Multispecialty multidisciplinary input into comorbidities along with treatment optimisation in heart failure reduces hospitalisation and clinic attendance.

AIMS: Heart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020-June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes. METHODS: Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost. RESULTS: 334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p<0.001), deprescribing to reduce anticholinergic burden (pre-MDT 1.85±0.4 vs 1.5±0.3 post-MDT; p<0.001), initiation of renin-angiotensin aldosterone system inhibitors in HF with reduced ejection fraction (HFrEF) with advanced chronic kidney disease (9% pre vs 71% post-MDT; p<0.001). Other interventions included potassium binders, treatment of anaemia, falls assessment, management of chest conditions, day-case ascitic, pleural drains and palliative support. Total cost of funding monthly multispecialty meetings was £32 400 and resultant 64 clinic appointments cost £9600. The post-MDT study period was associated with reduction in 481 clinic appointments (cost saving £72150) and reduced all-cause hospitalisations (pre-MDT 1.1±0.4 vs 0.6±0.1 post-MDT; p<0.001), reduction of 1586 hospital bed-days and cost savings of £634 400. Total cost saving to the healthcare system was £664 550. CONCLUSION: HF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

Diagnostic and treatment dilemmas of persistent chronic hypokalaemia in a patient with anorexia nervosa: a case report.

INTRODUCTION: Anorexia nervosa is an eating disorder that continues to have a devastating impact on the lives of both adolescents and adults worldwide. We present a case of persistent chronic hypokalaemia in a patient with anorexia nervosa. CASE PRESENTATION: A 26-year-old Caucasian woman was admitted to our eating disorders unit under Section 2 of Mental Health Act (1983) with a body mass index of 13.5 kg/m2. On admission, biochemical tests highlighted moderate hypokalaemia (3.0 mmol/L). She was immediately put on two tablets of Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride twice daily. An electrocardiogram showed signs of bradycardia with T-wave inversion in at least two chest leads. Throughout her admission, she exhibited a fluctuating potassium level (2.5 to 5.0 mmol/L). Once on the unit, she was put on Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride) but her potassium still tended to drop. On one occasion when she became normokalaemic, supplementation was stopped and she was put on observations. After 24 hours of 1 to 1 observation by ward staff including fluid input and output monitoring as well as search of her bedroom, she was again found to be hypokalaemic in spite of no evidence to suggest laxative or diuretic abuse. CONCLUSIONS: She kept reiterating to clinicians that her potassium depletion is hereditary, not associated with any purging behaviour and for that reason long-term administration of Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride) tablet remained essential. Self-denial was continued until her planned discharge; however, positive behavioural change was recorded whilst her blood showed normokalaemia for a whole week until her discharge.