A Trial of Heart Failure Disease Management in Skilled Nursing Facilities

描述(由申请人提供)：大约25%的因心力衰竭住院的联邦医疗保险患者已出院到熟练的护理机构，这一数字在2008年增加了两倍 过去的10年里。这些患者的再住院率和死亡率高于出院患者。熟练的护理设施为虚弱的心力衰竭患者提供了一个过渡场所，他们在住院后恢复了功能和独立性。医疗保险允许在住院后进行长达100天的熟练护理。尽管针对老年人的心力衰竭疾病管理方案的好处已经在其他环境中确立，但几乎没有证据表明当代心力衰竭管理与熟练护理机构提供的护理相结合。这项拟议的研究是1：1的随机整群试验，旨在研究心力衰竭患者在熟练护理设施中的心力衰竭疾病管理计划的效果。看护患者的医生将作为集群，每个熟练的护理设施将作为区块。每位医生将被随机分为两组，要么根据心力衰竭疾病管理计划管理他们的患者，要么接受常规护理。主要目标是辨别心力衰竭疾病管理计划是否会降低各种原因的住院、急诊科就诊和死亡率的综合结果。次要目标是确定心力衰竭疾病管理计划是否1)改善患者的健康状况和心力衰竭自我照顾能力，2)使患者更有可能回家，而不是出院，3)具有成本效益。这项研究的主要假设是，心力衰竭疾病管理计划将减少综合结果中的事件。心力衰竭疾病管理计划以心力衰竭的最佳实践为基础，包括心力衰竭护理的7个要素：记录射血分数、症状和活动评估、每日体重/饮食监测、药物滴定、患者和照顾者教育、出院说明和出院后7天内的随访。一名受过专业培训的心力衰竭护士代言人将与医生密切合作。心力衰竭护士代言人将负责该计划的所有要素，以确保保真度 干预的结果。这项研究的结果将确定在熟练的护理设施中实施心力衰竭疾病管理计划是否会改善患者的预后，并具有成本效益。这些结果将有可能通过改变在美国由熟练护理机构护理的老年人的心力衰竭护理，对公共健康产生重大影响。 公共卫生相关性：这项拟议的研究是对心力衰竭疾病管理计划的试验，与心力衰竭患者在熟练护理设施中的常规护理相比。这项提案旨在确定熟练的护理机构是否采用特定的HERT衰竭疾病管理做法，以减少患者的住院、急诊科就诊和死亡。由于在熟练护理设施中的成年人身体虚弱，并患有许多疾病，目前尚不清楚心力衰竭疾病的治疗是否会改变他们的结局。如果心力衰竭疾病管理是有益的，那么就有可能对公共健康产生重大影响 美国的老龄化人口。

DESCRIPTION (provided by applicant): Approximately 25% of Medicare patients hospitalized with heart failure are discharged to skilled nursing facilities and the numbers have tripled in the last 10 years. These patients have higher rehospitalization rates and mortality than those patients who are discharged to home. Skilled nursing facilities serve as a transitional site for debilitated heart failure patients where they regain function and independence following a hospitalization. Medicare allows up to 100 days of skilled nursing care post-hospitalization. Although the benefits of heart failure disease management programs targeted to the elderly have been established in other settings, there is little evidence of contemporary heart failure management integrated into the care delivered in the skilled nursing facilities. The proposed study is a 1:1 randomized cluster trial to study the effect of a heart failure disease management program for heart failure patients in skilled nursing facilities. The physicians who care for patients will serve as the cluster and each skilled nursing facility as the block. Each physician will be randomized to either manage their patients according to a heart failure disease management program or to usual care. The primary objective is to discern if a heart failure disease management program will decrease the composite outcome of all-cause hospitalizations, emergency department visits and mortality. The secondary objectives are to determine if a heart failure disease management program 1) improves patients' health status and heart failure self-care ability, 2) makes it more likely a patient will return home, rather tha be discharged to a facility and 3) is cost-effective. The primary hypothesis for this study is thata heart failure disease management program will decrease events in the composite outcome. The heart failure disease management program is based on best practices for heart failure and includes 7 elements of heart failure care: documentation of ejection fraction, symptom and activity assessment, daily weights/dietary surveillance, medication titration, patient and caregiver education, discharge instructions and a follow up visit within 7 days post-SNF discharge. A specialty trained heart failure nurse advocate will work closely with physicians. The heart failure nurse advocate will be responsible for all elements of the program to ensure fidelity of the intervention. Results from this study will determine if a heart failure disease management program in skilled nursing facilities improves patient outcomes and is cost-effective. These results will have the potential to have a large public health impact by transforming heart failure care for older adults who are cared for in skilled nursing facilities in the United States. PUBLIC HEALTH RELEVANCE: The proposed research study is a trial of a heart failure disease management program compared to usual care in skilled nursing facilities for patients with heart failure. This proposal aims to determine if skilled nursing facilities adopt specific hert failure disease management practices will patients have fewer hospitalizations, emergency department visits and deaths. Since adults in skilled nursing facilities are debilitated and have many illnesses it is unknown if HF disease management will change their outcomes. If heart failure disease management is beneficial then there is potential for great public health impact for the aging population in the United States.