Implementation of transmural disease management in patients admitted with advanced heart failure

Abstract

Objective The objective of this study was to assess the feasibility and impact on readmissions of transmural disease management across the borders of the cardiology department in patients with advanced heart failure (HF). Methods and results Consecutive patients, readmitted within one year for advanced HF by a dedicated specialist (n = 55), were followed for 22 10 months after implementation of a hospitalwide transmural disease management strategy. Participants received a tag in their electronic medical record, triggering a HF caregiver contact, with subsequent guideline-recommended, protocol-driven care on each cardiac or non-cardiac hospitalization as well as outpatient evaluation. Upon transition to outpatient follow-up, patients were instructed to call the HF caregiver with any question at low threshold. Readmission rates were prospectively collected. Despite receiving adequate treatment with neurohumoral blockers, patients (71 +/- 11 years; ejection fraction 35 +/- 13%) had spent 4% (27%) of the year preceding study inclusion in hospital, with 73% admitted once, 20% twice, and 7% more than twice for acute decompensated HF (ADHF). During the study, patients were exposed to 6 4 dedicated HF caregiver contacts. Participation in remote device monitoring increased from 31% to 92%, with 1(0-3) additional phone contacts per patient-year of follow-up in this subgroup (n = 24). All-cause mortality and readmission rates for ADHF were 10% and 25% after one year, and 19% and 39% after 2 years, respectively. Follow-up time spent in hospital decreased significantly to 2% (16%) (P value = 0.047). Conclusions Follow-up of advanced HF patients through transmural disease management is feasible and associated with favourable clinical outcome.