Discussion
We conclude from this study that both the COACH and the SMARTPHONE REMINDER intervention were acceptable to patients and feasible to be applied to HF patients at risk of rehospitalisation, and combined, are associated with a synergistic reduction in salt. Due to the nature of it being a pilot study, we do not address the generalisability to other populations at this point. Importantly, we observed that the COACH group had a profound reduction in the primary endpoint, rehospitalisation at 6 months, compared with other groups. Despite high LACE scores predicting significant rates of rehospitalisation,4 rehospitalisation for HF was extremely low in this study, as was mortality. However, the sample size was small. Therefore, both COACH and SMARTPHONE REMINDER interventions, as applied in this study, may be beneficial and have synergistic effects in improving patient lifestyle and outcome in HF, but our results need confirmation in a more generalisable and larger study.
Treatment interventions in this study were well accepted by patients. Our results, while not showing any improvements in patient medication compliance, did not show significant reduction in patient compliance out to 6 months which differs from other findings.11 It is important to note that high adherence rates observed in this study at baseline were in patients followed by a single cardiologist and specialised HF clinic. If future studies were undertaken, our results suggest the need for a larger sample size with an even higher risk group (high event rate) and powerful intervention to reduce readmission by more than 30%. This would require a multicentre study or a large network to accomplish.
A systematic approach, with emphasis on optimising HF care to reduce HF readmissions, has the potential to provide significant cost savings to the healthcare system. HF care strategies designed to improve and reinforce education, identify and address early signs and symptoms of HF exacerbation which have shown promise were included in the curriculum of this study. Further support is provided by a study of Medicare patients’ using home healthcare found, regardless of clinical severity of HF, there were 21%–46% fewer readmissions in patients with home health intervention. Depending on the severity, the cost savings to Medicare was between $C4588 and $C8010 per patient.12 We did not conduct a formal cost-benefit analysis. However, this study cost $C175 000. In 2022–2023, we had 918 admissions with a 20% readmission rate. Each admission cost on the average $C15 431. A 50% reduction in readmissions would reduce the present negative net margin of ($C5.9M) by $C1.4M.
Other modalities, such as telemonitoring (using transmitted weight, blood pressure and pulse rate) and telemedicine, especially using an NP who can prescribe evidence-based therapy, have also successfully reduced readmissions.13–15 Moreover, telemedicine, using structured interviewing by a trained provider, has had variable success recently and is expensive. Two recent telemonitoring studies have failed to show benefit; they did not employ NPs and required patients-activated monitoring.13 14 Often these programmes keep patients in a passive role and, as such, raise questions about optimum duration and cost-effectiveness. Recent small studies have focused on improved monitoring devices with better reporting capability including technical and educational support to medical staff and patients.16 17 These recent studies have demonstrated better satisfaction by both patients and providers. The present study is one of the first to demonstrate a large effect on HF rehospitalisation, however, mediated by sustaining medication adherence and dietary reduction is salt. These processes of care were not delivered by healthcare providers but by lay coaches and electronic providers. In summary, telemonitoring and telemedicine studies are improving. However, telemonitoring and telemedicine methodologies have failed to show large and consistent reductions in readmission rates at 6 months or 30 days in order to be recommended in current clinical practice guidelines.18–20
In this study, each intervention was a patient enabler. Providers were not part of the intervention. Our SMARTPHONE REMINDER intervention enabled patients by reminding them of appointments, medication schedules and salt restriction. Patient activation was the primary form of the SMARTPHONE REMINDER intervention. The COACH strategy was a face-to-face strategy employed over time, providing intense education about how patients can manage their condition. While we observed synergy between telemedicine and a coach to reduce salt intake, the COACH strategy had superior impact on rehospitalisation.
In this study, we did not test HF clinics and utilisation of HF NPs as physician extenders,20–26 which has been the intervention widely tested in other studies. In general, these measures have met with modest success in reducing readmission. Systematic reviews of NP-led HF clinics suggest that 6-month all-cause readmission rates can be reduced by as much as 18%. However, the range of improvement was large. Our results suggest that while acknowledging there is strong evidence favouring benefits of NPs in improving outcomes in the management of HF patients, improvement in readmission rates remains highly variable and could be improved by either more effective coaching, or telephonic interactions, as described here.
Disease management programmes11 24–28 propose the integration of multidisciplinary, multilevel and high-tech approaches to create close connections between patients and needed medical care. Our results align with the chronic care model proposed by Wagner27 28 which has as its ultimate goal an informed, activated patient interacting with a prepared proactive practice team, resulting in high quality and satisfying encounters with improved outcomes. Both interventions, COACH or SMARTPHONE REMINDER, used at least four of six pillars recommended by Wagner et al: patient education, enhanced delivery system, evidence-based treatment and use of enhanced information systems. In this study, we focused primarily on patient education and support. The prescribing cardiologist had excellent access to both clinical decision support and an electronic medical record. Prescribing adherence to beta blockers, ACE inhibitors and ARBs was high and patient adherence at 3 months improved from baseline in all three interventions. Clinic notes sent to family doctors, each visit, was the standard of care.
Other studies have demonstrated that patients, actively involved in their own care and adhering to treatment regimens, are more likely to have improved survival, fewer readmissions and experience better quality of life.29 30 Disease management programmes include enhancing adherence for patients with HF included medication education, disease education, self-monitoring and other strategic interventions. These known interventions were the basis of both the COACH and SMARTPHONE interventions of this study.27 29–36
There are some caveats to our results. First, these results are not generalisable. Patients were managed by a single cardiologist, experienced in HF and chronic disease management. Second, patients had frequent follow-ups with medication reconciliation each visit. Adherence was high at baseline and, more importantly, little evidence of attrition in patient adherence to evidence-based therapy, over time. Larger studies free of selection bias and which use up-to-date information tools allowing better coordination between patient and provider are necessary. This was a pilot study meant to inform future more definitive studies. It is possible that frequent follow-up by an experienced cardiologist influenced this result and not research interventions. Third, telephonic reminders are a less-invasive patient intervention. While it was acceptable by patients in our preliminary studies, this intervention could be more interactive, especially introducing a nurse available to interact with patients and to answer questions in a timely fashion. However, one advantage of a telephone intervention lies in its use with patients living far away who find it difficult to have frequent one-on-one contact with a coach. Hence, the two interventions can be combined in a way to be more effective in these remote patients. Our final caveat is that these results were obtained before the COVID pandemic. Optimal therapy for HF has expanded beyond beta blockers + ACE inhibitors or ARBs + MRAs to now include sodium-glucose Cotransporter-2 inhibitors and sacubitril/valsartan. Future studies will need to include all evidence-based therapies in educational materials and curricula for coaches and patients, alike.