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Heart failure in primary care with special emphasis on costs and benefits of a disease management programme
Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aim. Heart failure (HF) is a common condition associated with poor quality of life (QoL), high morbidity and mortality and is frequently occurring in primary health care (PHC). It involves a substantial economic burden on the health care expenditure. There are modern pharmacological treatments with evident impact on QoL, morbidity, mortality, and proved to be cost-effective. Despite this knowledge, the treatment of HF is considered somewhat insufficient. There are several HF management programmes (HFMP) showing beneficial effects but these studies is predominantly based in hospital care (HC).

The first aim of this thesis was to describe patients with HF in the PHC regarding gender differences, diagnosis, treatment and health related costs (I, II).The second aim was to evaluate whether HFMP have beneficial effects in the PHC regarding cardiac function, quality of life, health care utilization and health care-related costs (III,IV).

Methods. The initial study involved retrospective collection of data from 256 patients with symptomatic HF in PHC (I). The data collected were gender, age, diagnostics and ongoing treatment. The second study was an economic calculation performed on 115 patients (II). The economic data was retrospectively retrieved as the number of hospital days, visits to nurses and physicians in HC and PHC, prescribed cardiovascular drugs and performed investigation during retrospectively for one year. The third and fourth study was based on a randomized, prospective, open-label study which was subsequently performed (III,IV). The study enrolled 160 patients with systolic HF who were randomized to either an intervention or a control group. The patients in the intervention group retrieved follow-up of HF qualified nurses and physicians in the PHC, involving education about HF and furthermore, optimizing the treatment according to guidelines if possible. The patients in the control group had a followup performed by their regular general practitioner (GP) receiving customary management according to local routines but there was no contact with HF nurses. The primary endpoint of the study was a composite endpoint consisting of changes in survival, hospitalization, heart function and quality of life (QoL) and to compare differences in resource utilization and costs (III,IV).

Results. In the first study, the prevalence was 2% and the average age was 78 years (I). The most frequent cause of HF was IHD followed o hypertension. The diagnosis in the study population was based on clinical criteria and only 31% had been subjected to echocardiography. The most common treatment was diuretics (84%) and angiotensin converting enzyme inhibitors (ACEI) were used in 56% of patients. In the following prospective study, the intervention group had significant improvements in composite endpoints. There were in the intervention group more patients with reduced levels of NTproBNP (p=0.012) and improved cardiac function (p=0.03). No significant changes were found in New York Heart Association (NYHA) functional class or QoL. The intervention involved less health care contacts (p=0.04), less emergency ward visits (p=0.002) and hospitalizations (p=0.03). The total cost for HC and PHC was EUR 4471 in the intervention group and EUR 6638 in the control group which implies a cost reduction of EUR 2167 (33%).

Conclusions. HF is common in PHC with a prevalence of 2% the study population had an average age of 78 years. Only 31 % of the HF patients have performed an echocardiographic investigation. Treatment with ACEI occurred in 56 %. Differences were found between genders since women had performed significantly fewer echocardiographic investigations and, had less treatment with ACEI. When implementing HFMP in PHC, beneficial effects were found regarding cardiac function and health care-related costs in patients with systolic HF. These findings indicate that HFMP might be used even in PHC.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. , 49 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1391
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-104954DOI: 10.3384/diss.diva-104954ISBN: 978-91-7519-424-0 (print)OAI: oai:DiVA.org:liu-104954DiVA: diva2:700600
Public defence
2014-04-04, Berzeliussalen, Ingång 65, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Note

In the printed version are ISBN and page numbers missing but added in the electronic version.

Available from: 2014-03-04 Created: 2014-03-04 Last updated: 2014-03-12Bibliographically approved
List of papers
1. Patients in primary health care diagnosed and treated as heart failure, with special reference to gender differences
Open this publication in new window or tab >>Patients in primary health care diagnosed and treated as heart failure, with special reference to gender differences
2001 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 19, no 1, 14-19 p.Article in journal (Refereed) Published
Abstract [en]

Objective - The aim of the present study was to describe patients considered to have had heart failure (HF), or were being treated for HF, in a defined area in primary health care, e.g. diagnostic procedures, aetiologic diseases and management, and to evaluate whether there is a difference between the genders. Design - Descriptive retrospective investigation. Setting - ┼tvidaberg community situated in southeast Sweden, 12 400 inhabitants. Patients - 256 patients treated for symptomatic HF. Main outcome measures - Prevalence, aetiology, diagnostic procedures and management of HF and differences between the genders. Results - The diagnosis of HF was based on an objective evaluation of cardiac function in only 31% of the patients. Ischaemic heart disease (IHD) was the predominant associated disease, followed by hypertension. Therapy included diuretics (84%), angiotensin converting enzyme (ACE) inhibitors (56%) and digoxin (40%). Only 52% had optimal doses of ACE inhibitors. Women had a significantly higher mean age and their diagnoses were based on an objective diagnostic test (echocardiography) in only 20%. Women were prescribed ACE inhibitors to a lesser extent (43%) than men (64%) and with a lower optimal dose (44% versus 56% in men). Conclusion - There is still room for improvement in the management of HF in primary health care, especially in women, where the diagnosis is not generally based on an objective evaluation of cardiac function and where the treatment to a lesser extent than in men includes ACE inhibitors.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26732 (URN)10.1080/02813430117814 (DOI)11327 (Local ID)11327 (Archive number)11327 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2014-03-04Bibliographically approved
2. Cost of heart failure in Swedish primary healthcare
Open this publication in new window or tab >>Cost of heart failure in Swedish primary healthcare
2005 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 23, 227-232 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. To calculate the cost for patients with heart failure (HF) in a primary healthcare setting. Design. Retrospective study of all available patient data during a period of one year. Setting. Two healthcare centers in Linköping in the southeastern region of Sweden, covering a population of 19 400 inhabitants. Subjects. A total of 115 patients with a diagnosis of HF. Main outcome measures. The healthcare costs for patients with HF and the healthcare utilization concerning hospital days and visits to doctors and nurses in hospital care and primary healthcare. Results. The mean annual cost for a patient with HF was SEK 37 100. There were no significant differences in cost between gender, age, New York Heart Association functional class, and cardiac function. The distribution of cost was 47% for hospital care, 22% for primary healthcare, 18% for medication, 5% for nursing home, and 6% for examinations. Conclusion. Hospital care accounts for the largest cost but the cost in primary healthcare is larger than previously shown. The total annual cost for patients with HF in Sweden is in the range of SEK 5.0–6.7 billion according to this calculation, which is higher than previously known.Read More: http://informahealthcare.com/doi/abs/10.1080/02813430500197647

Keyword
cost heart failure
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-32240 (URN)10.1080/02813430500197647 (DOI)18115 (Local ID)18115 (Archive number)18115 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2014-03-04Bibliographically approved
3. The benefits of using a heart failure management programme in Swedish primary healthcare
Open this publication in new window or tab >>The benefits of using a heart failure management programme in Swedish primary healthcare
2013 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 15, no 2, 228-236 p.Article in journal (Refereed) Published
Abstract [en]

Heart failure (HF) is a common condition with which high mortality, morbidity, and poor quality of life are associated. It has previously been shown that use of HF management programmes (HFMPs) in HF clinics can be beneficial. The purpose of this study was to evaluate if the use of HFMPs also has beneficial effects on HF patients in primary healthcare (PHC). less thanbrgreater than less thanbrgreater thanThis is a randomized, prospective, open-label study including 160 patients from five PHC centres with systolic HF and a mean age of 75 years (standard deviation 7.8). In the intervention group, an intensive follow-up was performed by HF nurses and physicians providing information and education about HF and the optimization of HF treatment according to recognized guidelines. There was a significant improvement of composite endpoints in the intervention group. Significantly more patients with reduced N-terminal pro brain natriuretic peptide (P 0.012), improved cardiac function (P 0.03), fewer healthcare contacts (P 0.04), and fewer emergency room visits and admittances (P 0.0002 and P 0.03, respectively) could be seen in the intervention group when compared with the control group. less thanbrgreater than less thanbrgreater thanThe use of a HFMP in a PHC setting was found to have beneficial effects in terms of reducing the number of healthcare contacts and hospital admissions, and improving cardiac function in patients with systolic HF, even if the result should be interpreted with caution. It can therefore be recommended that HFMPs should be used in PHC.

Place, publisher, year, edition, pages
Oxford University Press (OUP): Policy B, 2013
Keyword
Heart failure, Heart failure management, Primary care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-89517 (URN)10.1093/eurjhf/hfs159 (DOI)000313831900015 ()
Available from: 2013-02-27 Created: 2013-02-26 Last updated: 2017-12-06
4. Resource use and cost implications of implementing a heart failure program for patients with systolic heart failure in Swedish primary health care
Open this publication in new window or tab >>Resource use and cost implications of implementing a heart failure program for patients with systolic heart failure in Swedish primary health care
Show others...
2014 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 176, 731-738 p.Article in journal (Refereed) Published
Abstract [en]

Aim: Heart failure (HF) is a common but serious condition which involves a significant economic burden on the health care economy. The purpose of this study was to evaluate cost and quality of life (QoL) implications of implementing a HF management program (HFMP) in primary health care (PHC).

Methods and results: This was a prospective randomized open-label study including 160 patientswith a diagnosis of HF from five PHC centers in south-eastern Sweden. Patients randomized to the intervention group received information about HF from HF nurses and from a validated computer-based awareness program. HF nurses and physicians followed the patients intensely in order to optimize HF treatment according to current guidelines. The patients in the control group were followed by their regular general practitioner (GP) and received standard treatment according to local management routines. No significant changes were observed in NYHA class and quality-adjusted life years (QALY), implying that functional class and QoL were preserved. However, costs for hospital care (HC) and PHC were reduced by EUR 2167, or 33%. The total cost was EUR 4471 in the intervention group and EUR 6638 in the control group.

Conclusions: Introducing HFMP in Swedish PHC in patients with HF entails a significant reduction in resource utilization and costs, and maintains QoL. Based on these results, a broader implementation of HFMP in PHC may be recommended. However, results should be confirmed with extended follow-up to verify  long-term effects.

Keyword
Heart failure. Disease management. Primary health care. Resource utilization. Health care cost.
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-104953 (URN)10.1016/j.ijcard.2014.07.105 (DOI)000343893300049 ()25131925 (PubMedID)
Note

On the day of the defence day of this article the status of the article was Manuscript and the original title was Resource use and cost implications of implementing a heart failure programme in Swedish Primary Health Care.

Available from: 2014-03-04 Created: 2014-03-04 Last updated: 2017-12-05Bibliographically approved

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