Addressing the burden of heart failure in Australia: the scope for home-based interventions.

The growing burden of heart failure (HF) challenges health practitioners to implement and evaluate models of care to facilitate optimal health related outcomes. Australia supports a publicly funded universal health insurance system with a strong emphasis on primary care provided by general practitioners. The burden of chronic HF, and a social and political framework favoring community-based, noninstitutionalized care, represents an ideal environment in which home-based HF programs can be implemented successfully. Cardiovascular nurses are well positioned to champion and mentor implementation of evidence-based, patient-centered programs in Australian communities. This paper describes the facilitators and barriers to implementation of best practice models in the Australian context. These include the challenge of providing care in a diverse, multicultural society and the need for clinical governance structures to ensure equal access to the most effective models of care.

Continuous home ambulatory intravenous inotropic drug therapy in severe heart failure: safety and cost efficacy.

Some patients with dilated cardiomyopathy who are inotrope dependent but remain well by undergoing infusions can be managed by ambulatory infusions at home. We report our results in 20 patients awaiting heart transplantation, unable to be weaned from intravenous inotropic therapy on 2 or more occasions, but who were well while receiving inotropes and received home ambulatory infusions. The patients were treated with ACE inhibitors, digoxin, diuretics, vasodilators, close electrolyte management, and low-dose amiodarone for those with more than four-beat ventricular tachycardia. Infusions were delivered by a tunneled subclavian catheter and syringe driver. Thirteen patients received dopamine, four received dobutamine, and three received both. Mean duration of inotropic therapy was 5 months with 70% of the time spent as an outpatient. Eleven patients received transplants, two remain on the waiting list, and seven died after being removed from the list because of general deterioration or renal dysfunction. There were no sudden deaths. Actuarial survival was 71% at 3 months, which is not less than that expected for an inotrope-dependent population. All patients with idiopathic dilated cardiomyopathy survived to transplantation. In contrast, all three with right heart failure caused by pulmonary vascular disease and four of seven with ischemic cardiomyopathy died. Inpatient days were reduced by 70%, leading to considerable cost savings. Home ambulatory inotropic therapy is safe, cost-effective, best suited to those with idiopathic dilated cardiomyopathy, and dramatically reduces inpatient hospital duration.