Factors Affecting Referral and Patient Access to Heart Function Clinics in Ontario: A Qualitative Study of Stakeholders.

Background: Though heart failure patients benefit from multidisciplinary care in heart function clinics (HFCs), utilization is suboptimal and inequitable. This study investigated factors influencing referral and patient access to HFCs from multiple stakeholders' perspectives, namely policy-makers (PM), providers at HFCs and patients. Methods: In this qualitative study, semi-structured interviews with a purposive sample of Ontario stakeholders were conducted between February-June 2020 and July-December 2022 (paused due to pandemic) via Teams. Interview transcripts were concurrently analyzed using systematic text condensation with Nvivo. Two authors coded individually, with disagreements discussed with senior author. Results: Interviews with 7 HFCs (6 physicians, 1 nurse), 6 PM and 4 patients were completed before saturation; 5 themes emerged. First, with regard to health system organization, stakeholders reported gaps related to continuity of care, limited capacity and insufficient funding. Second, with regard to referral appropriateness and timeliness, sub-themes related to unclear referral criteria, varying clinic scope, and delays in triage, testing and time-to-visit. The third theme related to clinic characteristics, raised issues of varying clinic services and composition of healthcare professions/expertise. The fourth theme regarding patient factors related to comorbidity/frailty, socioeconomic status, barriers due to location (parking, traffic) and affinity to specific providers. The final theme related to the COVID-19 pandemic concerned increased referral volumes, loss to follow-up care, transition to online delivery modalities and patient refusal of in-person visits. Many facilitators to improve HFC referral and access were raised. Conclusions: Resources must be provided, and stakeholders brought together to standardize and integrate the HF care continuum.

Contexte: Bien que les patients souffrant d'insuffisance cardiaque bénéficient de soins multidisciplinaires dans des cliniques de fonction cardiaque, l'utilisation de ces dernières est sous-optimale et inéquitable. Cette étude visait à examiner les facteurs influençant l'orientation et l'accès des patients aux cliniques de fonction cardiaque du point de vue de plusieurs parties prenantes, à savoir les décideurs politiques, les professionnels de la santé travaillant dans ces cliniques et les patients. Méthodologie: Dans le cadre de cette étude qualitative, des entretiens semi-structurés ont été menés de février à juin 2020 et de juillet à décembre 2022 (interruption en raison de la pandémie) sur la plateforme Teams avec un échantillon d'intervenants choisis à dessein. Les transcriptions des entretiens ont été analysées simultanément en utilisant la condensation systématique de l'information à l'aide du logiciel Nvivo. Deux auteurs ont effectué individuellement l'encodage, et les divergences ont fait l'objet de discussions avec l'auteur principal. Résultats: Des entretiens avec des professionnels de sept cliniques de fonction cardiaque (6 médecins, 1 infirmière), six décideurs politiques et quatre patients ont été réalisés avant l'atteinte de la saturation des réponses, ce qui a permis de dégager cinq thèmes. Premièrement, en ce qui concerne l'organisation du système de santé, les intervenants ont signalé des lacunes liées à la continuité des soins, une capacité limitée et à financement insuffisant. Deuxièmement, sur le plan de l'adéquation et de la rapidité de l'orientation, les sous-thèmes étaient liés à des critères d'orientation mal définis, à des champs variables d'application clinique et à des retards dans le triage, les tests et les consultations. Le troisième thème portait sur les caractéristiques des cliniques et les questions relatives à la diversité des services cliniques et à la composition du personnel et des experts en santé. Le quatrième thème avait trait aux patients, notamment leurs troubles concomitants, leur fragilité, leur statut socio-économique, les difficultés d'accès (stationnement, circulation) et l'affinité avec certains professionnels. Le dernier thème découlait de la pandémie de COVID- 19 et concernait l'augmentation du nombre de patients, la perte de contact durant le suivi, la transition vers des modalités de prestation en ligne et le refus des patients de se présenter en personne. La question de la nécessité d'un grand nombre de facilitateurs pour améliorer l'orientation et l'accès aux cliniques de fonction cardiaque a également a été soulevée. Conclusions: Des ressources supplémentaires sont requises, et les intervenants doivent travailler de concert afin d'assurer un continuum de soins normalisé et intégré pour les patients atteints d'insuffisance cardiaque.

The Caregiver Contribution to Heart Failure Self-care Instrument: Further Psychometric Testing in a European Sample.

The 20-item Caregiver Contribution to Heart Failure Self-care (CACHS) was developed and tested in a series of preliminary studies providing evidence for the validity of this instrument in Canada. The purpose of this study was to assess the initial psychometric testing of a translated version of the 20-item CACHS in a European sample using classical test theory and item response theory (IRT) methods. This study is a preplanned subanalysis of data from a multisite, descriptive study of caregivers (n = 277; mean age, 52.7 years; 70.4% female) of Italian patients with heart failure. The CACHS-Italian version demonstrated adequate validity and reliability using classical test theory methods. Using IRT methods, test information function was unimodal with more item information in the negative versus positive regions of the latent trait. Most items displayed moderate to high discrimination with acceptable levels of difficulty. Differential item functioning, which determines whether caregivers from different groups with equal amounts of the latent trait have different expected item responses, differed based on caregivers' biological sex as did the IRT discrimination "α" and difficulty "ß" parameters. Overall, the CACHS-Italian version demonstrated similar psychometric properties and excellent reliability as demonstrated in the Canadian sample. However, unlike the original Canadian English version, the CACHS-Italian version showed significant nonuniform differential item functioning, discrimination, and difficulty based on caregivers' biological sex. Ongoing examination of the CACHS-Italian version, particularly in men, is needed as is further linguistic validation using the Canadian CACHS-English version in non-North American English-speaking countries.

The relational dynamics of caregivers of patients with a left ventricular assist device for destination-therapy: A qualitative investigation.

BACKGROUND: Caregivers are critical to the recovery and management of patients with destination-therapy left ventricular assist devices (DT-LVADs). OBJECTIVE: To explore the needs and impacts of caregiving for patients with DT-LVAD relative to the various relationships caregivers navigate from the shared perspectives of patients, caregivers, and healthcare providers. METHODS: Qualitative descriptive secondary analysis. Patients with a DT-LVAD (n = 3), caregivers (n = 2), and healthcare providers (n = 13) from all DT-LVAD programs in Ontario, Canada were invited to participate in semi-structured interviews. We used thematic analysis to identify, analyze, organize, describe, and report caregiver-related themes. RESULTS: Eighteen participants were interviewed. The needs and impact of caregiving for patients with DT-LVADs were characterized by connection with others (relational), and drastic and ongoing changes from normalcy within established and new relationships (dynamics). CONCLUSIONS: DT-LVAD caregivers' unique needs may be a result of multi-leveled and compounding relational dynamics within and across established and new relationships. These could be considered to inform the content of targeted support strategies.

Referral and access to heart function clinics: A realist review.

RATIONALE, AIM, AND OBJECTIVES: Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics. METHODS: Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory. RESULTS: A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome). CONCLUSION: Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

Cross-cultural adaptation of the caregiver contribution to heart failure self-Care into Brazilian Portuguese and content validation.

BACKGROUND: The Caregiver Contribution to Heart Failure Self-Care (CACHS) is a Canadian instrument that assesses caregivers' (CGs) contributions to heart failure (HF) patients' self-care, but a Brazilian version was lacking. AIMS: To adapt CACHS into Brazilian Portuguese and to estimate the content validity of the adapted version. METHODS: A psychometric study of cross-cultural adaptation and content validation was conducted. Linguistic equivalence was assessed by eight professional experts. Content validity was assessed by an expert professional panel (n=8; for clarity, theoretical relevance and practical relevance) and a CG panel (n=46; for cognitive debriefing of the adapted instrument). In the cultural adaptation, the items were considered equivalent if experts reached an agreement ≥80%. In the content validation, the items were considered acceptable if content validity coefficients (CVC) were ≥0.70. RESULTS: The translated version was considered consistent with the original CACHS by the authors. In the second round of linguistic equivalence assessment, all items achieved 100% agreement, except for one item, which presented 75% agreement in conceptual equivalence. The CVC in the first and second rounds of content validity assessment by experts was 0.80 to 0.90. During cognitive testing, the CGs requested explanations on three items, which were reformulated. All CGs then understood the Brazilian version of CACHS, named CACHS - Versão Brasileira (CACHS-Br). CONCLUSIONS: CACHS-Br is equivalent to the original version and provided satisfactory evidence of content validity. Further psychometric testing of this version should allow for the measurement of the CG contributions to HF self-care in Brazil.

The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.

This joint Canadian Heart Failure Society and the CCS Heart Failure guidelines report has been developed to provide a pan-Canadian snapshot of the current state of clinic-based ambulatory heart failure (HF) care in Canada with specific reference to elements and processes of care associated with quality and high performing health systems. It includes the viewpoints of persons with lived experience, patient care providers, and administrators. It is imperative to build on the themes identified in this survey, through engaging all health care professionals, to develop integrated and shared care models that will allow better patient outcomes. Several patient and organizational barriers to care were identified in this survey, which must inform the development of regional care models and pragmatic solutions to improve transitions for this patient population. Unfortunately, we were unsuccessful in incorporating the perspectives of primary care providers and internal medicine specialists who provide the majority of HF care in Canada, which in turn limits our ability to comment on strategies for capacity building outside the HF clinic setting. These considerations must be taken into account when interpreting our findings. Engaging all HF care providers, to build on the themes identified in this survey, will be an important next step in developing integrated and shared care models known to improve patient outcomes.

Ce rapport conjoint des lignes directrices de la Société canadienne d'insuffisance cardiaque et de la Société canadienne de cardiologie (SCC) sur l'insuffisance cardiaque a été élaboré pour fournir un aperçu pancanadien de l'état actuel des soins ambulatoires de l'insuffisance cardiaque (IC) en clinique au Canada, en se référant spécifiquement aux éléments et aux processus de soins associés à des systèmes de santé très performants et de qualité. Il comprend les points de vue de personnes ayant une expérience vécue de l'IC, de prestataires de soins aux patients et d'administrateurs. Il est impératif de s'appuyer sur les thématiques identifiées dans cette enquête, en y engageant tous les professionnels de la santé, pour développer des modèles de soins intégrés et partagés qui permettront de meilleurs pronostics pour les patients. Plusieurs obstacles relatifs aux patients et organisationnels dont il faudra se soucier ont été identifiés dans cette enquête, qui doit servir de base à l'élaboration de modèles de soins régionaux et de solutions pragmatiques pour améliorer les transitions pour cette population de patients. Malheureusement, nous n'avons pas réussi à intégrer les points de vue des prestataires de soins primaires et des spécialistes en médecine interne qui fournissent la majorité des soins en IC au Canada, ce qui limite notre capacité à commenter les stratégies de renforcement des capacités en dehors du cadre des cliniques d'IC. Ces considérations doivent être prises en compte lors de l'interprétation de nos conclusions. L'engagement de tous les prestataires de soins de santé en IC à s'appuyer sur les thématiques identifiées dans cette enquête constituera une prochaine étape importante dans le développement de modèles de soins intégrés et partagés connus pour améliorer le pronostic des patients.

CCS/CHFS Heart Failure Guidelines: Clinical Trial Update on Functional Mitral Regurgitation, SGLT2 Inhibitors, ARNI in HFpEF, and Tafamidis in Amyloidosis.

In this update, we focus on selected topics of high clinical relevance for health care providers who treat patients with heart failure (HF), on the basis of clinical trials published after 2017. Our objective was to review the evidence, and provide recommendations and practical tips regarding the management of candidates for the following HF therapies: (1) transcatheter mitral valve repair in HF with reduced ejection fraction; (2) a novel treatment for transthyretin amyloidosis or transthyretin cardiac amyloidosis; (3) angiotensin receptor-neprilysin inhibition in patients with HF and preserved ejection fraction (HFpEF); and (4) sodium glucose cotransport inhibitors for the prevention and treatment of HF in patients with and without type 2 diabetes. We emphasize the roles of optimal guideline-directed medical therapy and of multidisciplinary teams when considering transcatheter mitral valve repair, to ensure excellent evaluation and care of those patients. In the presence of suggestive clinical indices, health care providers should consider the possibility of cardiac amyloidosis and proceed with proper investigation. Tafamidis is the first agent shown in a prospective study to alter outcomes in patients with transthyretin cardiac amyloidosis. Patient subgroups with HFpEF might benefit from use of sacubitril/valsartan, however, further data are needed to clarify the effect of this therapy in patients with HFpEF. Sodium glucose cotransport inhibitors reduce the risk of incident HF, HF-related hospitalizations, and cardiovascular death in patients with type 2 diabetes and cardiovascular disease. A large clinical trial recently showed that dapagliflozin provides significant outcome benefits in well treated patients with HF with reduced ejection fraction (left ventricular ejection fraction ≤ 40%), with or without type 2 diabetes.

Therapies for Advanced Heart Failure Patients Ineligible for Heart Transplantation: Beyond Pharmacotherapy.

Globally, there are ∼ 26 million people living with heart failure (HF), 50% of them with reduced ejection fraction, costing countries billions of dollars each year. Improvements in treatment of cardiovascular diseases, including advanced HF, have allowed an unprecedented number of patients to survive into old age. Despite these advances, patients with HF deteriorate and often require advanced therapies. As the proportion of elderly patients in the population increases, there will be an increasing number of patients to be evaluated for advanced therapies and an increasing number that do not qualify for, won't be considered for, or decline orthotopic heart transplantation. The purpose of this article is to review the benefits of palliative care (PC), exercise-based cardiac rehabilitation (ExCR), device therapy (cardiac resynchronization therapy and mitral clip), and mechanical circulatory support (MCS) in advanced HF patients who are transplant ineligible. PC interventions should be introduced early in the course of a patient's diagnosis to manage symptoms, address goals of care, and improve patient-centered outcomes. Further improvement in health-related quality of life as well as functional capacity can be achieved safely in patients with advanced HF through patient participation in ExCR. Device therapy and MCS can reduce HF hospitalizations and improve survival. In fact, early survival with MCS approaches that of heart transplantation. Despite their being transplant ineligible, there are a variety of treatment options available to patients to improve their quality of life, decrease hospitalizations, and potentially improve mortality.

The Spoke-Hub-and-Node Model of Integrated Heart Failure Care.

Heart failure (HF) is a significant public health concern. Specialized HF clinics provide the optimal environment to address the complex needs of these patients and improve outcomes. The current and growing population of patients with HF outstrips the ability of these clinics to deliver care. Integrated care is defined as health services that are managed and delivered so that people receive a seamless continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services. This approach requires coordination across different levels and sites of care within and beyond the health sector, according to changing patient needs throughout their lives. The spoke-hub-and-node (SHN) model represents an organization of care that works collaboratively with the primary care sector and is highly integrated with community-based multidisciplinary teams of health care professionals and specialty care. The purpose of this article is to analyze the requirements for successful implementation of SHN models. We consider the respective roles of HF clinics, HF nurse specialists, pharmacists, palliative care teams, telemonitoring, and solo practitioners. We also discuss levels of care delivery and the importance of patient stratification and patient flow. The SHN approach has the potential to build on and improve the chronic care model (CCM) to deliver centralized services to preserve high-quality patient-centred care at affordable costs.

Beyond the realist turn: a socio-material analysis of heart failure self-care.

For patients living with chronic illnesses, self-care has been linked with positive outcomes such as decreased hospitalisation, longer lifespan, and improved quality of life. However, despite calls for more and better self-care interventions, behaviour change trials have repeatedly fallen short on demonstrating effectiveness. The literature on heart failure (HF) stands as a case in point, and a growing body of HF studies advocate realist approaches to self-care research and policymaking. We label this trend the 'realist turn' in HF self-care. Realist evaluation and realist interventions emphasise that the relationship between self-care interventions and positive health outcomes is not fixed, but contingent on social context. This paper argues socio-materiality offers a productive framework to expand on the idea of social context in realist accounts of HF self-care. This study draws on 10 interviews as well as researcher reflections from a larger study exploring health care teams for patients with advanced HF. Leveraging insights from actor-network theory (ANT), this study provides two rich narratives about the contextual factors that influence HF self-care. These descriptions portray not self-care contexts but self-care assemblages, which we discuss in light of socio-materiality.

Enhancing Knowledge and InterProfessional care for Heart Failure (EKWIP-HF) in long-term care: a pilot study.

BACKGROUND: Heart failure (HF) affects 20% of long-term care (LTC) residents and is associated with significant morbidity, acute care visits, and mortality. Barriers to HF management are staff knowledge gaps and ineffective interprofessional (IP) communication. This pilot study assessed the acceptability, feasibility, and impact of an intervention to (1) improve HF knowledge; (2) improve IP communication; and (3) integrate improved knowledge and communication processes into work routines. METHODS: The intervention provides multimodal IP education about HF in LTC, including specialist-supported bedside teaching. It was piloted on single units in two facilities. A mixed-methods repeated-measures approach was used to collect qualitative and quantitative process and outcome data at baseline and 6 months post-intervention. RESULTS: Results were similar at both sites. Participants developed optimized IP communication to promote HF care. Results indicate a perceived increase in staff confidence and self-efficacy, strengthened assessment and clinical proficiency skills, and more effective IP collaboration. Staff deemed the intervention useful and feasible. CONCLUSIONS: This pilot study suggests that a novel intervention in which HF-specific knowledge is applied by LTC staff to improve IP collaboration in their own work place is acceptable and feasible and has a favourable preliminary impact on staff knowledge and IP communication.

A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes.

BACKGROUND: Having support from an informal carer is important for heart failure patients. Carers have the potential to improve patient self-care. At the same time, it should be acknowledged that caregiving could affect the carer negatively and cause emotional reactions of burden and stress. Dyadic (patient and informal carer) heart failure self-care interventions seek to improve patient self-care such as adherence to medical treatment, exercise training, symptom monitoring and symptom management when needed. Currently, no systematic assessment of dyadic interventions has been conducted with a focus on describing components, examining physical and delivery contexts, or determining the effect on patient and/or carer outcomes. OBJECTIVE: To examine the components, context, and outcomes of dyadic self-care interventions. DESIGN: A systematic review registered in PROSPERO, following PRISMA guidelines with a narrative analysis and realist synthesis. DATA SOURCES: PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials were searched using MeSH, EMTREE terms, keywords, and keyword phrases for the following concepts: dyadic, carers, heart failure and intervention. Eligible studies were original research, written in English, on dyadic self-care interventions in adult samples. REVIEW METHODS: We used a two-tiered analytic approach including both completed studies with power to determine outcomes and ongoing studies including abstracts, small pilot studies and protocols to forecast future directions. RESULTS: Eighteen papers - 12 unique, completed intervention studies (two quasi- and ten experimental trials) from 2000 to 2016 were reviewed. Intervention components fell into three groups - education, support, and guidance. Interventions were implemented in 5 countries, across multiple settings of care, and involved 3 delivery modes - face to face, telephone or technology based. Dyadic intervention effects on cognitive, behavioral, affective and health services utilization outcomes were found within studies. However, findings across studies were inconclusive as some studies reported positive and some non-sustaining outcomes on the same variables. All the included papers had methodological limitations including insufficient sample size, mixed intervention effects and counter-intuitive outcomes. CONCLUSIONS: We found that the evidence from dyadic interventions to promote heart failure self-care, while growing, is still very limited. Future research needs to involve advanced sample size justification, innovative solutions to increase and sustain behavior change, and use of mixed methods for capturing a more holistic picture of effects in clinical practice.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure.

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

Implementation of an interprofessional communication and collaboration intervention to improve care capacity for heart failure management in long-term care.

Heart failure affects up to 20% of nursing home residents and is associated with high morbidity, mortality, and transfers to acute care. A major barrier to heart failure management in nursing home settings is limited interprofessional communication. Guideline-based heart failure management programs in nursing homes can reduce hospitalisation rates, though sustainability is limited when interprofessional communication is not addressed. A pilot intervention, 'Enhancing Knowledge and Interprofessional Care for Heart Failure', was implemented on two units in two conveniently selected nursing homes to optimise interprofessional care processes amongst the care team. A core heart team was established, and participants received tailored education focused on heart failure management principles and communication processes, as well as weekly mentoring. Our previous work provided evidence for this intervention's acceptability and implementation fidelity. This paper focuses on the preliminary impact of the intervention on staff heart failure knowledge, communication, and interprofessional collaboration. To determine the initial impact of the intervention on selected staff outcomes, we employed a qualitative design, using a social constructivist interpretive framework. Findings indicated a perceived increase in team engagement, interprofessional collaboration, communication, knowledge about heart failure, and improved clinical outcomes. Individual interviews with staff revealed innovative ways to enhance communication, supporting one another with knowledge and engagement in collaborative practices with residents and families. Engaging teams, through the establishment of core heart teams, was successful to develop interprofessional communication processes for heart failure management. Further steps to be undertaken include assessing the sustainability and effectiveness of this approach with a larger sample.

Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study.

BACKGROUND: Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, we aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America; we also explored demographic, clinical, and socioeconomic variables associated with mortality. METHODS: We enrolled consecutive patients with heart failure (3695 [66%] clinic outpatients, 2105 [34%] hospital in patients) from 108 centres in six geographical regions. We recorded baseline demographic and clinical characteristics and followed up patients at 6 months and 1 year from enrolment to record symptoms, medications, and outcomes. Time to death was studied with Cox proportional hazards models adjusted for demographic and clinical variables, medications, socioeconomic variables, and region. We used the explained risk statistic to calculate the relative contribution of each level of adjustment to the risk of death. FINDINGS: We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables (New York Heart Association Functional Class III or IV, previous admission for heart failure, and valve disease) and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained. INTERPRETATION: Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are needed. FUNDING: The study was supported by Novartis.

The Caregiver Contribution to Heart Failure Self-Care (CACHS): Further Psychometric Testing of a Novel Instrument.

Caregivers (CGs) contribute important assistance with heart failure (HF) self-care, including daily maintenance, symptom monitoring, and management. Until CGs' contributions to self-care can be quantified, it is impossible to characterize it, account for its impact on patient outcomes, or perform meaningful cost analyses. The purpose of this study was to conduct psychometric testing and item reduction on the recently developed 34-item Caregiver Contribution to Heart Failure Self-care (CACHS) instrument using classical and item response theory methods. Fifty CGs (mean age 63 years ±12.84; 70% female) recruited from a HF clinic completed the CACHS in 2014 and results evaluated using classical test theory and item response theory. Items would be deleted for low (<.05) or high (>.95) endorsement, low (<.3) or high (>.7) corrected item-total correlations, significant pairwise correlation coefficients, floor or ceiling effects, relatively low latent trait and item information function levels (<1.5 and p > .5), and differential item functioning. After analysis, 14 items were excluded, resulting in a 20-item instrument (self-care maintenance eight items; monitoring seven items; and management five items). Most items demonstrated moderate to high discrimination (median 2.13, minimum .77, maximum 5.05), and appropriate item difficulty (-2.7 to 1.4). Internal consistency reliability was excellent (Cronbach α = .94, average inter-item correlation = .41) with no ceiling effects. The newly developed 20-item version of the CACHS is supported by rigorous instrument development and represents a novel instrument to measure CGs' contribution to HF self-care. © 2016 Wiley Periodicals, Inc.

Caregiver Contribution to Heart Failure Self-Care (CACHS).

AIM: While caregivers (CGs) make an important contribution to the self-care of heart failure (HF) patients, there are no reliable and valid tools for measuring such contributions. Current interventions that strive to optimize patient outcomes through self-care strategies neglect to account for CG contributions, a potential confounder on outcomes. The aim of the study was to develop an instrument that measures CG contributions to HF patients' self-care. DESIGN: The study design follows an established process for instrument development. METHODS: A systematic literature review and semi-structured interviews of CGs were conducted to identify measureable CG activities. Items were derived from thematic analysis of CG narratives. A content validity index was computed for each item (I-CVI). Items with an I-CVI of >0·70 were retained. Items with an I-CVI of 0·50-0·70 were revised for clarification and items with an I-CVI <0·5 were discarded, except in instances where fulsome theoretical or empirical evidence supported their retention. RESULTS: 14 CGs completed interviews and 10 CGs with 4 expert nurses completed I-CVI testing. Major interview themes included arranging appointments, medication adherence, monitoring, coordinating care, encouraging independence and taking action. A total of 36 items were constructed and underwent I-CVI testing. Following I-CVI testing, 27 items were retained, seven items were retained after revision based on CG feedback and two items were removed. This newly developed 34-item questionnaire represents current literature, CGs' experiences, excellent I-CVI scores and ready for further psychometric testing.

Canadian Cardiovascular Society Quality Indicators for Heart Failure.

A working group was convened by the Canadian Cardiovascular Society (CCS) in 2010 to identify quality indicators (QIs) for heart failure (HF). Using the CCS "Best Practices for Developing Cardiovascular Quality Indicators" methodology, a total of 49 "long-list" QIs was identified and rated. Subsequent ranking and discussion led to the selection of an initial "short-list" of 6 QIs to evaluate quality care, including daily assessment of blood chemistry indicators, chest radiography, patient education, in-hospital use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, assessment of left ventricular function, and 30-day hospital readmission. The short-list QIs were selected as being important for quality assurance and because the patient information, for the most part, can be captured during the inpatient setting, which would allow these QIs to be adopted more easily. These 6 QIs were subjected to a feasibility test that found that even within the inpatient setting, there is a significant gap between the existing knowledge infrastructure and the necessary information-tracking processes to measure QIs. Only 1 QI (30-day hospital readmission) can currently be measured comparatively across Canada, although the other 5 of 6 short-list QIs can be measured using other data collected by jurisdictions. Standardization and enhancements to knowledge infrastructure are essential to provide the comprehensive patient data necessary to evaluate the quality of HF care across Canada.

The Canadian Cardiovascular Society Heart Failure Companion: Bridging Guidelines to Your Practice.

The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily practice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and subsequent reassessments of patients, the order in which medications should be added, how newer medications should be included in treatment algorithms, and when left ventricular function should be reassessed. A new treatment algorithm for HF with reduced ejection fraction is included. Several other practical issues are addressed such as an approach to management of hyperkalemia/hypokalemia, treatment of gout, when medications can be stopped, and whether a target blood pressure or heart rate is suggested. Finally, elements and teaching of self-care are described. This tool will hopefully function to allow better integration of the HF Guidelines into clinical practice.