Improving medication titration in heart failure by embedding a structured medication titration plan

Background To improve up-titration of medications to target dose in heart failure patients by improving communication from hospital to primary care. Methods This quality improvement project was undertaken within three heart failure disease management (HFDM) services in Queensland, Australia. A structured medication plan was collaboratively designed and implemented in an iterative manner, using methods including awareness raising and education, audit and feedback, integration into existing work practice, and incentive payments. Evaluation was undertaken using sequential audits, and included process measures (use of the titration plan, assignment of responsibility) and outcome measures (proportion of patients achieving target dose) in HFDM service patients with reduced left ventricular ejection fraction. Results Comparison of the three patient cohorts (pre-intervention cohort A n\ua0=\ua096, intervention cohort B n\ua0=\ua095, intervention cohort C n\ua0=\ua089) showed increase use of the titration plan, a shift to greater primary care responsibility for titration, and an increase in the proportion of patients achieving target doses of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (A 37% vs B 48% vs C 55%, p\ua0=\ua00.051) and beta-blockers (A 38% vs B 33% vs C 51%, p\ua0=\ua00.045). Combining all three cohorts, patients not on target doses when discharged from hospital were more likely to achieve target doses of ACEI/ARB (p\ua

Striving to achieve best practice in heart failure disease management [Correspondence]

Based on a national audit of chronic heart failure (CHF) management programmes (CHF-MPs) conducted in 2006, Driscoll et al identified a disproportionate distribution ranging from 0 to 4.2 programmes/million population in the various states of Australia with many programmes not following best practice.1 We welcome their proposal to develop national benchmarks for CHF management and acknowledge the contributions of the Heart Foundation and health professionals in finalising these recommendations.2 We would like to share the Queensland experience in striving towards best practice with the number of CHF-MPs increasing from four (at the time of the 2006 survey) to 23, equating to 5.0 programmes/million population. Queensland now has a state-wide heart failure service steering committee with a focus on the development of CHF-MPs supported by a central coordinator..

A review of the quality of upper extremities skills test (QUEST) for children with cerebral palsy

Disorder of movement is the main feature of cerebral palsy. Yet, until recently, no easy-to-use validated measure of upper limb quality of movement has been available for children with cerebral palsy. The Quality of Upper Extremities Skills Test (QUEST) was developed to meet this need. The QUEST was developed for children aged 18 months to 8 years and this review finds that initial reliability and validity data are promising. The ability of the test to detect change, however, is less clear and there is little support for its discriminative properties. Some suggestions are made regarding administration and scoring procedures. Notwithstanding these limitations, the QUEST is identified as an important first step to the measurement of upper extremity quality of movement for children with cerebral palsy

Expert Comment: Is medication titration in heart failure too complex?

Large-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers decrease mortality and hospitalisation in patients with heart failure (HF) associated with a reduced left ventricular ejection fraction. This has led to high prescription rates; however, these drugs are generally prescribed at much lower doses than the doses achieved in the RCTs. A number of strategies have been evaluated to improve medication titration in HF, including forced medication up-titration protocols, point-of-care decision support and extended scope of clinical practice for nurses and pharmacists. Most successful strategies have been multifaceted and have adapted existing multidisciplinary models of care. Furthermore, given the central role of general practitioners in long-term monitoring and care coordination in HF patients, these strategies should engage with primary care to facilitate the transition between the acute and primary healthcare sectors

Implementing a Community-Based Model of Exercise Training Following Cardiac, Pulmonary, and Heart Failure Rehabilitation

Purpose: Encouraging patients to continue regular activity beyond the period of formal cardiac, heart failure, or pulmonary rehabilitation is a challenge faced by all program coordinators. The purpose of this study was to evaluate the feasibility of a community model run by fitness instructors as long-term maintenance for patients exiting a disease-specific rehabilitation program. Methods: Heartmoves programs were established in close proximity to all major tertiary hospitals in Brisbane, Queensland, Australia, and all eligible patients were offered supported referral to a program. Referred patients and rehabilitation staff were surveyed regarding perceived barriers to attendance. Referral rates and individual attendance rates for the first 12 weeks were recorded. Results: Over 12 months, 241 patients were referred to a community Heartmoves class, of whom 141 (59%) attended at least once and 76 (32% of referrals, 54% of initial attendees) attended more than 6 of the first 12 weeks. Preattendance surveys identified concerns about quality and safety, as well as social and logistic barriers. The programs proved to be sustainable, as evidenced by the growth of programs from 18 at the end of the project to 31 over a 18-month period. Conclusions: A supported referral pathway to Heartmoves provides a feasible and acceptable model for maintenance exercise following cardiac, heart failure, and pulmonary rehabilitation. Strategies that recognize and address barriers perceived by participants and by rehabilitation program staff should be part of the supported referral process

Heart education assessment and rehabilitation toolkit: Heart online. A web resource for clinicians [Conference Abstract]

Access to the right information at the right time is a challenge facing health professionals across the globe. HEART Online (www.heartonline.org.au) is a website designed to support the delivery of evidence based care for the prevention and rehabilitation of heart disease. It was developed by the Queensland Government and the National Heart Foundation of Australia and launched May 2013

Using clinical indicators in a quality improvement programme targeting cardiac care

Rationale. The Brisbane Cardiac Consortium, a quality improvement collaboration of clinicians from three hospitals and five divisions of general practice, developed and reported clinical indicators as measures of the quality of care received by patients with acute coronary syndromes or congestive heart failure. Development of indicators. An expert panel derived indicators that measured gaps between evidence and practice. Data collected from hospital records and general practice heart-check forms were used to calculate process and outcome indicators for each condition. Our indicators were reliable (kappa scores 0.7-1.0) and widely accepted by clinicians as having face validity. Independent review of indicator-failed, in-hospital cases revealed that, for 27 of 28 process indicators, clinically legitimate reasons for withholding specific interventions were found i