while the patient is in hospital through education and meeting with the HF nurse. Education and practising with the technology follows and the materials are given to the patients as well as explained to the relatives. At the point of discharge the timing of the first call is agreed. The frequency of calls varies greatly among the studies but in common the calls are weekly at least first two weeks after discharge and then get biweekly until two months after discharge. After that they become monthly. It is not clear how long the intervention should last: there are different periods, going from 3 months up to 2 years after the discharge. It is not clear when the effect is biggest, possibly within first 3 months.

Historically, patients with HF were not taught to self-monitor but were reviewed periodically by a doctor working in either primary or secondary care. Even in the high risk period after hospital discharge it was traditional to arrange hospital clinic review some weeks after discharge. During this visit the doctor would assess the patient and determine if changes to treatment were required. In many countries where there were only a few physicians with a special interest in the condition, many patients would be discharged back to primary care review alone. Such a model of patient flow is now considered outdated and substandard.

In interventions utilizing STS, the patient is monitored remotely while being at home (including a relative’s home, nursing home or residential care home). The patients are contacted in regular time intervals via telephone by either healthcare personnel (e.g. specialized HF nurses) or an automated telephone-based interactive response system. {40}

There is much that the patient and their family can do to monitor how well the heart failure syndrome is controlled. Professional monitoring should faciltate self-management, where patients adjust their therapy depending on the control of the HF failure recurrence. HF typically affects the elderly and their limited mobility and lack of social support may make hospital clinic attendance problematic. Remote monitoring (inlc. STS) has a role to widen access to care. After hospital discharge the patients in STS receive telephone calls initiated by nurse, aiming to educate, assess compliance with the medications, worsening of symptoms and signs of fluid retention. The nurses could adjust the medication over the phone or organize clinic appointments {100}.

Amongst CHF patients who have previously been admitted to hospital for this condition there is now good evidence that case management type interventions led by a HF specialist nurse reduces CHF related readmissions after 12 months follow up, all cause readmissions and all cause mortality. It is not possible to say what the optimal components of these case management type interventions are, however telephone follow up by the nurse specialist was a common component {68}. The limitation of STS is that the telephone calls are primarily initiated by the professional at preset times (usually protocol driven) and they are thus unable to detect more rapid changes in the condition.

In a RCT reported by Dunagan et al. {10}, patients in both UC and STS arms received educational material with information on the causes of HF, the basic principles of treatment, their role in routine care and monitoring of their condition, and appropriate strategies for managing a HF exacerbation. The intervention group received additional education from study nurses during scheduled telephone contact. During the telephone communication, nurses screened patients on HF exacerbations (administering also a screening instrument for this purpose), and also promoted self-management skills, appropriate diet and adherence to medications. Patients could contact the nurses in case they had questions or were experiencing exacerbation symptoms.

In the Trans-European Network–Home-Care Management System (TENS-HMS) study {9} patients in all arms were given an individualized written management plan that described what pharmacologic treatment they should receive, in what order, and how it should be monitored. The management plan focused on treatment of LV systolic dysfunction according to regional guidelines. For patients assigned to the Nurse Telephone Support, their management plan was sent to their primary care phycisian. In addition, they were contacted by telephone each month by a heart failure specialist nurse to assess their symptoms and current medication. The nurse could provide advice to the patient and feedback to the primary care provider.

 

In a matched cohort study conducted in the US {11} patients received a customised self-management intervention plan that included risk stratification; formal scheduled nurse education sessions; 24-hour access to a nurse counseling and symptom advice telephone line; printed action plans, workbooks, and individualized assessment letters; medication compliance reminders and vaccination reminders; and physician alerts about symptoms and signs of decompensation, as well as notification to physicians of gaps between patient-reported practice and guideline recommendations.

 

In HeartNetCare-HF study {200} initial personal contact between HF nurse and patient  and his relatives/friends were made during the hospitalization due to HF. Patient would be invited to the education where self monitoring of blood pressure, heartbeat, weight and HF symptoms would be explained and practised. Patients were given materials and calender to monitor the symptoms. They were  explained the STS programme and personal talk with HF nurse took place. The timing of the first call was defined at the moment of discharge. The STS had a clear structure and was prepared by cardiologist and clinical psychologist, the nurse was adequately educated on the matter. The call consisted of modules that were defined in advance and set script was followed, which was individually adjusted according to the responses of the patient. Modules for example were: medication, diet, physical activities etc. The results were statistically analysed after the call. The calls were placed 4 weeks after the hospitalization once a week, the length of the talk did not exceed 20 minutes and was documented. On the basis of the information the therapy was adapted and each week the doctor checked the results presented by nurse. Each week the nurses had a specific training with the cardiologist according to the problems that might have occured throughout the week {200}.

The frequencies of the calls and the length of STS support in months varies greatly among the studies. In a study by Kasper et al {240} telephone nurse coordinator and HF nurse placed telephone calls within 72 hours of discharge and then weekly for 1 month, twice in second month and monthly thereafter. Set script was followed. In Krumholz et al {240} nurse phoned patients weekly  for 4 weeks, biweekly for 8 weeks and then monthly for total intervention for 1 year. In Galbreath et al study {2} initial call frequency was weekly, with a transition to monthly for the duration of the intervention (18 months). After each call, a call summary was faxed to the patient’s PCP. Information or orders from the PCP could likewise be faxed to the DM. In another study the patients were contacted three times the first week after discharge, and then weekly for 11 weeks (4 contacts over 3 months) {1}. In the study by Dunagan et al. the calls occured weekly for 2 weeks and then according to the patient’s need. By Riegel et al, the frequency of calls was determined by nurses using decision support software {230}. In the U.S. matched cohort study {11} patients were stratified in three categories (low, medium, high risk) and the frequency of scheduled telephone calls by nurses during the 12 month programme was decided on this basis:  (low risk - 2 calls; medium risk - 7 calls, and high risk- 16 calls). In DIAL trial {100} the phone calls were made biweekly, after which the frequency was based on the nurse’s assessment of clinical need.

There is a dearth of evidence about how long patients should be supported by STS. It is possible that the greatest benefit in terms of education and medication patterns is accrued within a few weeks and that long-term monitoring is redundant {1180}. 

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Rupel V et al. Result Card ORG2 In: Rupel V et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305

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