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IIR 14-293 – HSR&D Study

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IIR 14-293
Group Medical Visits in Heart Failure for Post-Hospitalization Follow-Up
Wen-Chih Hank Wu MD
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: July 2015 - March 2020

BACKGROUND/RATIONALE:
Heart failure is a complex chronic illness where comprehensive patient-centered care is difficult and resource intensive. Studies have found patient self-care behaviors in HF (e.g. medication/dietary non-compliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. One potential solution to address patient and system factors based on the Chronic Care Model, is to use shared medical appointments (SMA), where a multi-disciplinary team of providers with expertise in nutrition, nursing, behavior and medication management join to manage heart failure in addition to and support of, the patient's regular physician visits, in a group setting. SMA's, can be a good solution to provide patient self-management support while also performing disease monitoring and medication management in an environment of peer support.

OBJECTIVE(S):
The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs).

The specific aims are:
Aim 1: To determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care, experience better cardiac health status measured by Kansas city Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D), from baseline to 180 days after randomization.
Aim 2: To determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care, have less hospitalizations at 180 days
Aim 3: To determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care, experience an increase in HF Self-Care behaviors from baseline through 180 days after randomization.
Aim 4: To determine for HF-SMA, perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (1) face-to-face interviews with a selected sample of patients and respective caregivers and (2) telephone interviews with stakeholders (physicians of the patients who underwent HF-SMA and physician administrators).

METHODS:
We propose a randomized controlled trial to enroll patients within 12 weeks of
discharge from a HF hospitalization and randomized them to receive either SMA intervention every other week for 8 weeks versus usual care for HF. We will determine, at 180 days from randomization, whether HF patients who
participate in HF-SMA, as compared to patients who receive usual care:
1. Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary
outcome), and overall health status (EQ5D, secondary outcome);
2. Have fewer hospitalization or death and
3. Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels.

For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators).

The sites will be Providence, Cleveland and Phoenix VA hospitals to enroll a total of 375 patients. The study duration will be 180 days for all patients from the time of randomization. We will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), randomization within each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist and a clinical pharmacist or nurse practitioner, without the presence of a physician (cardiologist will be available on call). The session will start with an assessment of patient needs followed by preassigned theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized medication case management.

FINDINGS/RESULTS:
No findings yet.

IMPACT:
The results may be used in health care management and system redesign to provide better quality and patient centered care for our veterans with HF. The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF support regular physician visits, in a peer support environment, all of which, are necessary to provide patient-centered care and improve outcomes.

PUBLICATIONS:

Journal Articles

  1. Wu WC, Parent M, Dev S, Hearns R, Taveira TH, Cohen L, Shell-Boyd J, Jewett-Tennant J, Marshall V, Gee J, Schaub K, LaForest S, Ball S. Group medical visits after heart failure hospitalization: Study protocol for a randomized-controlled trial. Contemporary clinical trials. 2018 Aug 1; 71:140-145.
  2. Cohen LB, Parent M, Taveira TH, Dev S, Wu WC. A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment. Journal of patient experience. 2017 Dec 1; 4(4):169-176.


DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: Treatment - Comparative Effectiveness
Keywords: Best Practices, Cardiovascular Disease, Care Coordination
MeSH Terms: none