Evaluation of an open access echocardiography service in the Netherlands: a mixed methods study of indications, outcomes, patient management and trends.

BACKGROUND: In our region (Eastern South Limburg, The Netherlands) an open access echocardiography service started in 2002. It was the first service of this kind in The Netherlands. Our study aims were: (1) to evaluate demand for the service, participation, indications, echocardiography outcomes, and management by the general practitioner (GP); (2) to analyse changes in indications and outcomes over the years. METHODS: (1) Data from GP request forms, echocardiography reports and a retrospective GP questionnaire on management (response rate 83%) of 625 consecutive patients (Dec. 2002-March 2007) were analysed cross-sectionally. (2) For the analysis of changes over the years, data from GP request forms and echocardiography reports of the first and last 250 patients that visited the service between Dec. 2002 and Feb. 2008 (n = 1001) were compared. RESULTS: The echocardiography service was used by 81% of the regional GPs. On average, a GP referred one patient per year to the service. Intended indications for the service were dyspnoea (32%), cardiac murmur (59%), and peripheral oedema (17%). Of the other indications (22%), one-third was for evaluation of suspected left ventricular hypertrophy (LVH). Expected outcomes were left ventricular dysfunction (LVD) (43%, predominantly diastolic) and valve disease (25%). We also found a high proportion of LVH (50%). Only 24% of all echocardiograms showed no relevant disease. The GP followed the cardiologist's advice to refer the patient for further evaluation in 71%. In recent patients, more echocardiography requests were done for 'cardiac murmur' and 'other' indications, but less for 'dyspnoea'. The proportions of patients with LVD, LVH and valve disease decreased and the proportion of patients with no relevant disease increased. The number of advices by the cardiologists increased. CONCLUSION: Overall, GPs used the open access echocardiography service efficiently (i.e. with a high chance of finding relevant pathology), but efficiency decreased slightly over the years. To meet the needs of the GPs, indications might be widened with 'suspicion LVH'. Further specification of the indications for open access echocardiography--by defining a stepwise diagnostic approach including ECG and (NT-pro)BNP--might improve the service.

Nurse-led self-management group programme for patients with congestive heart failure: randomized controlled trial.

AIM: This paper reports on of the effects of the Chronic Disease Self-Management Programme on psychosocial attributes, self-care behaviour and quality of life among congestive heart failure patients who experienced slight to marked limitation of physical activity. BACKGROUND: Most self-management programmes for congestive heart failure patients emphasize the medical aspects of this chronic condition, without incorporating psychosocial aspects of self-management. The programme has been used with various patient groups, but its effectiveness with congestive heart failure patients when led by pairs of cardiac nurse specialists and peer leaders is unknown. METHOD: A randomized controlled trial with 12 months of follow-up from start of the programme was conducted with 317 patients. Control group patients (n = 131) received usual care, consisting of regular outpatient checkups. Intervention group patients (n = 186) received usual care and participated in the six-week self-management programme. The programme teaches patients medical, social and emotional self-management skills. Twenty-one classes were conducted in six hospitals in the Netherlands, and data were collected between August 2004 and January 2007. RESULTS: Directly after the programme, statistically significant effects were found for cognitive symptom management (P < 0.001), self-care behaviour (P = 0.008) and cardiac-specific quality of life (P = 0.005). No effects were found at 6- and 12-month follow-up. CONCLUSION: Further research is necessary to study how long-term effectiveness of the programme with patients with congestive heart failure can be achieved, and how successful adaptations of the programme can be integrated into standard care.

Heart failure patients with a lower educational level and better cognitive status benefit most from a self-management group programme.

OBJECTIVE: The Chronic Disease Self-Management Programme (CDSMP)was recently evaluated among patients with congestive heart failure (CHF) in a randomized controlled trial (n = 317) with twelve months of follow-up after the start of the programme. That trial demonstrated short-term improvements in cardiac-specific quality of life. The current study assessed which of the patients participating in this trial benefited most from the CDSMP with respect to cardiac-specific quality of life. METHODS: Subgroup analyses were conducted using mixed-effects linear regression models to assess the relationship between patient characteristics and the effects of the CDSMP on cardiac-specific quality of life. RESULTS: In the short term, patients with better cognitive status benefited more from the CDSMP than their poorer functioning counterparts. In addition, lower educated patients benefited more from the CDSMP than their higher educated counterparts during total follow-up. CONCLUSION: Subgroup effects were found for cognitive status and educational level. Future research should be performed to validate current findings and further explore the conditions under which CHF patients may benefit more from the programme. PRACTICE IMPLICATIONS: These results indicate that lower educated patients, in particular, should be encouraged to participate in the CDSMP. In addition, healthcare practitioners are recommended to take into account potential cognitive impairments of patients.

Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study.

OBJECTIVES: The purpose of this study was to assess whether management of heart failure (HF) guided by an individualized N-terminal pro-B-type natriuretic peptide (NT-proBNP) target would lead to improved outcome compared with HF management guided by clinical assessment alone. BACKGROUND: Natriuretic peptides may be attractive biomarkers to guide management of heart failure (HF) and help select patients in need of more aggressive therapy. The PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study is, to our knowledge, the first large, prospective randomized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome. METHODS: A total of 345 patients hospitalized for decompensated, symptomatic HF with elevated NT-proBNP levels at admission were included. After discharge, patients were randomized to either clinically-guided outpatient management (n = 171), or management guided by an individually set NT-proBNP (n = 174) defined by the lowest level at discharge or 2 weeks thereafter. The primary end point was defined as number of days alive outside the hospital after index admission. RESULTS: HF management guided by this individualized NT-proBNP target increased the use of HF medication (p = 0.006), and 64% of HF-related events were preceded by an increase in NT-proBNP. Nevertheless, HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point (685 vs. 664 days, p = 0.49), nor did it significantly improve any of the secondary end points. In the NT-proBNP-guided group mortality was lower, as 46 patients died (26.5%) versus 57 (33.3%) in the clinically-guided group, but this was not statistically significant (p = 0.206). CONCLUSIONS: Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy, but failed to provide significant clinical improvement in terms of mortality and morbidity. (Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [PRIMA]; NCT00149422).