Organisation of the care of patients with heart failure
1998; Elsevier BV; Volume: 352; Linguagem: Inglês
10.1016/s0140-6736(98)90312-9
ISSN1474-547X
Autores Tópico(s)Cardiac pacing and defibrillation studies
ResumoHeart failure is a major cardiovascular problem with a steadily increasing incidence and prevalence.1Reitsma JB Mosterd A de Craen AJM et al.Increase in hospital admission rates for heart failure in the Netherlands, 1980–1993.Heart. 1996; 76: 388-392Crossref PubMed Scopus (117) Google Scholar, 2Kannel WB Ho K Thom T Changing epidemiological features of cardiac failure.Br Heart J. 1994; 72 (suppl): S3-S9Crossref PubMed Scopus (291) Google Scholar, 3Ghali JK Cooper R Ford E Trends in hospitalization rates for heart failure in the United States, 1973–1986.Arch Intern Med. 1990; 150: 769-773Crossref PubMed Google Scholar, 4Rich MW Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults.J Am Geriatr Soc. 1997; 45: 968-974PubMed Google Scholar, 5McMurray J McDonagh T Morrison CE Dargie HJ Trends in hospitalization for heart failure in Scotland 1980–1990.Eur Heart J. 1993; 14: 1158-1162Crossref PubMed Scopus (311) Google Scholar These increases are due to a higher proportion of elderly individuals in the population and also because effective treatment of acute myocardial infarction and hypertension exposes more patients to the risk of heart failure than in the past. Recent epidemiological studies that included patients without symptoms of heart failure suggest that the prevalence may greatly exceed that of earlier estimates.6McDonagh TA Morrison CE Lawrence A et al.Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population.Lancet. 1997; 350: 829-833Summary Full Text Full Text PDF PubMed Scopus (563) Google Scholar Based on data from the Framingham Study2Kannel WB Ho K Thom T Changing epidemiological features of cardiac failure.Br Heart J. 1994; 72 (suppl): S3-S9Crossref PubMed Scopus (291) Google Scholar the median survival is only 1·7 years in men and 3·2 years in women. Despite advances in the treatment of heart failure the prognosis remains poor.7CONSENSUS Trial Study GroupEffects of enalapril on mortality in severe congestive heart failure.N Engl J Med. 1987; 316: 1429-1435Crossref PubMed Scopus (4703) Google Scholar, 8Studies of Left Ventricular Dysfunction (SOLVD) InvestigatorsEffect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.N Engl J Med. 1991; 325: 293-302Crossref PubMed Scopus (6877) Google Scholar Heart failure is associated with frequent admissions to hospital which are a substantial burden on health-care providers.9McMurray J Davie A The pharmacoeconomics of ACE inhibitors in heart failure.Pharmacoecon. 1996; 9: 186-197Crossref Scopus (60) Google Scholar Furthermore, there are shortcomings in the diagnosis of heart failure and, even when correctly diagnosed, optimum treatment is not always given in accordance with current guidelines.10Remes J Miettinen H Reuanen A Pyorälä K Validity of clinical diagnosis of heart failure in primary health care.Eur Heart J. 1991; 12: 315-321Crossref PubMed Google Scholar, 11Svensk Läkemedelzstatistik (Medical Index Sweden—MIS), Sweden Apoteksbolaget AB, (National Corporation of Swedish Pharmacies, Stockholm1988–1997Google Scholar There is a need to improve the care of patients with heart failure. The entire spectrum of heart-failure management should be taken into account, and this includes the provision of adequate resources for diagnosis, the creation of an infrastructure that can meet the needs associated with treatment based on evidence from clinical trials, and the development of innovative strategies for optimum care of heart-failure patients in different settings (ie, urban vs rural or primary care vs specialist care). There has been an increase in hospital admissions due to heart failure. Discharges with heart failure as the primary diagnosis increased by almost 60% in Scotland between 1980 and 19903Ghali JK Cooper R Ford E Trends in hospitalization rates for heart failure in the United States, 1973–1986.Arch Intern Med. 1990; 150: 769-773Crossref PubMed Google Scholar and, similarly rose by 48% for men and 40% for women in the Netherlands between 1980 and 1993. Readmissions are frequent in patients previously hospitalised for heart failure, and a survey in the Netherlands showed that 14–34% of patients were readmitted within 6 months.1Reitsma JB Mosterd A de Craen AJM et al.Increase in hospital admission rates for heart failure in the Netherlands, 1980–1993.Heart. 1996; 76: 388-392Crossref PubMed Scopus (117) Google Scholar We have reported that of 207 patients 65–84 years old, admitted to hospital with heart failure, 76 (37%) were readmitted because of heart failure within 1 year; 32 patients (16%) were readmitted within 30 days.12Cline C Broms K Willenheimer R Israelsson B Erhardt L Hospitalization and health care costs due to congestive heart failure in the elderly.Am J Ger Cardiol. 1996; 5: 10-23PubMed Google Scholar Some of the principal factors that cause decompensation are arrhythmias, infections, poor compliance, angina, and iatrogenic variables such as inappropriate withdrawal of angiotensin-converting-enzyme (ACE) inhibition, excessive doses of diuretics, and digitalis intoxication.13Opasich C Febo O Riccardi G et al.Concomitant factors of decompensation in chronic heart failure.Am J Cardiol. 1996; 78: 354-357Summary Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 14Ghali JK Kadakia S Cooper R Ferlinz J Precipitating factors leading to decompensation of heart failure.Arch Intern Med. 1988; 148: 2013-2016Crossref PubMed Google Scholar A prospective study of patients in hospital with heart failure showed that 53% of early readmissions were preventable.15Vinson JM Rich MW Sperry JC Shah AS McNamara T Early readmission of elderly patients with congestive heart failure.J Am Geriatr Soc. 1990; 38: 1290-1295Crossref PubMed Scopus (635) Google Scholar The main contributing factors included non-compliance with medications or diet, inadequate discharge planning or follow-up, failed social-support system, and failure to seek medical attention promptly when symptoms recurred. The table shows the reported frequency of these various factors.TableCauses of readmission in patients with heart failureCause of readmissionFrequency*More than one diagnosis. Data derived from references 13, 15, and 25.Arrhythmias8–28%Infections16–23%Poor compliance15–32%Angina14–33%Iatrogenic factors10%Inadequate drug therapy17%Inadequate discharge planning or follow-up35%Failed social support system21%* More than one diagnosis. Data derived from 13Opasich C Febo O Riccardi G et al.Concomitant factors of decompensation in chronic heart failure.Am J Cardiol. 1996; 78: 354-357Summary Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 15Vinson JM Rich MW Sperry JC Shah AS McNamara T Early readmission of elderly patients with congestive heart failure.J Am Geriatr Soc. 1990; 38: 1290-1295Crossref PubMed Scopus (635) Google Scholar, 25Chin MH Goldman L Factors contributing to the hospitalization of patients with congestive heart failure.Am J Public Health. 1997; 87: 643-648Crossref PubMed Scopus (199) Google Scholar. Open table in a new tab More than a decade has passed since ACE inhibitors were first shown to decrease mortality and morbidity in patients with heart failure.7CONSENSUS Trial Study GroupEffects of enalapril on mortality in severe congestive heart failure.N Engl J Med. 1987; 316: 1429-1435Crossref PubMed Scopus (4703) Google Scholar, 8Studies of Left Ventricular Dysfunction (SOLVD) InvestigatorsEffect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.N Engl J Med. 1991; 325: 293-302Crossref PubMed Scopus (6877) Google Scholar An overview of randomised trials that included data beyond 90 days showed that the combined endpoint of total mortality or hospital admission fell by 24% in patients treated with ACE inhibitors.16Garg R Yusuf S Overview of randomised trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure.JAMA. 1995; 273: 1450-1456Crossref PubMed Scopus (1814) Google Scholar ACE inhibitors are cost-effective treatment for heart failure and treatment guidelines for heart failure recommend their use in all stages of symptomatic heart failure due to impaired left-ventricular systolic function.9McMurray J Davie A The pharmacoeconomics of ACE inhibitors in heart failure.Pharmacoecon. 1996; 9: 186-197Crossref Scopus (60) Google Scholar, 17The Task Force of the Working Group on Heart Failure of the European Society of CardiologyThe treatment of heart failure.Eur Heart J. 1997; 18: 736-753Crossref PubMed Scopus (405) Google Scholar, 18Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on evaluation and management of heart failure).in: Guidelines for the evaluation and management of heart failure. Circulation. 92. 1995: 2764-2784Google Scholar, 19Information från Läkemedelsverket Behandling av akut och kronisk hjèrsvikt.in: Rekommendationer. Treatment of acute and chronic heart failure. Recommendations Läkernedelsverket, Sweden, Uppsala1992Google Scholar In clinical practice, however, ACE inhibitors are still not widely used.20Krumholz HM Wang Y Parent EM Mockalis J Petrillo M Radford HJ Quality of care for elderly patients hospitalized with heart failure.Arch Intern Med. 1997; 157: 2242-2247Crossref PubMed Google Scholar, 21Philbin EF Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting.Clin Cardiol. 1998; 21: 103-108Crossref PubMed Scopus (87) Google Scholar, 22Smith LE Fabbri SA Pai R Ferry D Heywood JT Symptomatic improvement and reduced hospitalisation for patients attending a cardiomyopathy clinic.Clin Cardiol. 1997; 20: 949-954Crossref PubMed Scopus (71) Google Scholar Swedish data about ACE-inhibitor prescriptions suggest that less than 30% of patients are treated with an ACE inhibitor.11Svensk Läkemedelzstatistik (Medical Index Sweden—MIS), Sweden Apoteksbolaget AB, (National Corporation of Swedish Pharmacies, Stockholm1988–1997Google Scholar In patients with mild-to-moderate heart failure a survey showed that the use of ACE inhibitors by cardiologists, internists, and general practitioners was 80%, 71%, and 60%, respectively.23Edep ME Shah NB Tateo IM Massie BM Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines.J Am Coll Cardiol. 1997; 30: 518-526Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar Similarly, β-blockers decrease mortality in patients with heart failure, yet their use is quite limited.11Svensk Läkemedelzstatistik (Medical Index Sweden—MIS), Sweden Apoteksbolaget AB, (National Corporation of Swedish Pharmacies, Stockholm1988–1997Google Scholar, 24Packer M Colucci WS Sackner-Berstein JD et al.Double-blind, placebo-controlled study of the effects of carvedilol in patiners with moderate to severe heart failure: the PRECISE trial.Circulation. 1996; 94: 2793-2799Crossref PubMed Scopus (595) Google Scholar Poor compliance with prescribed drugs is an important cause of hospital readmission.13Opasich C Febo O Riccardi G et al.Concomitant factors of decompensation in chronic heart failure.Am J Cardiol. 1996; 78: 354-357Summary Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 14Ghali JK Kadakia S Cooper R Ferlinz J Precipitating factors leading to decompensation of heart failure.Arch Intern Med. 1988; 148: 2013-2016Crossref PubMed Google Scholar, 15Vinson JM Rich MW Sperry JC Shah AS McNamara T Early readmission of elderly patients with congestive heart failure.J Am Geriatr Soc. 1990; 38: 1290-1295Crossref PubMed Scopus (635) Google Scholar, 25Chin MH Goldman L Factors contributing to the hospitalization of patients with congestive heart failure.Am J Public Health. 1997; 87: 643-648Crossref PubMed Scopus (199) Google Scholar About 50% of patients comply with prescribed medication.26Wright EC Non-compliance—or how many aunts has Matilda?.Lancet. 1993; 342: 909-913Summary PubMed Scopus (209) Google Scholar Non-compliance increases mortality and because treatment response is often related to dose, non-compliance reduces treatment benefits—which is of particular relevance to ACE inhibitors.27Gallagher EJ Viscoli CM Horowitz RI The relationship of treatment adherence to the risk of death after myocardial infarction in women.JAMA. 1993; 270: 742-744Crossref PubMed Scopus (133) Google Scholar, 28Haynes RB McKibbon KA Kanani R Systematic review of randomised trials of intervention to assist patients to follow prescriptions for medications.Lancet. 1996; 348: 383-386Summary Full Text Full Text PDF PubMed Scopus (541) Google Scholar Although the use of ACE inhibitors has increased, the doses are far below those used in clinical trials.20Krumholz HM Wang Y Parent EM Mockalis J Petrillo M Radford HJ Quality of care for elderly patients hospitalized with heart failure.Arch Intern Med. 1997; 157: 2242-2247Crossref PubMed Google Scholar A study of patients in hospital showed that of those who were eligible for specific treatments, 86% received an ACE inhibitor—but only 14% received target doses.20Krumholz HM Wang Y Parent EM Mockalis J Petrillo M Radford HJ Quality of care for elderly patients hospitalized with heart failure.Arch Intern Med. 1997; 157: 2242-2247Crossref PubMed Google Scholar The long-term goals of care for patients with heart failure are not only to decrease mortality and morbidity, but also to improve quality of life, and reduce the burden on health-care systems, mainly by a reduction in hospital readmissions. Addressing all aspects of management is generally beyond the scope of the individual physician if all heart-failure patients are to be cared for. Therefore, there is a need for units that specialise in heart failure. Such units may vary in size and structure depending on epidemiological aspects of the referral population (figure 1). In urban areas with large populations, it is reasonable to establish a heart-failure clinic. The medical responsibility of the unit would ideally be held by cardiologists or internists with expertise and experience in the management of heart failure. Since heart failure has a high prevalence and commonly affects elderly people—who may have many concomitant disorders—the heart-failure clinic should be a multidisciplinary group and work on the principle of shared care (figure 2). The shared-care programme should be designed by those involved in the management of these patients (ie, cardiologists, internists, primary care physicians, and geriatricians) who agree about the distribution of responsibilities, patient-referral routines, and diagnostic and therapeutic guidelines. Provision should be made for quality control. Educational goals for patients, relatives, and health-care staff should be defined and guidelines for optimum non-pharmacological and pharmacological treatment should be specified. One important aim of the shared-care programme is continuity with optimum patient support at all levels. Heart-failure patients need emotional support, and this is a strong, independent predictor of fatal and nonfatal cardiovascular events.29Krumholz HM Butler J Miller J et al.Prognostic importance of emotional support for elderly patients hospitalized with heart failure.Circulation. 1998; 97: 958-964Crossref PubMed Scopus (299) Google Scholar Thus, there is a need for continuous, long-term support after discharge from hospital and it is mandatory that a shared-care programme takes this support into consideration for patients who do not have it in their home environment. Nurses are usually more available than doctors and may have a pivotal role in the care of heart-failure patients (figure 3). Heart-failure nurses need suitable training and education to meet the requirements and responsibilities associated with this task. Specific tasks of the heart-failure nurse include educating patients about the importance of recognising the signs and symptoms of heart failure and discussing individual risk factors and lifestyle changes. Information about the impact of heart failure on social activities, the importance of influenza vaccination, and contraceptive and hormone-replacement therapy are other important areas in which the nurse may contribute. Nurses can assume responsiblity for starting nonpharmacological treatment and can be delegated to adjust the dose of specific drugs such as diuretics, ACE inhibitors, and β-blockers. Furthermore, they can do physical examinations and order and interpret selected blood tests. Individual treatment and follow-up plans should be documented in the nurses' records—ideally on a computerised system for instant access. Nurses should also have the practical responsibility to establish a support network for each patient, which may include physiotherapists, social services, and medical staff in the community. The role of nurses in the implementation of a heart-failure clinic has been outlined in details.30Paul S Implementing an outpatient congestive heart failure clinic: the nurse practitioner role.Heart Lung. 1997; 26: 486-491Summary Full Text PDF PubMed Scopus (23) Google Scholar Patients with heart failure are chronically ill and, over time, will have increased symptoms. The disorder leads to a reduced quality of life and often, a state of anxiety. Attention to the patient's needs is therefore of utmost importance. Self-care, within the framework of collaborative management should be used as it is in other chronic diseases,31Von Korff M Gruman J Schaefer J Curry SJ Wagner EH Collaborative management in chronic illness.Ann Intern Med. 1997; 127: 1002-1097Crossref Scopus (1040) Google Scholar and information for patients and relatives should receive priority.18Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on evaluation and management of heart failure).in: Guidelines for the evaluation and management of heart failure. Circulation. 92. 1995: 2764-2784Google Scholar In this context, patient diaries that contain data such as weight and suitable diuretic adjustments may be useful. Symptoms that indicate worsening heart failure such as dyspnoea, orthopnoea, and nocturnal diuresis are easily observed. Regular control of bodyweight and ankle measurements are useful and self-adjustment of diuretic dose, after correct information has been given, is possible. A prospective randomised trial investigated the effect of multidisciplinary intervention during a 90 day period of follow-up on readmission rates, quality of life, and costs of care in patients with congestive heart failure at high risk of readmission.32Rich MW Beckham V Wittenberg C Level CL Freedland KE Carney RM A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.N Engl J Med. 1995; 333: 1190-1195Crossref PubMed Scopus (2023) Google Scholar The intervention was comprehensive education of the patient and family about heart failure and its treatment, individualised dietary assessment and instruction, social-service consultation, a review of medication to eliminate unnecessary drugs and simplify the regimen when discharge was planned, and intensive follow-up after discharge which included home visits and telephone contact. Hospital readmissions were 44·4% lower in the intervention group than in the controls and they had 36·6% fewer days in hospital than the control group. Compared with the control group, quality of life improved to a greater extent and the costs of care were US$460 lower in the intervention group. We carried out a prospective, randomised trial to assess the effect of a management programme for heart failure based mainly on patient education and follow-up for one year in the outpatient nurse clinic. The mean time to readmission was lengthened by 35 days (25%) and days in hospital were fewer in the intervention group than in the control group.33Cline CMJ Israelsson BA Willenheimer RB Broms K Erhardt LR A structured care programme reduces hospitalisation in elderly patients with congestive heart failure.in: Heart Failure Society of America First Annual Scientific Meeting, Baltimore 1997: 256Google Scholar Health-care costs per patient were US$1300 lower in the intervention group than in controls.34Cline CMJ, Israelsson BYA, Willenheimer RB, Broms K, Erhardt LR. A management programme for patients with heart failure is cost effective and reduces the need for hospitalisation. Heart (in press).Google Scholar The use of physicians and nurses with special expertise who exclusively manage patients with heart failure may substantially improve outcomes.35Abraham WT Bristow MR Specialized centers for heart failure management.Circulation. 1997; 96: 2755-2757Crossref PubMed Scopus (69) Google Scholar An uncontrolled study of 134 patients referred to a heart-failure clinic showed that the annual rate of hospital admission fell to 44% (53% reduction) compared with the year before referral. Also, peak oxygen consumption increased and quality of life improved.36Hanamanthu S Butler J Chomsky D Davis S Wilson JR Effect of a heart failure program on hospitalisation frequency and exercise tolerance.Circulation. 1997; 96: 2842-2848Crossref PubMed Scopus (190) Google Scholar Similarly, among 21 patients treated for 6 months in a cardiomyopathy clinic, there was a 100% reduction in the number of admissions for congestive heart failure and emergency visits.22Smith LE Fabbri SA Pai R Ferry D Heywood JT Symptomatic improvement and reduced hospitalisation for patients attending a cardiomyopathy clinic.Clin Cardiol. 1997; 20: 949-954Crossref PubMed Scopus (71) Google Scholar The introduction of a nurse practitioner in a heart-failure clinic has proved effective in reducing hospital admissions and medical costs during 1 year follow-up compared with the year before inclusion.37Cintron G Bigas C Linares E Aranda J Hernandez E Nurse practitioner role in a chronic congestive heart failure clinic: inhospital time, costs, and patient satisfaction.Heart Lung. 1983; 12: 237-240PubMed Google Scholar Physician-supervised, nurse-mediated implementation of pharmacological guidelines is also safe and effective. A comparison of events among 51 patients 6 months before and 6 months after inclusion, showed that the frequency of general medical and cardiology visits declined by 23% and 31%, respectively; emergency room visits by 67%; and hospital admissions for all causes by 74%.38West JA Miller NH Parker KM et al.A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization.Am J Cardiol. 1997; 79: 58-63Summary Full Text Full Text PDF PubMed Scopus (321) Google Scholar Graduated exercise training, structured cognitive therapy and stress management, and dietary intervention aimed at salt reduction and weight reduction in overweight people has, in a randomised study of 60 patients with NYHA class II-III heart failure, been shown to improve functional capacity, bodyweight, and mood in comparison with digoxin or placebo.39Kostis JB Rosen RC Cosgrove NM Shindler DM Wilson AC Nonpharmacologic therapy improves function and emotional status in congestive heart failure.Chest. 1994; 106: 996-1001Crossref PubMed Scopus (152) Google Scholar Efforts to improve patient compliance have been an integral part of management strategies for heart failure. However, a systematic review of randomised trials of interventions to assist patients to follow prescriptions showed that even the most effective interventions did not substantially improve adherence.28Haynes RB McKibbon KA Kanani R Systematic review of randomised trials of intervention to assist patients to follow prescriptions for medications.Lancet. 1996; 348: 383-386Summary Full Text Full Text PDF PubMed Scopus (541) Google Scholar Furthermore, easier access to health-care facilities, such as a heart-failure clinic may lead to an increase in readmissions. In a prospective, randomised trial of patients admitted to Veterans Affairs Medical Centres, an intervention that involved close follow-up by a nurse and a primary care physician and began before discharge and continued for 6 months, there was a significant 36% increase in readmissions in the intervention group compared with controls.40Weinberger M Oddone EZ Henderson WG Does increased access to primary care reduce hospital readmissions?.N Engl J Med. 1996; 334: 1441-1447Crossref PubMed Scopus (638) Google Scholar An Australian study on unplanned readmissions and out-of-hospital deaths in medical and surgical patients after discharge from hospital compared home-based intervention with usual care. The intervention included counselling before discharge and a single home visit to those thought to be at high risk of readmission. Unplanned readmissions, out-of-hospital deaths, and days in hospital were lower than in the intervention group compared with controls but did not result in a significant difference in the cost of hospital-based care between groups.41Stewart S Pearson S Luke CG Horowitz JD Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths.J Am Geriatr Soc. 1998; 46: 174-180Crossref PubMed Scopus (157) Google Scholar The organisation of care for heart-failure patients requires collaboration between various hospitals and primary care facilities since heart failure is a common cause of hospital admission and, readmissions are frequent.5McMurray J McDonagh T Morrison CE Dargie HJ Trends in hospitalization for heart failure in Scotland 1980–1990.Eur Heart J. 1993; 14: 1158-1162Crossref PubMed Scopus (311) Google Scholar, 12Cline C Broms K Willenheimer R Israelsson B Erhardt L Hospitalization and health care costs due to congestive heart failure in the elderly.Am J Ger Cardiol. 1996; 5: 10-23PubMed Google Scholar This collaboration may be difficult to establish in some countries. There may also be differences between nations in the extent to which nurses are prepared to take on the increased responsibility associated with their new role in the heart-failure clinic. This new role for nurses may also meet opposition among physicians who feel threatened by nurses having a more independent position. In view of the complex nature of heart failure and the diagnostic difficulties it presents, the shortcomings in implementing evidence-based medicine with regards to treatment, the greater use of β-blockade,24Packer M Colucci WS Sackner-Berstein JD et al.Double-blind, placebo-controlled study of the effects of carvedilol in patiners with moderate to severe heart failure: the PRECISE trial.Circulation. 1996; 94: 2793-2799Crossref PubMed Scopus (595) Google Scholar (which in inexperienced hands can be potentially harmful) the advent of multiple-drug therapy, and the evidence of increased efficacy of specialised clinics, it would seem appropriate that specialised heart-failure units be established. Specialised clinics for the care of patients with specific medical problems have been evaluated in other specialties as has the use of patient education.42Tougaard L Krone T Sorknaes A Ellegaard H the PASTMA groupEconomic benefits of teaching patients with chronic obstructive pulmonary disease about their illness.Lancet. 1992; 339: 1517-1520Summary PubMed Scopus (63) Google Scholar Clinics for diabetes and asthma have improved the outcomes of their patients. However, by contrast with these disorders, heart failure has an adverse prognosis and the patients are significantly older, which has to be taken into account. Therefore, specific requirements have to be met with regard to patient selection and tailoring intervention for the unit to be successful. Concentration of one disorder in a specific unit may seem simple, but experience has taught us that it is difficult to maintain enthusiasm over long periods. Built-in systems for quality assistance should therefore be encouraged in order to provide continuous feedback on the unit's performance. Care for patients with heart failure seems to be greatly improved if delivered by specialised units that use a multidisciplinary management approach. The benefits of these units in the management of heart-failure patients were seen in several clinical trials. However, caution is required in the interpretation of the results of nonrandomised trials in which the patients included are their own controls. Indeed, these studies show results of such magnitude as to induce a certain amount of scepticism. The positive effects of the randomised trials are much smaller. The evidence for the positive effects have to be validated for various groups of patients and proven even when applied in various settings. The effect of various strategies on outcomes in heart failure should be investigated.
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