Who cares? Improving the care pathway for heart failure in ... · PDF file10/7/2013 · Who cares? Improving the care pathway for heart failure in ... Dr Helen Hancock, Dr Helen Close,

∂ Helen Hancock PhD

Health Research Methodologist School of Medicine, Pharmacy & Health

Durham University

On behalf of the HFinCH team

Who cares? Improving the care pathway for heart failure in

residential care (HFinCH).

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Heart failure is disabling and deadly Complex diagnosis Prevalence increases with age Limited research in care home population Diagnosis and treatment can improve length & quality of life

Initial ideas ..

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Initial questions:

• How common is heart failure?

• What is the most effective diagnostic tool?

• Is optimal treatment possible?

• What do patients, care home staff and GPs think about care?

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Stakeholder Involvement

Existing heart failure support groups

Care home managers

Health care professionals

Clinical academics

Team and Organisations

Research Team: Prof James Mason, Dr Helen Hancock, Dr Helen Close, Prof Jerry Murphy, Prof Ahmet Fuat, Dr Mark de Belder, Miss Jennifer Wilkinson, Dr Raj Singh, Mrs Esther Wood, Mrs Gill Brennan, Mrs Jan Hart, Ms Jill Richardson, Mrs Gill Newton, Ms Alison Price, Dr Novin Manshani, Dr David Hodges, Dr Nehal Hussain, Dr Nitin Kumar, Ms Jane Curry, Mr Andrew Teggert, Mrs Doreen Edgar, Ms Heidi Riddle, Dr Douglas Wilson, Prof Pali Hungin.

Organisations: • James Cook University Hospital (South Tees NHS Foundation Trust) • Darlington Memorial Hospital (CDDFT) • North Tees PCT (Formerly Stockton-on-Tees Teaching PCT) • Newcastle University, Centre for Life • Residential and Nursing Care Homes • Durham University, School of Medicine, Pharmacy and Health

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Study Design

Four studies:

• Prevalence study

• Diagnostic accuracy study

• RCT

• Qualitative study

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Why RfPB?

First time this team had worked together

Clear patient benefit with strong stakeholder engagement

Within the funding limit of £250k

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Funding and Approvals

NIHR RfPB-funding: March 2008

NRES and governance approval: November 2008

Specialist NRES committee

Study duration: April 2009 - January 2011

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Prevalence Study

Primary Outcome: Prevalence of heart failure by type (LVSD or HFpEF)

Residents invited to participate (n=1172)

Residents starting diagnostic assessment (n=405)

Residents completing diagnostic assessment (n=399)

Withdrew (n=2) Unable to obtain echo (n=4)

Residential and nursing care homes in North East England (n=35)

Care homes declined participation (n=2)

Declined participation (n=756)

Residents from 33 care homes (n=1701)

Ineligible (n=529)

Residents recruited (n=416)

Died before assessment (n=4) Withdrew (n=7)

Methods 405 residents, 65–100 years of age, in 33 care homes Mini Mental State Examination – Consent – Eligibility Check Assessment Abbreviated Mental Test Score, demographic details, medical history (GP practice and Care home records), Quality of Life (EuroQol).

Physical assessment: Blood pressure, heart rate, respiratory rate, lung signs, orthopnoea, dyspnoea, displaced apex beat, third heart sound, jugular venous pressure, peripheral oedema, electrocardiogram, echocardiogram. Functional capacity as per New York Heart Association classification.

Blood tests: N-terminal pro / B-type natriuretic peptide (NT-pro BNP / BNP), urea and electrolytes (U&Es), liver function tests (LFTs), full bloods count (FBC), thyroid function tests (TFTs), high sensitivity C-reactive protein (hs-CRP), troponin, lipids and glucose. DNA, serum and plasma for possible future analysis.

Assessment of test acceptability

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Key Challenges

Process consent: MMSE and AMTS Consultee declaration required for 271 (66%) participants

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Request to NIHR for unfunded extension

Study extended by 6 months

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Key Challenges

Point prevalence of heart failure: 22.8% (n=91) Of these:

• HFpEF: 62.7% (n=57) • LVSD: 37.3% (n=34)

Only residents with LVSD eligible for the trial

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Request to NIHR for change to study design

Trial converted to a pilot study

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Key Challenges

Care homes proved a challenging research environment

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Key Challenges

Matching good science and pragmatics

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Key Successes

We did it!!!! Prevalence study

Diagnostic accuracy study

Pilot trial

Qualitative study 35% of eligible residents participated 98.5% (399/405) of participants completed assessments

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Publications • Hancock H, Close H, Mason J, Murphy J, Fuat A, Singh R, Wood E, de Belder M,

Brennan G, Hussain N, Kumar N, Wilson D, Hungin APS. High prevalence of undetected heart failure in long-term care residents: findings from the Heart Failure in Care Homes (HFinCH) study. European Journal of Heart Failure (2013) 15, 158–165 doi:10.1093/eurjhf/hfs165

• Mason JM, Hancock HC, Close H, Murphy J, Fuat A, de Belder M, Singh R, Teggert A, Wood E, Brennan G, Hussain N, Kumar N, Manshani N, Hodges D, Wilson D, Hungin APS. Utility of biomarkers in the differential diagnosis of heart failure in older people: Findings from the Heart Failure in Care Homes (HFinCH) diagnostic accuracy study. PLoS One 2013;8(1):e53560. doi: 10.1371/journal.pone.0053560. Epub 2013 Jan 11.

• Hancock H, Close H, Mason J, Murphy J, Hungin APS. Feasibility of evidence-based diagnosis and management of heart failure in older people in care: a pilot randomised controlled trial BMC Geriatrics 2012, 12:70 http://www.biomedcentral.com/1471-2318/12/70

• Close H, Hancock H, Mason JM, Murphy JJ, Fuat A, de Belder M, Hungin APS. “It’s somebody else’s responsibility” - Perceptions of general practitioners, heart failure nurses, care home staff, and residents towards heart failure diagnosis and management for older people in long-term care: a qualitative interview study

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Key points for future research

Allow time and resource to develop and deliver the proposal Engage key stakeholders early Demonstrate good science and the capacity to deliver Seek advice from others early Engage with the NIHR