Cost-Effectiveness of a Home Visit Program for Patients with Heart Failure in Brazil: Evidence from a Randomized Clinical Trial.

OBJECTIVE: Estimate the cost-effectiveness of a nurse-led home visit (HV) intervention as compared with the standard HF management, within a randomized clinical trial in Brazil. STUDY DESIGN: Cost-effectiveness study within a randomized trial. METHODS: To assess the cost-effectiveness of four home visits and four telephone calls by nurses in the management of patients with HF within a randomized clinical trial (RCT: NCT01213875) in a perspective Public (PHS-Public Healthcare System) and private healthcare systems of Brazil during time frame of 24 weeks. The outcome was a composite endpoint hospital readmission rate (first visit to the emergency room (ER) and hospital readmission), or all-cause death and incremental cost-effectiveness ratio (ICER) of the study intervention to conventional management. RESULTS: Home-based intervention was associated with a reduction in composite endpoint (RR 0.73; 95% confidence interval 0.54 - 0.99; P = 0.049), but at greater cost from the PHS perspective. The ICER at 24 weeks was R$585 per hospital readmission visit prevented. Within the private health insurance framework, home visits were associated with lower costs and lower readmission rates. Results were sensitive to the relative risk of the study intervention, admissions and intervention costs. CONCLUSIONS: In Brazil, an intervention based on nurse-led home visits of patients with HF showed a favorable cost-effectiveness profile within the framework of the PHS and was dominant within the private healthcare system. Our analysis suggests that implementation of this program could not only benefit patients, but also provide a financial incentive to health administrators.

Perfil de pacientes submetidos à cirurgia de revascularização miocárdica: implicações para o cuidado de enfermagem / Profile of patients undergoing to coronary artery bypass grafting: implications for nursing care / Perfil de pacientes sometidos a injerto de derivación coronaria: implicaciones en el cuidado de enfermería

A gravidade dos pacientes submetidos à cirurgia de revascularização do miocárdio (RM) tem aumentado consideravelmente nas últimas décadas. O objetivo deste estudo de coorte contemporâneo foi identificar o perfil clínico e cirúrgico dos pacientes submetidos à RM. Os dados foram extraídos do prontuário de 58 pacientes internados num hospital de referência em cardiologia de Porto Alegre, Rio Grande do Sul, no ano de 2006, desde a sua chegada até a alta ou o 7º dia de permanência na unidade de terapia intensiva (UTI). A idade média foi 65,3+9,7 anos, predominância do sexo masculino (70,7%), hipertensão arterial sistêmica foi a comorbidade mais prevalente (86,2%), seguida por dislipidemia (60,3%) e diabetes (36,2%). A cirurgia de RM isolada foi realizada em 82,8% da amostra, com circulação extracorpórea em 39,7% das cirurgias. Complicações pós-operatórias ocorreram em 48,3% dos pacientes; a fibrilação atrial (FA) foi a complicação mais frequente (20,7%). Houve associação entre idade, tempo de permanência na UTI e complicações pós-operatórias (p<0,05). Os pacientes submetidos à RM são majoritariamente homens, idosos, com fatores de risco clássicos para cardiopatia isquêmica, sendo a FA a complicação mais prevalente. O conhecimento acerca do perfil dos pacientes operados proporciona subsídios para a enfermagem planejar o cuidado em UTI.

The severity of patients undergoing coronary artery bypass grafting (CABG) has increased considerably in recent decades. This contemporaneous cohort study aimed to evaluate the clinical and surgical profile of patients undergoing CABG. Data were retrieved from medical records of 58 inpatients in hospital of reference in cardiology in Porto Alegre - Rio Grande do Sul, in the year of 2006, from the day of hospitalization until discharge, or during the 7 first days of stay in the intensive care unit (ICU).Patients were mostly males (70.7%) with a mean age 65.3+9.7 years; the most prevalent comorbidities were systemic arterial hypertension (86.2%), dyslipidemia (60.3%) and diabetes (36.2%). Forty-eight patients (82.8%) were submitted to CABG, with extracorporeal circulation in 39.7% of the cases. Postoperative complications, represented mostly by atrial fibrillation (AF) (20.7%), were observed in 48.3% of the patients. Correlations were observed between age, length of stay in the ICU and incidence of postoperative complications (p<0.05). Most patients undergoing CABG were male, aged and with classical risk factors for ischemic heart disease, among which AF is the most prevalent complication. The characteristics of patients undergoing myocardial revascularization surgery are of great importance for the nursing team to plan and deliver best quality care to ICU patients.

La gravedad de los pacientes sometidos a injerto de derivación coronaria (IDAC) ha aumentado considerablemente en las últimas décadas. El objetivo de este estudio (cohorte) fue identificar el perfil clínico y quirúrgico de pacientes sometidos a IDAC. Los datos fueron extraídos del prontuario hospitalar de 58 pacientes hospitalizados en un hospital de referencia en cardiología en Porto Alegre - Rio Grande do Sul, en el año 2006, desde su llegada hasta el día del alta o 7º día de permanencia en la unidad de terapia intensiva (UTI). La media de edad fue de 65,3+9,7 años, con predominio masculino (70,7%), hipertensión arterial sistémica fue la comorbilidad más prevalente (86,2%), seguida por dislipidemia (60,3%) y diabetes (36,2%). La cirugía RM aislada fue realizada en 82,8% del grupo. Complicaciones post operatorias ocurrieron en 48,3% del grupo; fibrilación arterial (FA) fue la complicación más frecuente (20,7%). Hubo asociación entre edad, tiempo de permanencia en UTI y complicaciones post operatorias (p<0.05). Los pacientes sometidos a IDAC son mayoritariamente hombres, de edad avanzada, con factores de riesgo clásicos para cardiopatía isquemica, siendo FA la complicación más prevalente. El conocimiento acerca del perfil de los pacientes operados facilitaría el cuidado en la UTI proporcionado por el equipo de enfermería.

Predictors of quality of life change after an acute coronary event.

BACKGROUND: The assessment of quality of life (QOL), identifying functional capacity and frequency of angina and other cardiac symptoms, are key issues in the treatment of chronic patients or in those with disease instability. OBJECTIVE: To identify predictors of quality of life (QOL) improvement in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). METHODS: Patients hospitalized in a cardiology reference hospital were assessed with the Seattle Angina Questionnaire (SAQ) at the time of admission and after 6 months. The analyzed outcome was the variation of the QOL score, resulting from the difference between the score after six months and the score at the time of admission. Differences between patients with or without 6-month QOL improvements regarding the demographic, clinical and therapeutic characteristics were assessed by univariate and multivariate analysis. RESULTS: Hypertensive patients presented lower improvement in QOL scores when compared to non-hypertensive ones [8.3(0-25) vs. 16.6(0-33.3); P=0.05], as well as patients with dyslipidemia, when compared to non-dyslipidemic ones [8.3(0-25) vs. 16.6(0-33.3); P=0.02]. Patients with unstable angina presented greater improvements in QOL in relation to those with NSTE myocardial infarction [16.6(0-33.3) vs. 8.3(-8.3-25); P=0.03]. By multivariate analysis, myocardial revascularization in the first 30-days was associated with the greater improvement in the QOL score (8.47 points; P=0.005). On the other side, the presence of dyslipidemia at the baseline evaluation was an independent predictor of worse QOL scores (-7.2 points; P=0.01). CONCLUSION: Myocardial revascularization was associated with improvement in the 6-month QOL scores, while dyslipidemia was associated with worse scores.

Preditores de mudança na qualidade de vida após um evento coronariano agudo / Predictors of quality of life change after an acute coronary event

FUNDAMENTO: A verificação de desfechos complementares torna-se relevante para os pacientes com instabilização da doença coronariana e tratamento farmacológico crônico. OBJETIVO: Identificar preditores de melhora na qualidade de vida relacionada à saúde em pacientes com síndrome coronariana aguda (SCASST) sem supradesnivelamento. MÉTODOS: Pacientes consecutivamente internados em um hospital de referência cardiológica foram prospectivamente avaliados com o Seattle Angina Questionnaire (SAQ) na internação e em seis meses. O desfecho analisado foi a variação do escore SAQ - qualidade de vida, resultante da diferença entre o escore em seis meses e o da internação. Verificaram-se as características demográficas, clínicas e terapêuticas associadas à melhora da qualidade de vida (análise univariada), assim como seus preditores (multivariada). RESULTADOS: Os hipertensos apresentaram uma variação do escore SAQ - qualidade de vida menor quando comparados aos não-hipertensos [8,3(0-25) vs 16,6(0-33,3); P=0,05], assim como pacientes com dislipidemia, quando comparados aos não-dislipidêmicos [8,3(0-25) vs 16,6(0-33,3); P=0,02]. Pacientes com angina instável apresentaram uma variação maior no escore em relação aos pacientes com infarto agudo do miocárdio (IAM) sem supradesnivelamento de ST [16,6(0-33,3) vs 8,3(-8,3-25); P=0,03]. Ajustada para as características clínicas e demográficas, a revascularização do miocárdio em até 30 dias após a SCASST, está associada com maior variação no escore SAQ - qualidade de vida (+8,47 pontos; P=0,005) e, a dislipidemia com piora (-7,2 pontos; P=0,01). CONCLUSÃO: A revascularização miocárdica está associada à melhora da qualidade de vida relacionada à saúde, mais pronunciada naqueles pacientes submetidos à cirurgia. A dislipidemia está associada à piora desse desfecho em seis meses.

BACKGROUND: The assessment of quality of life (QOL), identifying functional capacity and frequency of angina and other cardiac symptoms, are key issues in the treatment of chronic patients or in those with disease instability. OBJECTIVE: To identify predictors of quality of life (QOL) improvement in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). METHODS: Patients hospitalized in a cardiology reference hospital were assessed with the Seattle Angina Questionnaire (SAQ) at the time of admission and after 6 months. The analyzed outcome was the variation of the QOL score, resulting from the difference between the score after six months and the score at the time of admission. Differences between patients with or without 6-month QOL improvements regarding the demographic, clinical and therapeutic characteristics were assessed by univariate and multivariate analysis. RESULTS: Hypertensive patients presented lower improvement in QOL scores when compared to non-hypertensive ones [8,3(0-25) vs. 16,6(0-33,3); P=0,05], as well as patients with dyslipidemia, when compared to non-dyslipidemic ones [8,3(0-25) vs. 16,6(0-33,3); P=0,02]. Patients with unstable angina presented greater improvements in QOL in relation to those with NSTE myocardial infarction [16.6(0-33.3) vs. 8.3(-8,3-25); P=0,03]. By multivariate analysis, myocardial revascularization in the first 30-days was associated with the greater improvement in the QOL score (8.47 points; P=0,005). On the other side, the presence of dyslipidemia at the baseline evaluation was an independent predictor of worse QOL scores (-7.2 points; P=0.01). CONCLUSION: Myocardial revascularization was associated with improvement in the 6-month QOL scores, while dyslipidemia was associated with worse scores.