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abstract: BACKGROUND Heart failure treatment guidelines emphasize daily weight monitoring for patients with heart failure , but data to support this practice are lacking . Using a technology-based heart failure monitoring system , we determined whether daily reporting of weight and symptoms in patients with advanced heart failure would reduce rehospitalization and mortality rates despite aggressive guideline -driven heart failure care . METHODS This was a r and omized , controlled trial . Patients hospitalized with New York Heart Association class III or IV heart failure , with a left ventricular ejection fraction < or = 35 % were r and omized to receive heart failure program care or heart failure program care plus the AlereNet system ( Alere Medical , Reno , Nev ) and followed-up for 6 months . The primary end point was 6-month hospital readmission rate . Secondary end points included mortality , heart failure hospitalization readmission rate , emergency room visitation rate , and quality of life . RESULTS Two hundred eighty patients from 16 heart failure centers across the United States were r and omized : 138 received the  AlereNet system and 142 received st and ard care .  Mean age was 59 + /- 15 years and 68 % were male . The population had very advanced heart failure , New York Heart Association class III ( 75 % ) or IV ( 25 % ) , as evidence d by serum norepinepherine levels , 6-minute walk distance and outcomes .  No differences in hospitalization rates were observed . There was a 56.2 % reduction in mortality ( P < .003 ) for patients r and omized to the AlereNet group . CONCLUSIONS This is the largest multicenter , r and omized trial of a technology-based daily weight and symptom-monitoring system for patients with advanced heart failure . Despite no difference in the primary end point of rehospitalization rates , mortality was significantly reduced for patients r and omized to the AlereNet system without an increase in utilization , despite specialized and aggressive heart failure care in both groups BACKGROUND Hospital admissions for heart failure are common and readmission rates are high . Many admissions and readmissions may be avoidable , so that alternative strategies are needed to improve long-term management . METHODS We conducted a r and omized trial of the effect of a guideline -based intervention on rates of readmission within 90 days of hospital discharge and costs of care for patients who were hospitalized due to decompensated heart failure . The intervention consisted of comprehensive education of the patient and family , a prescribed diet and intensive application of guidelines ' recommendations on pharmacological therapy . The intervention started before discharge and continued thereafter with follow-up visits for up to 3 months . Two hundred and nine guideline -managed patients were compared to 209 concurrent normally-discharged patients . RESULTS Patients in the study group were more prescribed beta-blockers , ACE-inhibitors , angiotensin receptor blockers , and spironolactone . Sixteen patients ( 8 % ) in the intervention group and 31 ( 15 % ) among controls were readmitted for DRG 127 , within 3 months of discharge ( Fisher 's exact test , p < 0.01 ) , while the 6-month mortality rate was similar between groups ( 9 and 11.5 % respectively ) . Quality of life significantly improved from 5.6 + /- 1.0 to 6.1 + /- 1.9 ( Mann-Whitney U-test , p < 0.05 ) . The overall costs of care were lower for guideline -managed patients ( 110 vs 150 Euro per patient per month ) , due to the lower readmission rates . CONCLUSIONS Our study showed that a guideline -based management program for patients with heart failure at discharge improves quality of life and reduces readmission for DRG 127 and total bed days , allowing relevant cost savings Abstract Background : Disease management programmes ( DMPs ) improve quality of care for patients with heart failure ( HF ) . However , only a limited number of trials have studied the efficacy of such programmes for patients with heart failure with preserved ejection fraction ( HFPEF ) . Objective : To estimate the impact of a structured , nurse-led patient education programme and care plan in general practice on outcome parameters and events in patients with HFPEF . Methods : Single blinded r and omized clinical trial with an intervention over six months and a follow-up during 12 additional months . In the control group , the patients ( n = 41 ) were managed according to Russian national guidelines . Patients in the intervention group ( n = 44 )  received education on individual lifestyle changes and modifications of cardiovascular disease ( CVD ) risk factors , home-based exercise training and weekly nurse consultations in addition to usual care . Results : Six months after their inclusion , patients in the intervention group significantly improved body mass index , waist circumference , six-min walk test distance , total cholesterol , low-density lipoprotein , left ventricular end-diastolic volume index , quality of life and level of anxiety . After 18 months , there were 11 deaths ( 25 % ) or hospitalizations in the intervention group and 12 ( 29 % ) in the control group ( P = 0.134 ) . Cardiovascular mortality and readmission rate were not reduced significantly after six months of follow-up : the hazard ratio was 0.47 ( 95 % CI : 0.17–1.28 ; P = 0.197 ) . After 18 months , this was 0.85 ( 0.42–1.73 ; P = 0.658 ) . Conclusion : This primary care based DMP for patients with HFPEF improved the patients ’ emotional status and quality of life , positively influenced body weight , functional capacity and lipid profile , and attenuated heart remodelling Aim Multidisciplinary disease management programmes ( MDPs ) for heart failure have been shown to be effective in Western countries . However , it is not known whether they improve outcomes in a high population density country with a national health insurance programme . Methods In total , 349 patients hospitalized because of heart failure were r and omized into  control  and MDP groups . All-cause death and re-hospitalization related to heart failure were analyzed . The median follow-up period was approximately 2 years . Results Mean patient age was 60 years ; 31 % were women ; and 50 % of patients had coronary artery disease . MDP was associated with fewer all-cause deaths [ hazard ratio ( HR ) = 0.49 , 95 % confidence interval ( CI ) = 0.27–0.91 , P = 0.02 ] and heart failure-related re-hospitalizations ( HR = 0.44 , 95 % CI = 0.25–0.77 , P = 0.004 ) . MDP was still associated with better outcomes for all-cause death ( HR = 0.53 , 95 % CI = 0.29–0.98 , P = 0.04 ) and heart failure-related re-hospitalization ( HR = 0.46 , 95 % CI = 0.26–0.81 , P = 0.007 ) , after adjusting for age , diuretics , diabetes mellitus , chronic kidney disease , hypertension , sodium , and albumin . However , MDPs ’ effect on all-cause mortality and heart failure-related re-hospitalization was significantly attenuated after adjusting for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers or & bgr;-blockers . A stratified analysis showed that MDP combined with guideline -based medication had synergistic effects . Conclusions MDP is effective in lowering all-cause mortality and re-hospitalization rates related to heart failure under a national health insurance programme . MDP synergistically improves the effectiveness of guidelines -based medications for heart failure BACKGROUND Patients with heart failure ( HF ) experience depressive symptoms that contribute to poorer outcomes . We tested the effects of a brief cognitive therapy intervention on depressive symptoms , negative thinking , health-related quality of life , and cardiac event-free survival . METHODS AND RESULTS Hospitalized patients with depressive symptoms ( n = 41 , 66 ± 11 years , 45 % female , 81 % New York Heart Association Class III/IV ) were r and omly assigned  to control group or a brief , nurse-delivered cognitive therapy intervention , delivered during hospitalization and followed by a 1-week booster phone call  . Depressive symptoms , negative thinking , and health-related quality of life were measured at 1 week and 3 months . Cardiac event-free survival was assessed at 3 months . Mixed models repeated measures analysis of variance , Kaplan-Meier , and Cox regression were used for data analysis . There were significant improvements in depressive symptoms and health-related quality of life in both groups but no interactions between group and time . The control group had shorter 3-month cardiac event-free survival ( 40 % versus 80 % , P < .05 ) and a 3.5 greater hazard of experiencing a cardiac event ( P = .04 ) than the intervention group . CONCLUSION Nurses can deliver a brief intervention to hospitalized patients with heart failure that may improve short-term , event-free survival . Future research is needed to verify these results with a larger sample size OBJECTIVES The purpose of this study was to assess the rate of death and hospitalization for heart failure ( HF ) 1 and 3 years after a r and omized trial of telephone intervention aim ed to improve education and compliance in stable patients with HF ended . BACKGROUND The long-term effects of HF programs are not well known . METHODS In all , 1,518 patients with HF were r and omized into the DIAL ( R and omized Trial of Phone Intervention in Chronic Heart Failure ) . After completion of the trial , patients were followed up to 3 years to assess major outcomes . Compliance with diet , weight control , and treatment was evaluated . The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk ( RR ) , relative risk reduction , and Cox proportional hazards model for adjusting by potential confounders . RESULTS The rate of death or hospitalization for HF was lower in the intervention group ( 37.2 % vs. 42.6 % , RR : 0.81 , 95 % confidence interval [ CI ] : 0.69 to 0.96 ; p = 0.013 ) 1 and 3 years ( 55.7 % vs. 57.5 % , RR : 0.88 , 95 % CI : 0.77 to 1.00 ; p = 0.05 ) after the intervention ended . This benefit was mainly caused by a reduction in admission for HF ( 28.5 % vs. 35.1 % after 3 years , RR : 0.72 , 95 % CI : 0.60 to 0.87 ; p = 0.0004 ) . Patients who showed improvement in 1 or more of 3 key compliance indicators ( diet , weight control , and medication ) had lower risks of events . CONCLUSIONS The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended . This effect may be explained by the impact of the educational intervention on patients ' behavior and habits AIMS To test the effect of education and support by a nurse on self-care and re source utilization in patients with heart failure . METHODS A total of 179 patients ( mean age 73 , 58 % male , NYHA III-IV ) hospitalized with heart failure were evaluated prospect ively . Patients were r and omized to the study intervention or to ' care as usual '  . The supportive educative intervention consisted of intensive , systematic and planned education by a study nurse about the consequences of heart failure in daily life , using a st and ard nursing care plan developed by the research ers for older patients with heart failure . Education and support took place during the hospital stay and at a home visit within a week of discharge . Data were collected on self-care abilities , self-care behaviour , readmissions , visits to the emergency heart centre and use of other health care re sources . RESULTS Education and support from a nurse in a hospital setting and at home significantly increases self-care behaviour in patients with heart failure . Patients from both the intervention and the control group increased their self-care behaviour within 1 month of discharge , but the increase in the intervention group was significantly more after 1 month . Although self-care behaviour in both groups decreased during the following 8 months , the increase from baseline remained statistically significant in the intervention group , but not in the control group . No significant effects on re source utilization were found . CONCLUSIONS Intensive , systematic , tailored and planned education and support by a nurse results in an increase in patients ' self-care behaviour . No significant effects were found on use of health care re sources . Additional organisational changes , such as longer follow-up and the availability of a heart failure specialist would probably enhance the effects of education and support INTRODUCTION AND OBJECTIVES Multidisciplinary strategies for the management of heart failure ( HF ) improve outcomes . We aim ed to evaluate the effectiveness of noninvasive home telemonitoring in ambulatory patients with HF already included in a structured multidisciplinary HF program . METHODS Prospect i ve intervention study with before/after comparison design of an interactive telemedicine platform in HF patients , r and omized 1:1 into two groups : A ) Motiva System with educational videos , motivational messages , and question naires , and B ) Motiva System + self monitoring of blood pressure , heart rate , and weight . Hospitalizations were compared over 12 months prior to and post study inclusion . Quality of life was evaluated using the generic EuroQoL visual analogue scale and the specific question naire Minnesota Living With Heart Failure Question naire . RESULTS There were 92 patients included ( 71 % male ; 66.3 ± 11.5 years ; 71 % ischemic aetiology ) . During real-time telemonitoring over 11.8 months ( interquartile range 8.6 - 12 ) , 14,730 question naires were administered with 89 % median response rate . Hospitalizations for HF decreased by 67.8 % ( P = .010 ) and for other cardiac causes by 57.6 % ( P = .028 ) . The number of days in hospital for HF decreased by 73.3 % ( P = .036 ) , without statistically significant differences between groups , and for other cardiac causes by 82.9 % ( P = .008 ) . The perception of quality of life improved significantly both for the generic scale ( P < .001 ) and for the HF specific question naire ( P=.005 ) . CONCLUSIONS HF patients who used an interactive telehealth system with motivational support tools at home spent less time in hospital and felt their quality of life had significantly improved . No significant differences were observed between groups Background .The high cost of caring for patients with congestive heart failure ( CHF ) results primarily from frequent hospital readmissions for exacerbations . Home nurse visits after discharge can reduce readmissions , but the intervention costs are high . Objectives .To compare the effectiveness of three hospital discharge care models for reducing CHF-related readmission charges : 1 ) home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope ; 2 ) nurse telephone calls ; and 3 ) usual outpatient care . Research Design . One-year r and omized trial . Subjects . English-speaking patients 40 years of age and older with a primary hospital admission diagnosis of CHF . Measures .Our primary outcome was CHF-related readmission charges during a 6-month period after r and omization . Secondary outcomes included all-cause readmissions , emergency department ( ED ) visits , and associated charges . Results .Thirty-seven subjects were r and omized : 13 to home telecare , 12 each telephone care and 12 to usual care .  Mean CHF-related readmission charges were 86 % lower in the telecare group ( $ 5850 , SD $ 21,094 ) and 84 % lower in the telephone group ( $ 7320 , SD $ 24,440 ) than in the usual care group ( $ 44,479 , SD $ 121,214 ) . However , the between-group difference was not statistically significant . Both intervention groups had significantly fewer CHF-related ED visits ( P = 0.0342 ) and charges ( P = 0.0487 ) than the usual care group . Trends favoring both interventions were noted for all other utilization outcomes . Conclusions .Substantial reductions in hospital readmissions , emergency visits , and cost of care for patients with CHF might be achieved by widespread deployment of distance technologies to provide posthospitalization monitoring . Home telecare may not offer incremental benefit beyond telephone follow-up and is more expensive OBJECTIVE The aim was to investigate if family members of patients with chronic heart failure ( CHF ) increased knowledge about CHF through a group-based multi-professional educational programme and whether there was an effect on patients ' health care utilization . METHODS Family members ( n=128 ) were r and omly assigned to intervention-group ( IG ) who received CHF education programme or control-group ( CG ) who received information according to hospital routines .  Programme effects were evaluated with CHF knowledge question naire , patient readmissions and number of days hospitalised during 18 months . RESULTS Knowledge about CHF increased in both groups , significantly higher in IG at second assessment ( IG 16±1.9 vs. CG 14.9±2.1 , p=0.006 ) , and knowledge maintained at third assessment . In IG 17 patients were re-admitted at least once and 28 patients in CG due to CHF ( p=0.085 ) . There were no differences in frequency of readmissions or number of days hospitalised . CONCLUSION A group-based multi-professional education programme  increased family members ' knowledge about CHF . Despite this , effect on patient 's health care utilization could not be seen during follow-up period . PRACTICAL IMPLICATION S We suggest that CHF education programmes for family members should be provided at clinics , with information preferably repeated 2 - 3 times during a period of six months to maintain knowledge level OBJECTIVES The goal of this study was to make a head-to-head comparison of 2 common forms of multidisciplinary chronic heart failure ( CHF ) management . BACKGROUND Although direct patient contact appears to be best in delivering CHF management overall , the precise form to optimize health outcomes is less clear . METHODS This prospect i ve , multicenter r and omized controlled trial with blinded endpoint adjudication comprised 280 hospitalized CHF patients ( 73 % male , age 71 ± 14 years , and 73 % with left ventricular ejection fraction ≤45 % ) r and omized to home-based intervention ( HBI ) or specialized CHF clinic-based intervention ( CBI )  . The primary endpoint was all-cause , unplanned hospitalization or death during 12- to 18-month follow-up . Secondary endpoints included type/ duration of hospitalization and healthcare costs . RESULTS The primary endpoint occurred in 102 of 143 ( 71 % ) HBI versus 104 of 137 ( 76 % ) CBI patients ( adjusted hazard ratio [ HR ] : 0.97 [ 95 % confidence interval ( CI ) : 0.73 to 1.30 ] , p = 0.861 ) : 96 ( 67.1 % ) HBI versus 95 ( 69.3 % ) CBI patients had an unplanned hospitalization ( p = 0.887 ) , and 31 ( 21.7 % ) versus 38 ( 27.7 % ) died ( p = 0.252 ) . The median duration of each unplanned hospitalization was significantly less in the HBI group ( 4.0 [ interquartile range ( IQR ) : 2.0 to 7.0 ] days vs. 6.0 [ IQR : 3.5 to 13 ] days ; p = 0.004 ) . Overall , 75 % of all hospitalization was attributable to 64 ( 22.9 % ) patients , of whom 43 ( 67 % ) were CBI patients ( adjusted odds ratio : 2.55 [ 95 % CI : 1.37 to 4.73 ] , p = 0.003 ) . HBI was associated with significantly fewer days of all-cause hospitalization ( -35 % ; p = 0.003 ) and from cardiovascular causes ( -37 % ; p = 0.025 ) but not for CHF ( -24 % ; p = 0.218 ) . Consequently , healthcare costs ( $ AU3.93 vs. $ AU5.53 million ) were significantly less for the HBI group ( median : $ AU34 [ IQR : 13 to 81 ] per day vs. $ AU52 [ 17 to 140 ] per day ; p = 0.030 ) . CONCLUSIONS HBI was not superior to CBI in reducing all-cause death or hospitalization .  However , HBI was associated with significantly lower healthcare costs , attributable to fewer days of hospitalization . ( Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [ WHICH ? ] ; ACTRN12607000069459 ) OBJECTIVES Medicare penalizes hospitals with 30-day readmissions above their expected rates . Hospitals have responded by implementing transitional care interventions ; however , there is limited evidence to inform the development of a successful intervention . STUDY DESIGN Parallel-group , stratified , r and omized controlled trial . METHODS A total of 512 patients hospitalized at 2 community hospitals , with congestive heart failure ( CHF ) or chronic obstructive pulmonary disease ( COPD ) , were r and omly assigned to the intervention ( n = 253 ) or usual care ( n = 259 ) . The intervention encompassed a 90-day hospital-based transitional care program . The primary end points were 30- and 90-day all-cause readmissions . Secondary measures included all-cause emergency department ( ED ) visits and mortality . RESULTS On average , study participants were 67 years of age , 57 % female , and 70 % insured by Medicare . There was no statistical difference between treatment groups on 30-day readmission incidence rates ( difference , 0.040 ; 95 % CI , -0.047 to 0.127 ; P = .36 ) , or 90-day readmission incidence rates ( difference of 0.035 ; 95 % CI -0.122 to 0.192 ; P = .66 ) . Groups also did not differ in ED visit incidence rates at 30 or 90 days . The mortality rate among patients with CHF showed no difference between groups ( risk ratio = 0.90 ; 95 % CI , 0.40 - 2.05 ) . However , for COPD , mortality at 90 days was lower in the intervention group than in the usual care group ( risk ratio = 0.28 ; 95 % CI , 0.10 - 0.83 ) . CONCLUSIONS St and -alone community hospitals may be unable to prevent readmissions despite the use of comprehensive , evidence -based intervention components that are within their control . Better collaboration between hospitals and community-based providers is needed to ensure continuity of care for discharged patients . TRIAL REGISTRATION Clinical Trials.gov , Identifier : NCT01855022 Background —Although disease management programs for patients hospitalized with heart failure ( HF ) are effective , they are , however , often re source intensive , limiting their uptake . Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for patients with HF . Methods and Results —In this r and omized controlled trial , Reciprocal Peer Support ( RPS ) arm patients participated in a HF nurse practitioner – led goal setting group session , received brief training in peer communication skills , and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform . Participants were also encouraged to attend 3 nurse practitioner – facilitated peer support group sessions .  Patients in the nurse care management arm attended a nurse practitioner – led session to address their HF care questions and receive HF educational material s and information on how to access care management services .  The median age of the patients was 69 years ; 51 % were female and 26 % were racial/ethnic minorities . Only 55 % of RPS patients participated in peer calls or group sessions . In intention-to-treat analyses , the RPS and nurse care management groups did not differ in time-to-first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths . There were no differences in improvements in 6-month measures of HF-specific quality of life or social support . Conclusions —Among patients recently hospitalized for HF , more than half of RPS participants had no or minimal engagement with the RPS program , and the program did not improve outcomes compared with usual HF nurse care management . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00508508 Background : Previous investigators have demonstrated that patient adherence to optimal weight monitoring result ed in fewer heart failure (HF)–related  rehospitalizations . Objective : The aim of this study was to determine whether a weight management ( WM ) intervention can improve patients ’ WM ability and cardiac function and reduce HF-related rehospitalizations . Methods : Heart failure patients were r and omly assigned to an  intervention group ( n = 32 ) or a  control group ( n = 34 ) . The intervention group received the WM intervention , including education about regular daily weight monitoring and coping skills when detecting sudden weight gain , with a WM booklet and scheduled telephone visits . Patients ’ WM ability was measured by the Weight Management Question naire ( WMQ ) . We compared scores on the WMQ , New York Heart Association ( NYHA ) classification , and HF-related rehospitalizations between the 2 groups at enrollment and at 6 months . We also analyzed the association of adherence to weight monitoring and rehospitalization in the intervention group during the 6-month follow-up . Results : There were no significant differences in weight monitoring adherence , WM ability , and NYHA classification between the 2 groups at baseline . At 6 months , scores on all 4 subscales of the WMQ significantly increased within the intervention group , and the WM- practice subscale significantly improved within the control group . Adherence to weight monitoring was significantly improved in the intervention group compared with the control group ( 81.25 % vs 11.76 % ; P < .01 ) . At 6 months , there was a significant improvement in NYHA class in the intervention group compared with the control group ( P = .03 ) . Rehospitalizations related to HF were also fewer in the intervention group ( 0.28 ± 0.63 vs 0.79 ± 1.18 ; P = .03 ) during the follow-up duration . In the intervention group , those who weighed themselves regularly reported less HF-related rehospitalizations than did those who did not ( 0.23 ± 0.43 vs 0.50 ± 1.23 ; P = .62 ) . Conclusion : This study demonstrates that the WM intervention had a positive impact on patients ’ adherence to weight monitoring , WM ability , and NYHA classification and reduced HF-related rehospitalization UNLABELLED The objective of the study was to evaluate whether improvements obtained during an intervention programme were maintained after the programme was stopped . 153 patients discharged with a diagnosis of heart failure ( HF ) were r and omized to either usual care or an intervention programme , which included patient education , consultation with the cardiologist and monitoring in the Heart Failure Unit . After an average period of 16+/-8 months , the intervention programme was stopped . One year later , all the patients were re-examined to assess HF readmissions , all-cause mortality , quality of life , and prescribed medical treatment . During the 16+/-8-month treatment period , patients in the intervention group had a lower rate of HF readmissions ( 17 % vs. 51 % , p<0.01 ) , less all-cause mortality ( 13 % vs. 27 % , p=0.03 ) , improvement in quality of life ( 1.5+/-0.8 vs. 1.9+/-1 , p=0.03 ) and optimisation of medical treatment was achieved . One year after stopping the intervention , there was no difference in HF readmissions ( 28 % vs. 25 % , p=0.72 ) , all-cause mortality ( 14 % vs. 17 % , p=0.64 ) and quality of life ( 1.7+/-0.9 vs. 1.8+/-1 , p=0.24 ) between the groups . Survival and the probability of not being readmitted due to HF were similar in both groups . There was also a reduction in the use of beta-blockers and spironolactone in the intervention group . CONCLUSIONS The positive effects of an intervention programme are clearly reduced when it is stopped , due to less strict control of the patients and a decrease in the use of drugs with proven efficacy in HF PURPOSE This work addresses the unanswered question of whether multidisciplinary care ( MDC ) of heart failure ( HF ) can reduce readmissions when optimal medical care is applied in both intervention and control groups . METHODS In a r and omized , controlled study , 98 patients ( mean age , 70.8 + /- 10.5 years ) admitted to hospital with left ventricular failure ( New York Heart Association Class IV ) were assigned to routine care ( RC , n = 47 ) or MDC ( n = 51 ) . All patients received the same components of inpatient , optimal medical care of HF : specialist-led inpatient care ; titration to maximum tolerated dose of angiotensin-converting enzyme inhibitor before discharge ; attainment of predetermined discharge criteria ( weight stable , off all intravenous therapy , and no change in oral regimen for 2 days ) . Only those in the MDC group received inpatient and outpatient education and close telephone and clinic follow-up . The primary study endpoint was rehospitalization or death for a HF-related issue at 3 months . MAIN FINDINGS At 3 months , four people had events in the MDC group ( 7.8 % rate over 3 months ) compared with 12 people ( 25.5 % rate over 3 months ) in the RC group ( P = 0.04 ) . CONCLUSION These data demonstrate for the first time the intrinsic benefit of MDC in the setting of protocol -driven , optimal medical management of HF . Moreover , the event rate of 7.8 % at 3 months , as the lowest reported rate for such a high-risk group , underlines the value of this approach to the management of heart failure BACKGROUND Managing patients with heart failure ( HF ) is labor intensive , and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation . We tested the effect of an Internet-based telemedicine ( T ) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF . METHODS AND RESULTS HF patients in NYHA Class II-IV were r and omized to usual care ( UC , n = 24 ) or T ( T plus UC , n = 24 ) and followed for 1 year .  Office visits , emergency department visits , hospitalizations , telephone calls , and number of Internet communications were measured over the 1-year period . Left ventricular ejection fraction ( EF ) was assessed by echocardiography in both groups . For T , mean age was 53.2 + /- 2.0 years ( 72 % male , 61 % Caucasian , 39 % African American ) . For UC , mean age was 54.1 + /- 2.6 years ( 76 % male , 72 % Caucasian , 14 % African American , and 14 % Hispanic ) .  HF etiologies and EF were similar in both groups . During the 12-month period , UC had 74 total phone calls to the practice , whereas T had 88 telephone calls plus 1887 telemedicine data messages ( 6.5 messages/patient/month ) . ER visits were lower in the T group ( T 5 , UC 12 ; P < .05 ) . Hospital admissions ( T 24 , C 40 ; P = .025 ) and total hospital days ( T 84 , UC 226 days ; P < .005 ) were lower in T. Unscheduled clinic visits ( T 13 , UC 13 ; P = NS ) and scheduled clinic visits ( T 78 , UC 94 ; P = NS ) were similar in both groups . CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations , hospital days , and emergency department visits BACKGROUND Nursing approaches to manage patients with heart failure ( HF ) showed benefits in reducing the morbidity and mortality . However , combining intra-hospital education with telephone contact after hospital discharge has been little explored . OBJECTIVE To compare two nursing intervention groups among patients hospitalized due to decompensated HF : the intervention group ( IG ) received educational nursing intervention during hospitalization followed by telephone monitoring after discharge and the  control group  ( CG ) received in-hospital intervention only . Outcomes were levels of HF and self-care knowledge , the frequency of visits to the emergency room , rehospitalizations and deaths in a three-month period . METHODS R and omized clinical trial . We studied adult HF patients with left ventricle ejection fraction ( LVEF ) < 45 % who could be contacted by telephone after discharge .  HF awareness was evaluated through a st and ardized question naire that also included questions regarding self-care knowledge , which was answered during the hospitalization period and three months later . For patients in the IG group contacts were made using phone calls and final interviews were conducted in both groups at end of the study . RESULTS Forty-eight patients were assigned to the IG and 63 to the CG . Mean age ( 63 ± 13 years ) and L ( around 29 % ) were similar in the two groups . Scores for HF and self-care knowledge were similar at baseline . Three months later , both groups showed significantly improved HF awareness and self-care knowledge scores ( P < 0.001 ) . Other outcomes were similar . CONCLUSION An in-hospital educational nursing intervention benefitted all HF patients in underst and ing their disease , regardless of telephone contact after discharge OBJECTIVE The purpose of this study was to test the efficacy of a heart failure ( HF ) training program on patients ' ability to recognize and respond to changes in HF symptoms . The primary aim was to compare event-free survival at 90 days . METHODS A total of 99 HF patients r and omized to the HF symptom training intervention or usual care completed instruments about self-care ( Self-Care of HF Index ) and at baseline and 3 months . Demographic , clinical , and comorbidity data were collected by interview and chart review . Time to first event ( death or a HF-related hospitalization ) was tracked by electronic records and patient interview . RESULTS The sample was predominately male ( 67.7 % ) , elderly ( 67.7 yrs ± 12.1 ) and Caucasian ( 88.9 % ) . The intervention group reported more events but the difference was not significantly different ( χ(2 ) = 1.18 , p = 0.26 ) . There was no difference in survival time between groups ( χ(2 ) = 1.53 , p = 0.216 ) . In paired t-tests , the intervention group had significantly improved self-care maintenance , management and confidence scores ( all p < 0.01 ) . The usual care group had significantly improved self-care maintenance and management ( both p < 0.01 ) . Improvements in self-care maintenance and confidence were higher in the intervention group compared with usual care ( 18.0 vs. 12.9 points ) . CONCLUSIONS HF symptom awareness training appeared to have an early but not sustained benefit result ing in no difference in 90-day event-free survival . However , larger improvement in self-care maintenance and confidence scores in the intervention group compared to usual care is promising . Embedding meaningful symptom monitoring strategies in self-care maintenance interventions requires further investigation Context People with chronic conditions may need tailored , practical help for managing their conditions . Contribution This 12-month trial of assistance with managing systolic- dysfunction heart failure r and omly assigned 406 ethnically diverse adults from Harlem , New York , to usual care or nurse management .  Nurses counseled nurse management patients about sodium intake , fluid buildup , medication adherence , and self-management of symptoms ; served as a bridge between patients and physicians ; and regularly called patients to discuss problems . Compared with usual care patients , nurse management patients had fewer hospitalizations and better functioning . Implication s Nurse management can improve some outcomes in ethnically diverse patients with systolic-dysfunction heart failure in ambulatory practice s. The Editors Heart failure disproportionately affects black and elderly people and is a leading cause of hospitalization among people 65 years of age or older ( 1 , 2 ) . Although effective therapies can improve functioning and survival in patients with systolic dysfunction , many patients may not be receiving the full benefit of existing knowledge ( 35 ) . Patients play a critical role in managing a chronic condition , such as heart failure . Patients may not realize that specific symptoms are related to heart failure or that adhering to medications and diet can reduce symptoms and life-threatening episodes ( 6 ) . Evidence -based guidelines for systolic dysfunction recommend that physicians not only offer patients effective therapies but also teach them the importance of adherence and self-monitoring ( 3 , 4 ) . Clinicians have fallen short in prescribing angiotensin-converting enzyme inhibitors and -blockers for patients with systolic dysfunction ( 5 , 7 , 8) . When prescribed , the doses have often been lower than those proven to convey greater benefits ( 3 , 9 ) . Clinicians have also documented counseling only a fraction of patients with heart failure about self-management ( 10 , 11 ) . System-related factors may also influence patients ' ability to obtain quality care ( 12 , 13 ) . Systematic review s of clinical behavior change have suggested that interventions targeted to specific problems are more likely to be successful ( 14 , 15 ) . On the basis of shortfalls identified in patient self-management and clinical care in Harlem , New York , a predominately nonwhite area , we tailored a nurse management intervention to address documented problems and evaluated its effectiveness in a r and omized , controlled trial . Our trial among primarily minority patients addresses important gaps in the literature . We targeted problems documented among patients with heart failure in Harlem , enrolled patients from ambulatory care practice s , r and omly assigned patients to either nurse management or usual care , and evaluated the patients ' subsequent health-related outcomes . We hypothesized that patients in the  focused nurse management program  would have fewer hospitalizations and report better functioning than patients in usual care . Methods Development of the Intervention During interviews with patients with heart failure at Mount Sinai Hospital , New York , New York , patients reported inadequate underst and ing of heart failure and their role in managing it ( 6 ) . Less than half of patients followed a very-low-salt diet , and only about one quarter weighed themselves daily . Regarding clinical management , medical records noted prescriptions for an angiotensin-converting enzyme inhibitor or hydralazinedinitrate combination in 82 % of 322 consecutive black patients with documented systolic dysfunction who were scheduled for visits at the general medicine clinic at Harlem Hospital from February 1995 through February 1997 . The prescribed doses , however , equaled or exceeded those found to be efficacious in clinical trials in only 26 % of these patients ( 3 ) . In design ing a nurse management intervention to address these problems , we built on a Stanford University program that evaluated primarily privately insured patients at Kaiser Permanente in northern California ( 16 , 17 ) . We adapted their question naire on the frequency of foods eaten to incorporate those that are common among African-American and Hispanic people in Harlem . Setting s and Recruitment All 4 hospitals in Harlem , the area 's major providers , collaborated in the trial : 1 large private academic medical center ( 1171 beds ) , 2 medium-sized municipal hospitals ( 286 beds and 363 beds ) , and 1 smaller private community hospital ( 200 beds ) . In 2000 , these hospitals had 521 , 267 , 218 , and 168 discharges for the heart failure diagnosis-related group ( code 127 ) , respectively . All are not-for-profit institutions . The trial had the following inclusion criteria : adults 18 years of age or older ; systolic dysfunction documented on a cardiac test ( echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization ) ; English- language or Spanish- language speakers ; community-dwelling at enrollment ; and current patient in a general medicine , geriatrics , or cardiology clinic or office at a participating site . Exclusion criteria were medical conditions that prevented interaction with the nurse , including blindness , deafness , or cognitive impairment ; medical conditions requiring individualized management that might differ from st and ard protocol , namely pregnancy , renal dialysis , or terminal illness ; or procedures that corrected systolic dysfunction , such as heart transplantation . Of the 216 clinicians ( 209 physicians and 7 physicians ' assistants or nurse practitioners ) in participating practice s , 1 clinician declined permission to recruit his patients . The institutional review boards for each site approved the study . We identified patients with International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) , and diagnosis-related group codes on outpatient or inpatient billings for heart failure , March 1999 through February 2001 , who had at least 1 clinician visit to a participating practice and impaired systolic dysfunction . We defined impaired systolic dysfunction as a left ventricular ejection fraction less than 0.40 or moderately or severely reduced systolic dysfunction on echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization . We obtained clinicians ' permission to recruit specific patients and sent each approved patient a letter from the site 's physician coordinator . Bilingual recruiters telephoned eligible patients or approached them at scheduled clinician appointments . The recruiter confirmed each patient 's eligibility , obtained written informed consent to participate in the study , conducted the baseline survey , and telephoned the project manager for the treatment group assignment . The recruiter conveyed the assignment to the patient and , for each nurse management patient , scheduled the in-person appointment with a nurse . We provided telephone service for 3 patients who did not have it so we could telephone patients in both treatment groups every 3 months for data on end points and so nurse management patients could participate in the intervention . R and omization and Treatment Groups The project 's statistician used a computer-generated , r and om-number sequence without blocking or stratification to central ly determine r and omization assignments and concealed treatment group assignments in sealed , opaque envelopes . Usual care patients received federal consumer guidelines for managing systolic dysfunction but no other intervention ( 18 ) . In the nurse management intervention , 1 of 3 trained registered nurses met once with each patient ( Table 1 ) . In counseling the patient , the nurse stressed the relationship among sodium intake ; fluid buildup ; and symptoms , such as shortness of breath . Nurses mailed patients the reports from the food-frequency question naire after each administration . The nurse also served as a bridge between the patient and the clinician ( Table 1 ) . A local clinical advisory committee implemented national evidence -based guidelines , and a committee of key clinicians from participating sites approved the protocol ( 3 , 4 ) . Nurses contacted patients ' clinicians to discuss specific medications and arranged any prescription changes and examinations ordered ( Table 1 ) . An internist monitored the nurses ' work , initially in weekly and then in biweekly meetings , and a cardiologist provided oversight and substituted for the internist at regular meetings , as necessary . Table 1 . Components of Nurse Management * One nurse who was bilingual in English and Spanish delivered the intervention primarily at the 2 municipal hospitals , a second bilingual nurse delivered the intervention primarily at the small community hospital , and the second and a third English- language speaking nurse delivered the intervention primarily at the academic center . All 3 nurses covered each other , especially for the follow-up telephone calls . Outcomes and Measurement To measure hospitalizations , we used billing data from the 4 participating hospitals . At quarterly telephone surveys , interviewers who were blinded to treatment assignment asked patients about hospitalizations at nonparticipating hospitals ; however , we present the analysis of billing data because they measure hospitalizations independent of possibly socially acceptable responses or survey nonresponse of the patients . For functional status , we used the generic Short Form-12 ( SF-12 ) physical component score and the condition-specific Minnesota Living with Heart Failure ( MLHF ) Question naire , with both scales administered at the quarterly interviews . We measured deaths recorded in the National Death Index plus deaths reported by patients ' families for patients with no subsequent billings . Since both nurse management and usual care involved only services delivered in routine practice , the study did not monitor adverse effects . As required by the Background . The growing number of patients with congestive heart failure has increased both the pressure on hospital re sources and the need for community management of the condition . Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines ’ recommendations for coordination and education . Positive outcomes have been reported from trials evaluating multiple interventions , enhanced hospital discharge , and follow-up through the addition of a case management role . The question remains if similar gains could be achieved working with usual hospital and community nurses . Methods . A 12-week , prospect i ve , r and omized controlled trial was conducted of the effect of transitional care on health-related quality of life ( disease-specific and generic measures ) , rates of readmission , and emergency room use .  The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge . Results . At 6 weeks after hospital discharge , the overall Minnesota Living with Heart Failure Question naire ( MLHFQ ) score was better among the Transitional Care patients ( 27.2 ± 19.1 SD ) than among the Usual Care patients ( 37.5 ± 20.3 SD;P = 0.002 ) . Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ ’s Physical Dimension and Emotional Dimension subscales . Differences in generic quality life , as assessed by the SF-36 Physical component , Mental Component , and General Health subscales , were not significantly different between the Transition and Usual Care groups . At 12 weeks postdischarge , 31 % of the Usual Care patients had been readmitted compared with 23 % of the Transitional Care patients ( P = 0.26 ) , and 46 % of the Usual Care group visited the emergency department compared with 29 % in the Transitional Care group ( & khgr;2 = 4.86 , df 1 , P = 0.03 ) . Conclusions . There were significant improvements in health-related quality of life ( HRQL ) associated with Transitional Care and less use of emergency rooms BACKGROUND Outcomes related to chronic heart failure ( HF ) remain relatively poor , despite advances in pharmacological therapy and medical and nursing care . Experts agree that outpatient care may be among the factors that affect HF outcomes . We hypothesized that the method by which outpatient care is delivered may affect outcomes in this patient population . METHODS A prospect i ve , r and omized design was used to compare HF outcomes from 216 patients r and omized to 1 of 2 home health care delivery methods for 3 months after discharge . Care was delivered by the home nurse visit ( HNV ) or the nurse telemanagement ( NTM ) method . In the latter , patients used transtelephonic home monitoring devices to measure their weight , blood pressure , heart rate , and oxygen saturation . These data were transmitted daily to a secure Internet site . An advanced- practice nurse worked collaboratively with a cardiologist and subsequently treated patients via the telephone . Both delivery methods used the same HF-specific clinical guidelines to direct care . Outcomes include HF readmissions and length of stay , anxiety , depression , self-efficacy , and quality of life . Data were primarily tested using a 2-group analysis of variance ( ANOVA ) . We used a repeated- measures ANOVA to conduct preintervention-postintervention analyses . RESULTS After 3 months , patients in the  NTM group ( n = 108 ; mean + /- SD age , 62.9 + /- 13.2 years ; 83 % African American ; 64 % female ) had fewer HF readmissions ( 13 vs 24 ; P</=.001 ) with shorter lengths of stay ( 49.5 vs 105.0 days ; P</=.001 ) compared with the HNV group ( n = 108 ; mean + /- SD age , 63.2 + /- 12.6 years ; 89 % African American ; 62 % female ) . Hospitalization charges at 3 months were less in the NTM group compared with the HNV group ( $ 65 023 vs $ 177 365 ; P</=.02 ) . At 6 and 12 months , cumulative readmission charges in the NTM group were also less ( $ 223 638 vs $ 500 343 [ P<.03 ] and $ 541 378 vs $ 677 710 [ P</=.16 ] , respectively ) compared with the HNV group . Quality of life was significantly improved for both groups when we compared postintervention and preintervention scores . CONCLUSION The adaptation of state-of-the-art computerized technology to closely monitor patients with HF with advanced- practice nurse care under the guidance of a cardiologist significantly improves HF management while reducing the cost of care BACKGROUND We sought to determine if outcomes with exercise training in heart failure ( HF ) vary according to ventricular pacing type . METHODS AND RESULTS Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training ( HF-ACTION ) r and omized 2,331 out patients with HF and left ventricular ejection fraction ≤35 % to usual care plus exercise training or usual care alone .  We examined the relationship between outcomes and r and omized treatment according to ventricular pacing status with the use of Cox proportional hazards modeling . In HF-ACTION 1,118 patients ( 48 % ) had an implanted cardiac rhythm device : 683 with right ventricular ( RV ) and 435 with biventricular ( BiV ) pacemakers . Patients with pacing devices were older , more frequently white , and had lower peak VO2 ( P < .001 for all ) . Peak VO2 improved similarly with training in groups with and without pacing devices . The primary composite end point-all-cause death or hospitalization-was reduced only in patients r and omized to exercise training without a device ( hazard ratio [ HR ] 0.79 , 95 % confidence interval [ CI ] 0.67 - 0.93 [ P = .004 ] ; RV lead : HR 1.04 , 95 % CI 0.84 - 1.28 [ P = .74 ] ; BiV pacing : HR 1.05 , 95 % CI 0.82 - 1.34 [ P = .72 ] ; interaction P = .058 ) . CONCLUSIONS Exercise training may improve exercise capacity in patients with implanted cardiac devices . However , the apparent beneficial effects of exercise on hospitalization or death may be attenuated in patients with implanted cardiac devices and requires further study BACKGROUND We examined the effect of a home-based intervention ( HBI ) on readmission and death among " high-risk " patients with congestive heart failure discharged home from acute hospital care . METHODS Hospitalized patients with congestive heart failure and impaired systolic function , intolerance to exercise , and a history of 1 or more hospital admissions for acute heart failure were r and omized to either usual care ( n=48 ) or HBI at 1 week after discharge ( n=49 ) .  Home-based intervention comprised a single home visit ( by a nurse and pharmacist ) to optimize medication management , identify early clinical deterioration , and intensify medical follow-up and caregiver vigilance as appropriate . The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge . Secondary end points included duration of hospital stay and overall mortality . RESULTS During follow-up , patients in the HBI group had fewer unplanned readmissions ( 36 vs 63 ; P=.03 ) and fewer out-of-hospital deaths ( 1 vs 5 ; P=.11 ) : 0.8+/-0.9 vs 1.4+/-1.8 ( mean + /- SD ) events per patient assigned to HBI and usual care , respectively ( P=.03 ) . Patients in the HBI group also had fewer days of hospitalization ( 261 vs 452 ; P=.05 ) and fewer total deaths ( 6 vs 12 ; P=.11 ) . Patients assigned to usual care were more likely to experience 3 or more readmissions for acute heart failure ( P=.02 ) . Predictors of unplanned readmission were ( 1 ) 14 days or more of unplanned readmission during the 6 months before study entry ( odds ratio [ OR ] , 5.2 ; 95 % confidence interval [ CI ] , 1.8 - 16.2 ) , ( 2 ) previous admission for acute myocardial ischemia ( OR , 3.3 ; 95 % CI , 1.2 - 9.1 ) , and ( 3 ) an albumin plasma concentration of 38 g/L or less ( OR , 2.4 ; 95 % CI , 1.2 - 6.0 ) . Home-based intervention was also associated with a trend toward reduced risk of unplanned readmission ( OR , 0.4 ; 95 % CI , 0.2 - 1.1 ) . CONCLUSION Among a cohort of high-risk patients with congestive heart failure , HBI was associated with reduced frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge from the hospital Background : This study evaluated the effectiveness of using trained volunteer staff in reducing 30-day readmissions of congestive heart failure ( CHF ) patients . Methods : From June 2010 to December 2010 , 137 patients ( mean age 73 years ) hospitalized for CHF were r and omly assigned to either : an interventional arm ( arm A ) receiving dietary and pharmacologic education by a trained volunteer , follow-up telephone calls within 48 hours , and a month of weekly calls ; ora control arm ( arm B ) receiving st and ard care . Primary outcomes were 30-day readmission rates for CHF and worsening New York Heart Association ( NYHA ) functional classification ; composite and all-cause mortality were secondary outcomes . Results : Arm A patients had decreased 30-day readmissions ( 7 % vs 19 % ; P ! .05 ) with a relative risk reduction ( RRR ) of 63 % and an absolute risk reduction ( ARR ) of 12 % . The composite outcome of 30-day readmission , worsening NYHA functional class , and death was decreased in the arm A ( 24 % vs 49%;P ! .05 ; RRR 51 % , ARR 25 % ) . St and ard-care treatment and hypertension , age $ 65 years and hypertension , and cigarette smoking were predictors of increased risk for readmissions , worsening NYHA functional class , and all-cause mortality , respectively , in the multivariable analysis . Conclusions : Utilizing trained volunteer staff to improve patient education and engagement might be an efficient and low-cost intervention to reduce CHF readmissions OBJECTIVE The objective of the study was to evaluate the effectiveness of a single home-based educational intervention for patients admitted with heart failure . METHODS There were 106 patients : 42 in the intervention group and 64 in the control group . Patients were r and omly assigned to receive an intervention by nursing staff 1 week after discharge . Primary end points were readmissions , emergency department visits , deaths , costs , and quality of life . RESULTS During the 24-month follow-up , there were fewer mean emergency department visits in the intervention group than in the control group ( .68 vs 2.00 ; P = .000 ) , fewer unplanned readmissions ( .68 vs 1.71 ; P = .000 ) , and lower costs ( € 671.56 = $ 974.63 = GBP598.42 per person vs € 2,154.24 = $ 3,126.01 = GBP1,919.64 ; P = .001 ) . There was a trend toward fewer out-of-hospital deaths ( 14 [ 46.6 % ] vs 31 [ 55.3 % ] ; P = .45 ) and improvement in quality of life . CONCLUSION Patients with heart failure who receive a home-based educational intervention  experience fewer emergency department visits and unplanned readmissions with lower healthcare costs BACKGROUND Heart failure is a common and important cause of morbidity and mortality . Disease management offers promise in reducing the need for hospitalization and improving quality of life for heart failure patients , but experimental data on the efficacy of such programs are limited . METHODS AND RESULTS A total of 151 patients hospitalized with heart failure were r and omized to usual care or scheduled telephone calls by specially trained nurses promoting self-management and guideline -based therapy as prescribed by primary physicians . Nurses also screened patients for heart failure exacerbations , which they managed with supplemental diuretics or by contacting the primary physician for instructions . Outcomes included time to hospital encounter , mortality , number and cost of hospitalizations , functional status , and satisfaction with care . Intervention patients had a longer time to encounter ( hazard ratio [ HR ] = 0.67 ; 95 % confidence interval [ CI ] 0.47 - 0.96 ; P = .029 ) , hospital readmission ( HR = 0.67 ; CI 0.46 - 0.99 ; P = .045 ) , and heart failure-specific readmission ( HR = 0.62 ; CI 0.38 - 1.03 ; P = .063 ) . The number of admissions , hospital days , and hospital costs were significantly lower during the first 6 months after intervention but not at 1 year . The intervention had little effect on functional status , mortality , and satisfaction with care . CONCLUSION A nurse-administered , telephone-based disease management program delayed subsequent health care encounters , but had minimal impact on other outcomes Despite efforts to improve the discharge planning process and subsequent outcomes , existing mechanisms fail to accurately identify elders ' needs for follow-up care . Studies report rehospitalization rates ranging from 12 to 50 % . The two aims of this study were to ( 1 ) examine the difference in outcomes for elders hospitalized with heart failure and caregivers who participated in a professional-patient partnership model of discharge planning  compared to those who received the usual discharge planning  and ( 2 ) examine differences in costs associated with hospital readmission and use of the emergency room following hospital discharge . A before- and -after nonequivalent control group design was used for this study . Data were collected from the control and the intervention cohorts before discharge and at 2 weeks and 2 months postdischarge . One hundred and fifty-eight patient-caregiver dyads completed both the predischarge and 2-weeks postdischarge interviews ; 140 also completed a 2-month follow up . The average age of elders was 73.7 years ; the average age of the caregivers was 58.5 years . The findings indicated that elders in the intervention cohort felt more prepared to manage care , reported more continuity of information about care management and services , felt they were in better health , and when readmitted spent fewer days in the hospital than the control cohort . Caregivers in the intervention cohort also reported receiving more information about care management and having a more positive reaction to caregiving 2 weeks postdischarge than the control cohort Objective : To evaluate the effects of a nurse based outpatient management programme for elderly patients discharged with heart failure from a university hospital . Design : Patients with heart failure ( New York Heart Association class II – IV ) and left ventricular systolic dysfunction aged 60 years or more were r and omly assigned to follow up within the management programme or to conventional follow up , usually in primary care . Of the 208 participants , 58 % were men , mean age was 75 years , and mean ejection fraction 34 % . All patients were scheduled for three observational study visits at six month intervals . The primary end point was quality of life ( QoL ) and secondary end points were hospitalisation and mortality . Results : More patients achieved target doses of angiotensin converting enzyme ( ACE ) inhibitors in the intervention group than in the control group ( 82 % v 69 % , 88 % v 69 % , and 88 % v 74 % of recommended target doses at 6 , 12 , and 18 months of follow up , respectively , p < 0.05 for all ) . Patients with initial low QoL had a poor prognosis . After a mean 1122 days of follow up , 82 % of all patients had been readmitted . There were on average 4.7 readmissions per patient and 66 % were due to non-cardiac diagnoses . There were no differences in QoL or health care consumption between the two study groups during follow up . Conclusion : A nurse based management programme is more effective than follow up in primary care in optimising medication for elderly patients with heart failure . However , such a programme does not seem to have a favourable influence on QoL or readmission rate during long term follow up AIMS To determine the effect of an integrated heart failure management programme , involving patient and family , primary and secondary care , on quality of life and death or hospital readmissions in patients with chronic heart failure . METHODS AND RESULTS This trial was a cluster r and omized , controlled trial of integrated primary / secondary care compared with usual care for patients with heart failure . The intervention involved clinical review at a hospital-based heart failure clinic early after discharge , individual and group education sessions , a personal diary to record medication and body weight , information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic . Follow-up was for 12 months . One hundred and ninety-seven patients admitted to Auckl and Hospital with an episode of heart failure were enrolled in the study . There was no significant difference between the intervention and control groups for the combined end-point of death or hospital readmission . The physical dimension of quality of life showed a greater improvement in the intervention group from baseline to 12 months compared with the control group ( -11.1 vs -5.8 respectively , 2 P=0.015 ) . The main effect of the intervention was attributable to the prevention of multiple admissions ( 56 intervention group vs 95 control group , 2 P=0.015 ) and associated reduction in bed days . CONCLUSIONS This integrated management programme for patients with chronic heart failure  improved quality of life and reduced total hospital admissions and total bed days INTRODUCTION AND OBJECTIVES Home-based interventions after hospital discharge in patients with heart failure ( HF ) have been shown to decrease readmission and mortality rates . The primary aim of this study was to determine the effect of a home-based educational intervention carried out by nursing staff on the readmission rate , emergency department visits , and healthcare costs . PATIENTS AND METHOD Patients hospitalized with systolic HF were r and omly assigned to receive either usual care or a single home-based educational intervention 1 week after discharge . RESULTS Between July 2001 and November 2002 , 70 patients entered the study : 34 in the intervention group and 36 in the control group . During the 6-month follow-up , there were fewer unplanned readmissions in the intervention group than in the control group ( 0.09 vs 0.94 ; P<.001 ) , fewer emergency department visits ( 0.21 vs 1.33 ; P<.001 ) , and fewer out-of-hospital deaths ( 2 vs 11 ; P<.01 ) . Costs were also significantly lower in the intervention group ( difference , ; 1190.9 ; P<.001 ) . Moreover , patient-perceived health status , as indicated by scores on a quality -of-life question naire , increased significantly in the intervention group . CONCLUSIONS In a cohort of patients with systolic HF who received a home-based educational intervention there were significant reductions in the unplanned readmission rate , mortality , and healthcare costs , and better quality of life . Some limitations of the study warrant validation of the result ats in further studies Background —Although interventions combining patient education and postdischarge management have demonstrated benefits in patients with chronic heart failure , the benefit attributable to patient education alone is not known . We hypothesized that a patient discharge education program would improve clinical outcomes in patients with chronic heart failure . Methods and Results —We conducted a r and omized , controlled trial of 223 systolic heart failure patients and compared the effects of a 1-hour , one-on-one teaching session with a nurse educator to the st and ard discharge process . Subjects were contacted by telephone at 30 , 90 , and 180 days to collect information about clinical events , symptoms , and self-care practice s. The primary end point of the study was the total number of days hospitalized or dead in the 180-day follow-up period . Subjects r and omized to receive the teaching  session  ( n=107 ) had fewer days hospitalized or dead in the follow-up period ( 0 and 10 days , median and 75th percentiles ) than did controls ( n=116 , 4 and 19 days ; P=0.009 ) . Patients receiving the education intervention had a lower risk of rehospitalization or death ( relative risk , 0.65 ; 95 % confidence interval , 0.45 to 0.93 ; P=0.018 ) . Costs of care , including the cost of the intervention , were lower in patients receiving the education intervention than in control subjects by $ 2823 per patient ( P=0.035 ) . Conclusions —The addition of a 1-hour , nurse educator – delivered teaching session at the time of hospital discharge result ed in improved clinical outcomes , increased self-care measure adherence , and reduced cost of care in patients with systolic heart failure OBJECTIVE To evaluate the effectiveness of a Transcendental Meditation ( TM ) stress reduction program for African Americans with congestive heart failure ( CHF ) . DESIGN R and omized , controlled study PARTICIPANTS AND INTERVENTION We recruited 23 African American patients > or = 55 years of age who were recently hospitalized with New York Heart Association class II or III CHF and with an ejection fraction of < .40 . Participants were r and omized to either TM or health education ( HE ) group . MAIN OUTCOME MEASURES Primary outcome measure was six-minute walk test ; secondary outcomes were generic and disease-specific health-related quality of life , quality of well being , perceived stress , Center for Epidemiologic Studies Depression Scale ( CES-D ) , rehospitalizations , brain natriuretic peptide , and cortisol . Changes in outcomes from baseline to three and six months after treatment were analyzed by using repeated measures analysis of variance , covarying for baseline score . RESULTS For the primary outcome of functional capacity , the TM group significantly improved on the six-minute walk test from baseline to six months after treatment compared to the HE group ( P = .034 ) . On the secondary outcome measures , the TM group showed improvements in SF-36 subscales and total score on the Minnesota Living with Heart Failure scale . On the CES-D , the TM group showed significant decrease from baseline to six months compared to the HE group ( P = .03 ) . Also , the TM group had fewer rehospitalizations during the six months of followup . CONCLUSIONS Results indicate that TM can be effective in improving the quality of life and functional capacity of African American CHF patients . Further validation of outcomes is planned via a large , multicenter trial with long-term follow-up INTRODUCTION AND OBJECTIVES The objective of this study was to determine whether a home-based intervention can reduce mortality and hospital readmissions and improve quality of life in patients with heart failure . METHODS A r and omized clinical trial was carried out between January 2004 and October 2006 . In total , 283 patients admitted to hospital with a diagnosis of heart failure were r and omly allocated to a home-based intervention ( intervention group ) or usual care ( control group ) . The primary end-point was the combination of all-cause mortality and hospital readmission for worsening heart failure at 1-year follow-up . RESULTS The primary end-point was observed in 41.7 % of patients in the intervention group and in 54.3 % in the control group . The hazard ratio was 0.70 ( 95 % confidence interval [ CI ] 0.55 - 0.99 ) . Taking significant clinical variables into account slightly reduced the hazard ratio to 0.62 ( 95 % CI 0.50 - 0.87 ) . At the end of the study , the quality of life of patients in the intervention group was better than in the control group ( 18.57 vs. 31.11 ; P < .001 ) . CONCLUSIONS A home-based intervention for patients with heart failure reduced the aggregate of mortality and hospital readmissions and improved quality of life INTRODUCTION AND OBJECTIVES To determine the effectiveness of a primarily educational intervention in heart failure ( HF ) patients implemented in a home care unit . METHODS This r and omized controlled clinical trial involved 279 HF patients who were discharged from a tertiary-care hospital between February 2001 and June 2002 . Patients with dementia , terminal non-cardiac disease , or chronic obstructive pulmonary disease were excluded . Data collected included the cause of cardiac decompensation . A primarily educational intervention was implemented in the patient 's home for up to 15 days after hospital discharge . Treatment was adjusted during the first week if necessary . The primary outcome measure was the 1-year cumulative incidence of readmission or death . Secondary measures were the incidence of readmission , mortality , and emergency department admission .  Telephone interviews were carried out 3 , 6 and 12 months after discharge , and clinical records were up date d when necessary . Emergency department admission in the first 6 months was monitored . RESULTS At 1-year follow-up , 62 of the 137 patients ( 45.3 % ) in the intervention group had been readmitted or died , compared with 75 of the 142 ( 52.8 % ) in the control group , ( relative risk=0.86 , P=.232 ) . Among patients who suffered decompensation because failure to adhere to treatment , 16 of the 45 ( 35.6 % ) in the intervention group were readmitted or died , compared with 34 of the 56 ( 60.7 % ) control group patients ( relative risk=0.59 , P=.016 ) . CONCLUSIONS This intervention is feasible but , when applied indiscriminately to every discharged heart failure patient , the best that can be expected is only a modest reduction in readmission and death rates , which , in this study in particular , did not achieve statistical significance BACKGROUND Despite the availability of proven therapies , outcomes in patients with heart failure ( HF ) remain poor . In this 2-stage , multicenter trial , we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF . METHODS AND RESULTS In Stage 1 , a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme ( ACE ) inhibitors and other HF medications . Before discharge ( Stage 2 ) , patients were r and omized to a patient support program ( PSP ) ( education about HF , self-monitoring , adherence aids , newsletters , telephone hotline , and follow-up at 2 weeks , then monthly for 6 months after discharge ) or usual care . In Stage 1 ( 766 patients )  ACE inhibitor use increased from 58 % on admission to 83 % at discharge ( P < .0001 ) , and the daily dose ( in enalapril equivalents ) increased from 11.3 + /- 8.8 mg to 14.5 + /- 8.8 mg ( P < .0001 ) . In Stage 2 ( 276 patients ) there was no difference in ACE inhibitor adherence , but a reduction in cardiovascular-related emergency room visits ( 49 versus 20 , P = .030 ) , hospitalization days ( 812 versus 341 , P = .003 ) , and cost of care ( 2,531 Canadian dollars less per patient ) in favor of the PSP . CONCLUSION Simple interventions can improve ACE inhibitor use and patient outcomes BACKGROUND Hospital admissions among patients with congestive heart failure ( CHF ) are a major contributor to health-care costs . Previous investigations suggest that the therapeutic efficacy of pharmacotherapy in CHF may be improved by strategies incorporating home visits to identify and address factors precipitating deterioration and result ant readmission . METHODS Chronic CHF patients discharged home after acute hospital admission were r and omly assigned usual care ( n=100 ) or a multidisciplinary , home-based intervention ( n=100 )  , consisting of a home visit by a cardiac nurse 7 - 14 days after discharge . The primary endpoint of the study was frequency of unplanned readmission plus out-of-hospital death within 6 months . FINDINGS During 6 months ' follow-up there were 129 primary endpoint events in the usual-care group and 77 in the intervention group ( p=0.02 ) . More intervention-group than usual-care patients remained event-free ( 38 vs 51 ; p=0.04 ) . Overall , there were fewer unplanned readmissions ( 68 vs 118 ; p=0.03 ) and associated days in hospital ( 460 vs 1173 ; p=0.02 ) among intervention-group patients . Hospital-based costs were Australian $ 490,300 for the intervention group and A$ 922,600 for the usual-care group ( p=0.16 ) ; the mean cost of the intervention was A$ 350 per patient , and other community-based costs were similar for both groups . INTERPRETATION A home-based intervention has the potential to decrease the rate of unplanned readmissions and associated health-care costs , prolong event-free and total survival , and improve quality of life among patients with chronic CHF HF is a leading health care concern , often under-recognized and under-treated in older women . Management of this complex condition frequently requires a multidisciplinary approach and a clinical pathway can be used to deliver coordinated care . This report is based on the intervention/treatment arm ( n = 45 ) of a r and omized controlled trial in older women who participated in a multidisciplinary clinic . We describe the development of a clinical pathway for HF and the variance reporting including factors affecting adherence with the pathway . Variances are patient or staff actions that did not meet the expected outcomes . Of the 45 intervention arm female patients , 5 were able to fully complete the program , meaning that all of the intended 12 visits were completed successfully . Thirteen women missed more than three clinic visits , and the rest attended most visits . Variance tracking identified that visits were interrupted most often by patient-related health issues , such as fatigue and pain , which may not be surprising given the expected multiple co-morbidities in this population . Transportation problems were identified as a barrier to attendance . Our study demonstrates that a clinical pathway can be implemented in an older , female population with HF . This report identifies some of the challenges and provides future recommendations for prospect i ve pathway development AIMS This paper is a report on the effectiveness of a self-management programme based on the self-efficacy construct , in older people with heart failure . BACKGROUND Heart failure is a major health problem worldwide , with high mortality and morbidity , making it a leading cause of hospitalization . Heart failure is associated with a complex set of symptoms that arise from problems in fluid and sodium retention . Hence , managing salt and fluid intake is important and can be enhanced by improving patients ' self-efficacy in changing their behaviour . DESIGN R and omized controlled trial . METHODS Heart failure patients attending cardiac clinics in northern Taiwan from October 2006-May 2007 were r and omly assigned to two groups : control ( n = 46 ) and intervention ( n = 47 ) . The intervention group received a 12-week self-management programme that emphasized self-monitoring of salt/fluid intake and heart failure-related symptoms . Data were collected at baseline as well as 4 and 12 weeks later . Data analysis to test the hypotheses used repeated- measures anova models . RESULTS Participants who received the intervention programme had significantly better self-efficacy for salt and fluid control , self-management behaviour and their heart failure-related symptoms were significantly lower than participants in the control group . However , the two groups did not differ significantly in health service use . CONCLUSION The self-management programme improved self-efficacy for salt and fluid control , self-management behaviours , and decreased heart failure-related symptoms in older Taiwanese out patients with heart failure . Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease BACKGROUND The aim of this study was to determine the effects of a home-based exercise program on clinical outcomes .  Exercise training improves exercise capacity in patients with heart failure ( HF ) but the long-term effects on clinical outcomes remain unknown . METHODS We r and omized 173 patients with systolic HF to control ( n = 87 ) or home-based exercise ( n = 86 ) . The primary end point was a composite of all-cause hospitalizations , emergency department admissions , urgent transplantation , and death at 12 months . Functional performance ( as assessed by cardiopulmonary exercise testing and the 6-minute walk test ) , quality of life , and psychological states were measured at baseline , 3 months , and 6 months . RESULTS There was no significant difference between experimental and control groups in the combined clinical end point at 12 months and in functional status , quality of life , or psychological states over 6 months . Patients in the exercise group had a lower incidence of multiple ( 2 or more ) hospitalizations compared with the control group : 12.8 % versus 26.6 % , respectively ( P = .018 ) . CONCLUSIONS A home-based walking program that incorporated aerobic and resistance exercise did not result in improved clinical outcomes at 1-year follow-up in this cohort of patients with systolic HF . However , the exercise program result ed in reduced rehospitalization rates Exercise is an important behavior for long-term weight control in overweight and obese patients . However , little evidence exists confirming such findings in patients with advanced heart failure ( HF ) . Using a prospect i ve , experimental design , the effects of 24 weeks of a low-level , home-based walking program on weight loss were studied in overweight and obese ( body mass index > or = 27 kg/m(2 ) ) patients with advanced HF who were r and omized to exercise ( n = 48 ) and control ( n = 51 ) groups .  Weight changes between the 2 groups at baseline and 6 months were compared using repeated- measures analysis of variance . Patients were on average aged 53.3 + /- 10.1 years and predominantly male ( 75 % ) , Caucasian ( 57 % ) , and married ( 55 % ) . Most patients were in New York Heart Association class III or IV ( 67 % ) , with a mean ejection fraction of 25 % . Patients in the exercise group showed significant weight reduction from baseline to 6 months compared with those in the control group ( -6.37 + /- 11.7 vs -0.33 + /- 9.3 kg , p = 0.002 ) . No significant differences were noted between the 2 groups in 6-minute walk distance or depression , although the changes were in the anticipated direction . Modest weight losses of > 5 % were associated with cardiopulmonary exercise test-documented workload levels at 6 months ( r = 0.331 , p = 0.006 ) , as well as decreased depression ( r = -0.315 , p = 0.01 ) and hostility ( r = -0.355 , p = 0.005 ) . The number of hospital admissions was significantly smaller for patients in the exercise group compared with those in the control group ( 0.63 + /- 0.94 vs 1.07 + /- 0.95 , p < 0.05 ) . In conclusion , the findings demonstrate the beneficial effects of a low-level , home-based walking program on weight loss in overweight and obese patients with advanced HF OBJECTIVE The purpose of this study was to determine the effect of a tailored message intervention on heart failure readmission rates , quality of life , and health beliefs in persons with heart failure ( HF ) . DESIGN This r and omized control trial provided a tailored message intervention during hospitalization and 1 week and 1 month after discharge . Theoretic framework The organizing framework was the Health Belief Model . SUBJECTS Seventy persons with a primary diagnosis of chronic HF were included in the study . RESULTS HF readmission rates and quality of life did not significantly differ between the treatment and control groups . Health beliefs , except for benefits of medications , significantly changed from baseline in the treatment group in directions posited by the Health Belief Model . CONCLUSIONS A tailored message intervention changed the beliefs of the person with HF in regard to the benefits and barriers of taking medications , following a sodium-restricted diet , and self-monitoring for signs of fluid overload . Future research is needed to explore the effect of health belief changes on actual self-care behaviors BACKGROUND A growing body of evidence suggests that the fluid accumulation plays a key role in the pathophysiology of heart failure ( HF ) and that the inflammatory and neurohormonal activation contribute strongly to the progression of this disorder . METHODS AND RESULTS The study evaluated the long-term effects of 2 different sodium diets on cytokines neurohormones , body hydration and clinical outcome in compensated HF out patients ( New York Heart Association Class II ) . A total of 173 patients ( 105 males , mean age 72.5+/-7 ) recently hospitalized for worsening advanced HF and discharged in normal hydration and in clinical compensation were r and omized in 2 groups ( double blind ) . In Group 1 , 86 patients received a moderate restriction in sodium ( 120mmol to 2.8g/day ) plus oral furosemide ( 125 to 250 mg bid ) ; in Group 2 , 87 patients : received a low-sodium diet ( 80mmol to 1.8g/day ) plus oral furosemide ( 125 to 250 mg bid ) . Both groups were followed for 12 months and the treatment was associated with a drink intake of 1000mL daily . Neurohormonal ( brain natriuretic peptide , aldosterone , plasma rennin activity ) and cytokines values ( tumor necrosis factor-alpha , interleukin-6 ) were significantly reduced with a significant increase of the anti-inflammatory cytokine interleukin-10 at 12 months in normal , P < .0001 ) than low-sodium group . The low-sodium diet showed a significant activation of neurohormones and cytokines and worsening the body hydration , whereas moderate sodium restriction maintained dry weigh and improved outcome in the long term . CONCLUSIONS Our results appear to suggest a surprising efficacy of a new strategy to improve the chronic diuretic response by increasing Na intake and limiting fluid intake . This counterintuitive approach underlines the need for a better underst and ing of factors that regulate sodium and water h and ling in chronic congestive HF . A larger sample of patients and further studies are required to evaluate whether this is due to the high dose of diuretic used or the low-sodium diet We evaluated a structured pharmaceutical care program for elderly patients ( > 65 yrs ) with congestive heart failure ( CHF ) based on objective measures of disease control , quality of life , and use of health care facilities in a r and omized , controlled , longitudinal , prospect i ve clinical trial . The 42 patients in group A received education from a pharmacist on the disease and its treatment , and lifestyle changes that could help control symptoms . Patients also were encouraged to monitor their symptoms and comply with prescribed drug therapy . If necessary , dosage regimens were simplified in liaison with hospital physicians . The 41 control patients ( group B ) received st and ard care . The following outcome measures were assessed in all patients at baseline ( before the start of the trial ) and at 3 , 6 , 9 , and 12 months : 2-minute walk test , blood pressure , body weight , pulse , forced vital capacity , quality of life [ disease-specific ( Minnesota Living with Heart Failure question naire ) and generic ( SF-36 ) ] , knowledge of symptoms and drugs , compliance with therapy , and use of health care facilities ( hospital admissions , visits to emergency room , emergency calls ) . Patients in group A showed improved compliance with drug therapy , which in turn improved their exercise capacity compared with those in group B ; education on management of symptoms , lifestyle changes , and dietary recommendations were also of benefit . Group A patients significantly improved knowledge of their drug therapy over the 12-month study and had fewer hospital admissions compared with group B patients . They also had improved outcomes compared with group B , despite the small sample s. An extension of this trial to other sites with pooling of results would provide additional evidence of the value of this structured program in elderly patients with CHF BACKGROUND The multidisciplinary approach to managing heart failure has been shown to improve outcomes . The role of a clinical pharmacist in treating heart failure has not been evaluated . METHODS One hundred eighty-one patients with heart failure and left ventricular dysfunction ( ejection fraction < 45 ) undergoing evaluation in clinic were r and omized to an intervention or a control group . Patients in the intervention group received clinical pharmacist evaluation , which included medication evaluation , therapeutic recommendations to the attending physician , patient education , and follow-up telemonitoring . The control group received usual care . The primary end point was combined all-cause mortality and heart failure clinical events . All clinical events were adjudicated by a blinded end point committee . RESULTS Baseline characteristics were similar except for slightly higher age in the intervention group . Median follow-up was 6 months . All-cause mortality and heart failure events were significantly lower in the intervention group compared with the control group ( 4 vs 16 ; P= .005 ) . In addition , patients in the intervention group received higher angiotensin-converting enzyme inhibitor doses as reflected by the median fraction of target reached ( 25th and 75th percentiles ) , 1.0 ( 0.5 and 1 ) and 0.5 ( 0.1875 and 1 ) in the intervention and control groups , respectively ( P<.001 ) . The use of other vasodilators in angiotensin-converting enzyme inhibitor-intolerant patients was higher in the intervention group ( 75 % vs 26 % ; P= .02 ) . CONCLUSIONS Outcomes in heart failure can be improved with a clinical pharmacist as a member of the multidisciplinary heart failure team . This observation may be due to higher doses of angiotensin-converting enzyme inhibitors and /or closer follow-up Objective To study the effects of a management programme on hospitalisation and health care costs one year after admission for heart failure . Design Prospect i ve , r and omised trial . Setting University hospital with a primary catchment area of 250 000 inhabitants . Patients 190 patients ( aged 65–84 years , 52.3 % men ) hospitalised because of heart failure . Intervention Two types of patient management were compared . The intervention group received education on heart failure and self management , with follow up at an easy access , nurse directed outpatient clinic for one year after discharge . The control group was managed according to routine clinical practice . Main outcome measures Time to readmission , days in hospital , and health care costs during one year . Results The one year survival rate was 71.8 % ( n = 79 ) in the control group and 70.0 % ( n = 56 ) in the intervention group ( NS ) . The mean time to readmission was longer in the intervention group than in the control group ( 141 ( 87 ) v106 ( 101 ) ; p < 0.05 ) and number of days in hospital tended to be fewer ( 4.2 ( 7.8 ) v 8.2 ( 14.3 ) ; p = 0.07 ) . There was a trend towards a mean annual reduction in health care costs per patient of US$ 1300 ( US$ 1 = SEK 7.76 ) in the intervention group compared with costs in the controls ( US$ 3594 v 2294 ; p = 0.07 ) . Conclusions A management programme for patients with heart failure discharged after hospitalisation  reduces health care costs and the need for readmission BACKGROUND Patients with chronic heart failure characteristically have multiple hospital admissions for symptom control , deleteriously affecting their quality of life and imposing a burden on national healthcare costs . We assessed the effect of a novel transtelephonic monitoring and follow-up program on the admission rate and length of hospital stay as well as changes in their subjectively rated quality of life of patients with chronic heart failure . METHODS This prospect i ve 1-year study was conducted on compliant subscribers to ' SHL ' , a telecardiological service with > 60,000 subscribers , who were admitted > or = 2 times during the previous year for recurrent pulmonary edema or deterioration in heart failure . Their heart rate , blood pressure and body weight measurements were now automatically transmitted daily to ' SHL"s data bank and added to stored and up date d medical records . A question naire survey acquired information on their quality of life . RESULTS The study cohort included 118 patients , mean age 75 years ( range 49 - 89 years ) , 65 % males , a II-IV class functional capacity and a 25 % ( range 10 - 39 % ) mean ejection fraction . There was a 66 % reduction in the total hospitalization days ( from 1623 in the year preceding study entry to 558 during the study period , p<0.0001 ) . Although only 38/118 patients were hospitalized , most participants reported a significant subjective improvement in their quality of life . CONCLUSIONS Data are provided to demonstrate that a transtelephonic system allowing primary care at the patient 's home can significantly reduce hospitalization rate and length of stay and significantly enhance the quality of life of patients with chronic heart failure Studies have shown that patients with compensated heart failure ( HF ) receiving high diuretic doses associated with normal sodium diet and fluid intake restrictions demonstrated significant reductions in readmissions and mortality compared with those who received low-sodium diets , and over a 6-month observation period , a reduction in neurohormonal activation was also observed . The aim of this study was to evaluate the effects of different sodium diets associated with different diuretic doses and different levels of fluid intake on hospital readmissions and neurohormonal changes after 6-month follow-up in patients with compensated HF . Four hundred ten consecutive patients with compensated HF ( New York Heart Association class II to IV ) aged 53 to 86 years , with ejection fractions < 35 % and serum creatinine < 2 mg/dl , were r and omized into 8 groups : group A ( n = 52 ) : 1,000 ml/day of fluid intake , 120 mmol/day , and 250 mg furosemide twice daily ; group B ( n = 51 ) : 1,000 ml/day of fluid intake , 120 mmol/day , and 125 mg furosemide twice daily ; group C ( n = 51 ) : 1,000 ml/day fluid intake , 80 mmol/day , and 250 mg furosemide twice daily ; group D ( n = 51 ) : 1,000 ml/day fluid intake , 80 mmol/day , and 125 mg furosemide twice daily ; group E ( n = 52 ) : 2,000 ml/day fluid intake , 120 mmol/day , and 250 mg furosemide twice daily ; group F ( n = 50 ) : 2,000 ml/day fluid intake , 120 mmol/day , and 125 mg furosemide twice daily ; group G ( n = 52 ) : 2,000 ml/day fluid intake , 80 mmol/day , and 250 mg furosemide twice daily ; and group H ( n = 51 ) : 2,000 ml/day fluid intake , 80 mmol/day , and 125 mg furosemide twice daily . All patients received the treatments > or=30 days after discharge and for 180 days afterward . Signs of HF , body weight , blood pressure , heart rate , laboratory parameters , electrocardiograms , echocardiograms , brain natriuretic peptide , aldosterone , and plasma renin activity were examined at baseline and 180 days later . Group A showed the best results , with a significant reduction ( p < 0.001 ) in readmissions , brain natriuretic peptide , aldosterone , and plasma renin activity compared with the other groups during follow-up ( p < 0.001 ) . In conclusion , these data suggest that the combination of a normal-sodium diet with high diuretic doses and fluid intake restriction , compared with different combinations of sodium diets with more modest fluid intake restrictions and conventional diuretic doses , leads to reductions in readmissions , neurohormonal activation , and renal dysfunction BACKGROUND Patients with heart failure must monitor for and recognize escalating symptoms to take action to relieve symptoms and decrease hospitalizations . However , symptom monitoring is not commonly performed . One way to promote patients ' engagement in symptom monitoring is by providing a symptom diary . PURPOSE The aim of this study was to test the effect of a comprehensive daily symptom diary intervention on event-free survival and health-related quality of life ( HRQOL ) . METHODS Patients were r and omized into either intervention ( n = 23 ) or usual-care groups ( n = 21 ) . The intervention group received a symptom diary with self-care education and counseling at baseline with 5 follow-up calls for 3 months . All patients were interviewed to obtain survival data at 1 month and 3 months . HRQOL was measured at baseline , 1 month , and 3 months . Kaplan-Meier curves with the log-rank test were used to compare group differences in time to first event . Linear mixed models were conducted to examine the relationship between groups and changes in HRQOL over 3 months . RESULTS The intervention group had longer event-free survival than the usual-care group ( P = .03 ) . There were no differences in changes in HRQOL scores between the groups over 3 months . CONCLUSIONS Positive effects of the intervention on survival were found . However , there was no significant difference in changes in HRQOL BACKGROUND Currently , fluid restriction recommendations in heart failure ( HF ) are based on expert opinion . After implementing a 1,000-mL/d fluid restriction for 60 days after discharge , outcomes were examined . METHODS AND RESULTS In a r and omized controlled design , hyponatremic patients ( serum sodium ≤137 mg/dL ) received usual care ( UC ; n = 26 ) or 1,000 mL/d fluid restriction ( n = 20 ) at discharge . Quality of life ( QoL ) , thirst , difficulty following fluid recommendations , adherence to fluid restriction , HF emergency care , HF rehospitalization , and all-cause death were examined . Mean age was 62.8 ± 12.8 years ; 46 % were white . There were no differences by group in baseline demographics , comorbidities , and QoL , except that more UC patients had New York Heart Association ( NYHA ) functional class III/IV status ( P = .019 ) . Median [ interquartile range ] QoL scores were better in the 1,000 mL/d group for symptom burden ( 83.3 [ 68.8 - 91.7 ] vs 50 [ 29.2 - 79.2 ] ; P = .018 ) , total symptoms ( 77.1 [ 58.1 - 91.7 ] vs 54.2 [ 30.2 - 73.9 ] ; P = .022 ) , overall QoL summary ( 72.6 [ 52.2 - 86.3 ] vs 51.0 [ 37.7 - 68.5 ] ; P = .038 ) , and clinical QoL summary ( 75.5 [ 57.8 - 92.9 ] vs 59.1 [ 35.7 - 77.3 ] ; P = .039 ) . There were no group differences in thirst , difficulty adhering to fluid recommendations , adherence to fluid restriction , or health care consumption . CONCLUSIONS The 1,000 mL/d fluid restriction led to improved QoL at 60 days after discharge . Future research in a larger more heterogeneous sample is needed Background : Heart failure ( HF ) has clinical ly significant psychological and physical consequences for older persons , and hospitalization for HF is frequent and costly to the Medicare program . As HF is the most common primary Medicare home care diagnosis , there is a critical need to develop home care services that improve heath-related outcomes for this population . The primary aim of this pilot study was to develop , implement , and test the initial feasibility and potential efficacy of the Home-Care Education , Assessment , Remote-Monitoring , and Therapeutic Activities ( HEART ) trial , a nurse-directed multicomponent home care intervention . Observed outcomes were quality of life ( QOL ) , depressive symptoms , and 90-day hospitalization . Methods : Twenty-four patients with a primary diagnosis of HF were assigned to the intervention ( n = 12 ) or control group ( n = 12 ) according to geographical location in a large multibranch Medicare-certified home health agency . Intervention group patients received 8 structured nurse education visits using evidence -based protocol s design ed in previous trials to teach HF self-management and to prevent/reduce depression , as well as a telemonitoring system . Control group patients received usual care and telemonitoring .  Quality of life was assessed using the Minnesota Living With Heart Failure question naire . Depressive symptoms were assed using the Patient Health Question naire 9 at baseline and 90-day study end point . Results : Study protocol s and instrumentation were found to be feasible and effective . Examination of enrollment data led to a reevaluation of eligibility criteria . Patients participating in the HEART intervention demonstrated significantly improved QOL ( F = 8.99 , P = .007 ) and significantly reduced depressive symptoms ( F = 35.10 , P = .001 ) in comparison to control group patients at the study end point . There was a trend toward lower hospital readmission rates in the intervention group ( 16 % vs 25 % ) , but this was not statistically significant . Conclusion : This pilot study suggests that a full-scale trial of the HEART intervention is feasible OBJECTIVE To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure ( HF ) . METHOD A r and omized , prospect i ve , open clinical trial in patients admitted for HF . The patients assigned to the intervention group received information about the disease , drug therapy , diet education , and active telephone follow-up . Visits were completed at 2 , 6 , and 12 months . Hospital re-admissions , days of hospital stay , treatment compliance , satisfaction with the care received , and quality of life ( EuroQol ) were evaluated ; a financial study was conducted in order to assess the possible impact of the program . The intervention was performed by the pharmacy department in coordination with the cardiology unit . RESULTS 134 patients were included , with a mean age of 75 years and a low educational level . The patients of the intervention group had a higher level of treatment compliance than the patients in the control group . At 12 months of follow-up , 32.9 % fewer patients in the intervention group were admitted again vs. the control group . The mean days of hospital stay per patient in the control group were 9.6 ( SD=18.5 ) vs. 5.9 ( SD=14.1 ) in the intervention group . No differences were recorded in quality of life , but the intervention group had a higher score in the satisfaction scale at two months [ 9.0 ( SD=1.3 ) versus 8.2 ( SD=1.8 ) p=0.026 ] . Upon adjusting a Cox survival model with the ejection fraction , the patients in the intervention group had a lower risk of re-admission ( Hazard ratio 0.56 ; 95 % CI : 0.32 - 0.97 ) . The financial analysis evidence d savings in hospital costs of euro 578 per patient that were favorable to the intervention group . CONCLUSIONS Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure , the total days of hospital stay , and improves treatment compliance without increasing the costs of care Objective : To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure . Design : Prospect i ve , r and omized clinical trial , with 2:1 assignment to the study intervention or usual care . Setting : 550-bed secondary and tertiary care university teaching hospital . Patients and participants : 98 patients ≥70 years of age ( mean 79±6 years ) admitted with documented congestive heart failure . Interventions : Comprehensive multidisciplinary treatment strategy consisting of intensive teaching by a geriatric cardiac nurse , a detailed review of medications by a geriatric cardiologist with specific recommendations design ed to improve medication compliance and reduce side effects , early consultation with social services to facilitate discharge planning , dietary teaching by a hospital dietician , and close follow-up after discharge by home care and the study team . Measurements and main results : All patients were followed for 90 days after initial hospital discharge . The primary study endpoints were rehospitalization within the 90-day interval and the cumulative number of days hospitalized during follow-up . The 90-day readmission rate was 33.3 % ( 21.7%–44.9 % ) for the patients receiving the study intervention ( n=63 ) compared with 45.7 % ( 29.2–62.2 % ) for the control patients ( n=35 ) . The mean number of days hospitalized was 4.3±1.1 ( 2.1–6.5 ) for the treated patients vs. 5.7±2.0 ( 1.8–9.6 ) for the usual-care patients . In a prospect ively defined subgroup of patients at intermediate risk for readmission ( n=61 ) , readmissions were reduced by 42.2 % ( from 47.6 % to 27.5 % ; p=0.10 ) , and the average number of hospital days during follow-up decreased from 6.7±32 days to 3.2±1.2 days ( p = NS ) . Conclusions : These pilot data suggest that a comprehensive , multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days , particularly in patients at moderate risk for early rehospitalization . Further evaluation of this treatment strategy , including an assessment of the cost-effectiveness , is warranted Background : The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure ( HF ) patients . Objective : The purpose of this article is to ( 1 ) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies , ( 2 ) describe re sources and material s used in the group clinic appointment , and ( 3 ) present results supporting this patient-centered group intervention . Methods : This clinical trial included 198 HF patients ( r and omized to either group clinical appointments or to st and ard care ) . Data were collected from 72 group clinic appointments via patients ’ ( 1 ) group clinic session evaluations , ( 2 ) HF self-care behaviors skills , ( 3 ) HF-related discouragement and quality of life scores , and ( 4 ) HF-related reshopitalizations during the 12-month follow-up . Also , the costs of delivery of the group clinical appointments were tabulated . Results : Overall , patients rated group appointments as 4.8 of 5 on the “ helpfulness ” in managing HF score . The statistical model showed a 33 % decrease in the rate of rehospitalizations ( incidence rate ratio , 0.67 ) associated with the intervention over the 12-month follow-up period when compared with control patients ( & khgr;21 = 3.9 , P = .04 ) . The total cost for implementing 5 group appointments was $ 243.58 per patient . Conclusion : The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care . In turn , better self-care was associated with reductions in HF-related hospitalizations Purpose : Many health systems have implemented interventions to reduce the rate of heart failure readmissions . Pharmacists have the training and expertise to provide effective medication-related education . However , few studies have examined the impact of discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations . Methods : This was a nonr and omized intervention study evaluating the impact of a  pharmacy student and resident-led discharge counseling program on heart failure readmissions . The primary end point was the 30-day heart failure readmission rate . Secondary end points included self-reported patient underst and ing of medications , number of medication errors documented , and estimated associated cost avoidance . Results : A total of 86 and 94 patients were enrolled into the intervention and control groups , respectively . No statistically significant difference in readmission rates was detected between the intervention and the control groups . Thirty-four medication errors and discrepancies were documented , or 1 for every 2.5 patients counseled , result ing in an estimated cost avoidance of $ 4241 for the institution . Eighty-nine percent of patients who received discharge counseling agreed they had a better underst and ing of their medications after speaking with a pharmacy resident or student . Conclusions : There was no statistically significant difference in readmission rates ; however , several medication errors were prevented , and a large percentage of patients expressed an improved underst and ing of their medications AIMS Mild cognitive impairment ( MCI ) is prevalent in heart failure , and can contribute to poor self-care and higher hospital readmissions . Strategies to improve self-care in patients with MCI have not been studied . This r and omized controlled trial aim ed to test the effect of a targeted intervention on self-care , heart failure knowledge , and 30-day readmissions . METHODS AND RESULTS The study included 125 patients hospitalized for exacerbation of heart failure who screened positive for MCI . The treatment group received a targeted self-care teaching intervention using principles of cognitive training .  Self-care , heart failure knowledge , depression , and social support were assessed at baseline and 30 days post-discharge . Mean heart failure knowledge scores improved significantly in the intervention group , but decreased in the control group ( P < 0.001 ) . When controlling for other variables , patients in the intervention group showed a greater increase in heart failure knowledge than patients in the control group ( P = 0.027 ) . Black race was significantly associated with lower heart failure knowledge scores ( P = 0.030 ) . Mean change scores for self-care showed greater improvement in the intervention group when compared with the control group ; however , this was not statistically significant . There was no difference in readmission rates between the groups . CONCLUSION It is feasible to conduct a r and omized controlled trial in patients with MCI . Patients in the treatment group had greater heart failure knowledge at 30 days post-discharge ; however , this did not impact readmission rates . Further research is needed to describe how MCI affects self-care and knowledge , and how race and other factors may influence outcomes in this population OBJECTIVE To explore the effects on the st and ardized management of patients with coronary atherosclerotic heart disease complicated with chronic heart failure . METHODS A total of 823 patients discharged from our department were r and omly enrolled . Among 734 patients with follow-up consents , they were divided into management and control groups ( n = 440 , 294 ) . The management group received st and ardized out-of-hospital management , regular health education and follow-ups of telephone and outpatient visits . RESULTS Compared with the control group , the management group had lower rates of all-cause mortality , cardiac death and readmission due to cardiovascular events ( CVE ) declining by 26.5 % , 32.2 % and 57.0 % respectively . Over a 4-year period , the annular survival rate of management group was 92 % , 85 % , 83 % and 82 % while that of control group 95 % , 89 % , 82 % and 75 % respectively . Patient compliance of digoxin and diuretics in the control group was inferior to that in the management group . CONCLUSION Through st and ardized out-of-hospital management , the patients with coronary atherosclerotic heart disease plus chronic heart failure may achieve significant benefits through reducing the rates of all-cause mortality , cardiac death and readmission due to CVE and improving survival rate Abstract Objectives . To evaluate whether a new home intervention system ( HIS , OPTILOGG ® ) consisting of a specialised software , a tablet computer ( tablet ) wirelessly connected to a weight scale may improve self-care behaviour , health-related quality of life ( HRQoL ) , knowledge about heart failure ( HF ) and reduce hospital days due to HF . Design . 82 patients ( 32 % females ) with mean age : 75 ± 8 years hospitalised with HF were r and omised at discharge to an intervention group ( IG ) equipped with the HIS or to a control group ( CG ) receiving st and ard HF information only . The tablet contained information about HF and lifestyle advice according to current guidelines . It also showed present dose of diuretic , changes in patient-measured weight and HRQoL over time . Results . After 3 months the IG displayed a dramatic improvement in self-care with p < 0.05 ( median IG : 17 [ IQR : 13 , 22 ] and CG : 21 [ IQR : 17 , 25 ] ) . The disease-specific HRQoL was measured by Kansas City Cardiomyopathy Question naire . The IG had significantly higher score ( median IG : 65.1 [ IQR : 38.5 , 83.3 ] vs. CG : 52.1 [ IQR : 41.1 , 64.1 ] p < 0.05 ) and an improved physical limitation ( median IG : 54.2 [ IQR : 37.7 , 83.3 ] vs. CG : 45.8 [ IQR : 25.0 , 54.2 ] p < 0.05 ) There was no difference in knowledge . IG showed fewer HF-related days in the hospital , with 1.3 HF-related hospital days/patient versus 3.5 in CG ( risk ratio : 0.38 ; 95 % confidence interval : 0.31–0.46 ; p < 0.05 ) . Conclusion . HF patients with a HIS tablet computer and scale improved in self-care and HRQoL. Days in hospital due to HF were reduced . A medical device that is easy to use can be a valuable tool for improving self-care and outcome in patients with HF Peer support has been used effectively in a variety of patient population s , but its effectiveness in improving outcomes in persons with chronic heart failure has not been explored . We trained 9 persons with heart failure to mentor other heart failure patients  and tested the effectiveness of this approach in a r and omized controlled clinical trial . A low proportion ( 37 % ) of the eligible population of hospitalized patients agreed to participate . At the end of the 3-month trial , there was significantly higher heart failure self-care in the intervention group ( P < .05 ) . The only difference in social support was a significant decline in perceived support reciprocity in the intervention group ( F = 5.94 , P = .004 ) . No significant group differences in heart failure readmissions , length of stay , or cost were evident at 90-days , although the heart failure readmission rate was 96 % higher in the intervention group when compared to that in the control group . The reasons for low overall enrollment and high readmission rates in the intervention group require further study . Including additional self-care education by a professional , rather than leaving all the education to the mentor , could strengthen the peer support intervention trialed in this study . Small group meetings may be less intrusive and more desirable for this patient population Community care for heart failure patients is difficult due to multiple comorbidities , polypharmacy , and advanced age of patients . Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community setting s. The purpose of this study 1 was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home . Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks . Patients who received telephone interventions had fewer hospital readmissions ( 13 % ) than the comparison group ( 35 % ) . Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Question naire OBJECTIVES To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses ( APNs ) to elders hospitalized with heart failure . DESIGN R and omized , controlled trial with follow-up through 52 weeks postindex hospital discharge . SETTING Six Philadelphia academic and community hospitals . PARTICIPANTS Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure . INTERVENTION A 3-month APN-directed discharge planning and home follow-up protocol . MEASUREMENTS Time to first rehospitalization or death , number of rehospitalizations , quality of life , functional status , costs , and satisfaction with care . RESULTS Mean age of patients ( control n=121 ; intervention n=118 ) enrolled was 76 ; 43 % were male , and 36 % were African American .  Time to first readmission or death was longer in intervention patients ( log rank chi(2)=5.0 , P=.026 ; Cox regression incidence density ratio=1.65 , 95 % confidence interval=1.13 - 2.40 ) . At 52 weeks , intervention group patients had fewer readmissions ( 104 vs 162 , P=.047 ) and lower mean total costs ( $ 7,636 vs $ 12,481 , P=.002 ) . For intervention patients , only short-term improvements were demonstrated in overall quality of life ( 12 weeks , P<.05 ) , physical dimension of quality of life ( 2 weeks , P<.01 ; 12 weeks , P<.05 ) and patient satisfaction ( assessed at 2 and 6 weeks , P<.001 ) . CONCLUSION A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death , reduced total number of rehospitalizations , and decreased healthcare costs , thus demonstrating great promise for improving clinical and economic outcomes BACKGROUND Congestive heart failure is the most common indication for admission to the hospital among older adults . Behavioral factors , such as poor compliance with treatment , frequently contribute to exacerbations of heart failure , a fact suggesting that many admissions could be prevented . METHODS We conducted a prospect i ve , r and omized trial of the effect of a nurse-directed , multidisciplinary intervention on rates of readmission within 90 days of hospital discharge , quality of life , and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure . The intervention consisted of comprehensive education of the patient and family , a prescribed diet , social-service consultation and planning for an early discharge , a review of medications , and intensive follow-up . RESULTS Survival for 90 days without readmission , the primary outcome measure , was achieved in 91 of the 142 patients in the treatment group , as compared with 75 of the 140 patients in the control group , who received conventional care ( P = 0.09 ) . There were 94 readmissions in the control group and 53 in the treatment group ( risk ratio , 0.56 ; P = 0.02 ) . The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group ( 54 vs. 24 , P = 0.04 ) , whereas the number of readmissions for other causes was reduced by 28.5 percent ( 40 vs. 29 , P not significant ) . In the control group , 23 patients ( 16.4 percent ) had more than one readmission , as compared with 9 patients ( 6.3 percent ) in the treatment group ( risk ratio , 0.39 ; P = 0.01 ) . In a subgroup of 126 patients , quality -of-life scores at 90 days improved more from base line for patients in the treatment group ( P = 0.001 ) . Because of the reduction in hospital admissions , the overall cost of care was $ 460 less per patient in the treatment group . CONCLUSIONS A nurse-directed , multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure BACKGROUND Heart failure ( HF ) disease management programs are widely implemented , but data about their effect on outcome have been inconsistent . METHODS The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure ( COACH ) was a multicenter , r and omized , controlled trial in which 1023 patients were enrolled after hospitalization because of HF . Patients were assigned to 1 of 3 groups : a control group ( follow-up by a cardiologist ) and 2 intervention groups with additional basic or intensive support by a nurse specializing in management of patients with HF .  Patients were studied for 18 months . Primary end points were time to death or rehospitalization because of HF and the number of days lost to death or hospitalization . RESULTS Mean patient age was 71 years ; 38 % were women ; and 50 % of patients had mild HF and 50 % had moderate to severe HF . During the study , 411 patients ( 40 % ) were readmitted because of HF or died  from  any cause : 42 % in the control group , and 41 % and 38 % in the basic and intensive support groups , respectively ( hazard ratio , 0.96 and 0.93 , respectively ; P = .73 and P = .52 , respectively ) . The number of days lost to death or hospitalization was 39 960 in the control group , 33 731 days for the basic intervention group ( P = .81 ) , and 34 268 for the intensive support group ( P = .49 ) . All-cause mortality occurred in 29 % of patients in the control group , and there was a trend toward lower mortality in the intervention groups combined ( hazard ratio , 0.85 ; 95 % confidence interval , 0.66 - 1.08 ; P = .18 ) . There were slightly more hospitalizations in the 2 intervention groups ( basic intervention group , P = .89 ; and intensive support group , P = .60 ) . CONCLUSIONS Neither moderate nor intensive disease management by a nurse specializing in management of patients with HF reduced the combined end points of death and hospitalization because of HF compared with st and ard follow-up . There was a nonsignificant , potentially relevant reduction in mortality , accompanied by a slight increase in the number of short hospitalizations in both intervention groups . Clinical Trial Registry http://trialregister.nl Identifier : NCT 98675639 Eighty-two patients aged > or = 70 years with heart failure were r and omized to a gentle , seated exercise program or to usual care .  Six-minute walk distance and quality of life did not change between groups , but daily activity as measured by accelerometry increased in the exercise group relative to the control group In this r and omized controlled trial we tested the efficacy of an intervention program ( CARE : Creating Avenues for Relative Empowerment ) for improving outcomes of hospitalized older adults and their family caregivers ( FCGs ) . FCG-patient dyads ( n = 407 ) were r and omized into two groups . The CARE group received a two-session empowerment-educational program 1 - 2 days post-admission and 1 - 3 days pre-discharge . The attention control group received a generic information program during the same timeframe . Follow-up was at 2 weeks and 2 months post-discharge . There were no statistically significant differences in patient or FCG outcomes . However , inconsistent evidence of role outcome differences suggests that CARE may benefit certain FCG subgroups instead of being a one-size-fits-all intervention strategy . Closer examination of CARE 's mechanisms and effects is needed OBJECTIVE To investigate the business case of  postdischarge care transition ( PDCT ) among Medicare beneficiaries by conducting a cost-benefit analysis . DESIGN R and omized controlled trial . SETTING A general hospital in upstate New York State . PARTICIPANTS Elderly Medicare beneficiaries being treated from October 2008 through December 2009 were r and omly selected to receive services as part of a comprehensive PDCT program ( intervention--173 patients ) or regular discharge process ( control--160 patients ) and followed for 12 months . INTERVENTION The intervention comprised five activities : development of a patient-centered health record , a structured discharge preparation checklist of critical activities , delivery of patient self-activation and management sessions , follow-up appointments , and coordination of data flow . MEASUREMENTS Cost-benefit ratio of the PDCT program ;  self-management skills and abilities . RESULTS The 1-year readmission analysis revealed that control participants were more likely to be readmitted than intervention participants ( 58.2 % vs 48.2 % ; P = .08 ) ; with most of that difference observed in the 91 to 365 days after discharge . Findings from the cost-benefit analysis revealed a cost-benefit ratio of 1.09 , which indicates that , for every $ 1 spent on the program , a saving of $ 1.09 was realized . In addition , participating in a care transition program significantly enhanced self-management skills and abilities . CONCLUSION Postdischarge care transition programs have a dual benefit of enhancing elderly adults ' self-management skills and abilities and producing cost savings . This study builds a case for the inclusion of PDCT programs as a reimbursable service in benefit packages BACKGROUND It is still a matter of debate whether exercise training ( ET ) is a beneficial treatment in chronic heart failure ( CHF ) . METHODS AND RESULTS To determine whether long-term moderate ET improves functional capacity and quality of life in patients with CHF and whether these effects translate into a favorable outcome , 110 patients with stable CHF were initially recruited , and 99 ( 59+/-14 years of age ; 88 men and 11 women ) were r and omized into 2 groups . One group ( group T , n=50 ) underwent ET at 60 % of peak & f1;O2 , initially 3 times a week for 8 weeks , then twice a week for 1 year . Another group ( group NT , n=49 ) did not exercise . At baseline and at months 2 and 14 , all patients underwent a cardiopulmonary exercise test , while 74 patients ( 37 in group T and 37 in group NT ) with ischemic heart disease underwent myocardial scintigraphy .  Quality of life was assessed by question naire . Ninety-four patients completed the protocol ( 48 in group T and 46 in group NT ) . Changes were observed only in patients in group T. Both peak & f1;O2 and thallium activity score improved at 2 months ( 18 % and 24 % , respectively ; P<0 . 001 for both ) and did not change further after 1 year . Quality of life also improved and paralleled peak VO2 . Exercise training was associated both with lower mortality ( n=9 versus n=20 for those with training versus those without ; relative risk (RR)=0.37 ; 95 % CI , 0.17 to 0.84 ; P=0.01 ) and hospital readmission for heart failure ( 5 versus 14 ; RR=0.29 ; 95 % CI , 0.11 to 0.88 ; P=0.02 ) . Independent predictors of events were ventilatory threshold at baseline ( beta-coefficient=0.378 ) and posttraining thallium activity score ( beta-coefficient -0.165 ) . CONCLUSIONS Long-term moderate ET determines a sustained improvement in functional capacity and quality of life in patients with CHF . This benefit seems to translate into a favorable outcome BACKGROUND Multidisciplinary heart failure programs including patient education and self-management strategies such as daily recording of body weight and use of a patient diary decrease hospital readmissions and improve quality of life . However , the degree of uptake of individual components of these programs and their contribution to patient benefit are uncertain . METHODS Patients with heart failure admitted to Auckl and Hospital were r and omised into the management or usual care groups of the Auckl and heart failure management study ( AHFMS ) . Patients in the management group were given a heart failure diary for the recording of daily weights , attended a heart failure clinic and were encouraged to attend three education sessions . Patients in the usual care group received routine clinical care , mainly from general practitioners . Patients were followed to 12 months . This study investigated the uptake of self-management by assessing diary use and self-weighing behaviour in the group receiving the heart failure intervention , and compared the level of knowledge of heart failure self-management of the management group to the control group after 12 months . RESULTS Of the 197 patients in the AHFMS , 100 patients were included in the management group  and received a diary and education about heart failure self-management including  monitoring weight daily .  Of these patients , 76 patients used the diary  . These patients were on more medication ; were more likely to attend the education sessions , heart failure clinic , and primary care , and had a lower mortality rate over the course of the study . Variables independently associated with use of the diary included less severe symptoms ( OR 15 , 95 % confidence intervals 1.7 , 144 ) , frequent attendance at the heart failure clinic ( OR 15 , 95 % CI 3 , 78 ) and attendance at an education session ( OR 8 , 95 % CI 1.5 , 42 ) . Of the 76 patients who used the diary , 51 weighed themselves regularly . More of these patients owned scales at home ; they were also more likely to attend the education sessions , and experienced fewer hospital admissions than those patients who did not weigh themselves regularly . Variables independently associated with regular self-weighing included the presence of scales at home ( OR 6.3 , 95 % CI 1.7 , 14.1 ) , left ventricular ejection fraction > 30 % ( OR 4.3 , 95 % CI 1.1 , 17.5 ) , and attendance at the education session(s ) ( OR 6.3 , 95 % CI 1.7 , 14.1 ) . Patients in the management group exhibited higher levels of knowledge at 12 months of follow-up and were more likely to monitor their condition using daily weighing , compared to the control group . CONCLUSIONS At 12 months of follow-up , implementation of self-management strategies including daily weight monitoring and level of education on self-management was significantly higher in the management group than the control group . For the patients in the management group , not using the diary or inability to perform daily weighing were associated with less frequent attendance at the heart failure clinic and education sessions and poorer health outcomes . In this study , attendance at the education sessions was associated with the adoption of self-management , underlining the importance of education in multidisciplinary heart failure programmes . Self-weighing could be increased by provision of scales to all patients . The subset of patients who did not adopt self-management strategies in this study were at high risk of death or readmission This study sought to determine the effect of an advanced- practice -nurse (APN)-led telephone intervention on hospital readmissions , quality of life , and self-care behaviors ( SCBs ) of patients with heart failure ( HF ) . Twenty participants were r and omly assigned to either an experimental group that received the APN-led telephone intervention ( ALTI ) or a control group that received usual care in this pretest-posttest experimental study . The results of this study support the idea that an ALTI positively impacts outcomes of patient with HF  , particularly by improving SCBs and decreasing hospital readmissions . An ALTI warrants consideration to improve outcomes of patients with HF AIMS Disease management programs can reduce hospitalizations in high-risk heart failure ( HF ) patients , but generalizability to the population hospitalized for HF remains to be proven . We aim ed to assess the effectiveness of a discharge and outpatient management program in a non-selected cohort of patients hospitalized for HF . METHODS AND RESULTS Patients admitted with decompensated HF were r and omized to receive usual care ( n=174 ) or an  intervention ( n=164 ) consisting of a comprehensive hospital discharge planning and close follow-up at a HF clinic . After a median of 509 days , there were fewer events ( readmission or death ) in the intervention as compared with the control group ( 156 vs. 250 ) , which represents 47 % ( 95%CI : 29 - 65 ; P<0.001 ) event reduction per observation year . At 1-year , time to first event , time to first all-cause and HF readmission , and time to death were increased in the intervention group ( P<0.001 ) . All-cause and HF readmission rates per observation year were significantly lower , quality of life improved and overall cost of care was reduced in the intervention group . CONCLUSIONS This comprehensive hospital discharge and outpatient management program prolonged time to first event , reduced hospital readmissions , improved survival and quality of life of patients hospitalized for HF , while reducing cost of management Background Heart failure is a common and costly condition , particularly in the elderly . A range of models of interventions have shown the capacity to decrease hospitalizations and improve health-related outcomes . Potentially , cardiac rehabilitation models can also improve outcomes . Aim To assess the impact of a nurse-coordinated multidisciplinary , cardiac rehabilitation program to decrease hospitalizations , increase functional capacity , and meet the needs of patients with heart failure . Method In a r and omized control trial , a total of 105 patients were recruited to the study . Patients in the intervention group received an individualized , multidisciplinary 12-week cardiac rehabilitation program , including an individualized exercise component tailored to functional ability and social circumstances . The control group received an information session provided by the cardiac rehabilitation coordinator and then follow-up care by either their cardiologist or general practitioner . This trial was stopped prematurely after the release of state-based guidelines and funding for heart failure programs . Results During the study period , patients in the intervention group were less likely to have been admitted to hospital for any cause ( 44 vs. 69 % , P = 0.01 ) or after a major acute coronary event ( 24 vs. 55 % , P = 0.001 ) . Participants in the intervention group were more likely to be alive at 12 months , ( 93 vs. 79 % ; P = 0.03 ) ( odds ratio = 3.85 ; 95 % confidence interval = 1.0314.42 ; P = 0.0042 ) . Quality of life scores improved at 3 months compared with baseline ( intervention t = 4.37 , P [ 0.0001 ; control t= 3.52 , P [ 0.01 ) . Improvement was also seen in 6-min walk times at 3 months compared with baseline in the intervention group ( t = 3.40 ; P = 0.01 ) . Conclusion This study shows that a multidisciplinary heart failure cardiac rehabilitation program , including an individualized exercise component , coordinated by a specialist heart failure nurse can substantially reduce both all-cause and cardiovascular readmission rates , improve functional status at 3 months and exercise tolerance BACKGROUND Chronic heart failure ( CHF ) remains a common cause of disability , death and hospital admission . Several investigations support the usefulness of programs of disease management for improving clinical outcomes . However , the effect of home-based telemanagement programs on the rate of hospital readmission is still unclear and the cost-effectiveness ratio of such programs is unknown . The aim of the study was to determine whether a home-based telemanagement ( HBT ) programme in CHF patients decreased hospital readmissions and hospital costs in comparison with the usual care ( UC ) follow-up programme over a one-year period . METHODS AND RESULTS Four hundred-sixty CHF patients ( pts ) , aged 57+/-10 years were r and omised to two management strategies : 230 pts to HBT programme and 230 pts to UC programme .  The HBT pts received a portable device , transferring , by telephone , a one-lead trace to a receiving station where a nurse was available for interactive teleconsultation . The UC pts were referred to their primary care physicians and cardiologists . The primary objective of the study was one-year hospital readmission for cardiovascular reasons . During one-year follow-up 55 pts ( 24 % ) in HBT group and 83 pts ( 36 % ) in UC group had at least one readmission ( RR=0.56 ; 95 % CI : 0.38 - 0.82 ; p=0.01 ) . After adjusting for clinical and demographic characteristics , the HBT group had a significantly lower risk of readmission compared with the UC group ( HR=0.50 , 95 % CI : 0.34 - 0.73 ; p=0.01 ) . The intervention was associated with a 36 % decrease in the total number of hospital readmissions ( HBT group : 91 readmissions ; UC group : 142 readmissions ) and a 31 % decrease in the total number of episodes of hemodynamic instability ( 101 in HBT group vs 147 in UC group ) . The rate of hearth failure-related readmission was 19 % ( 43 pts ) in HBT group and 32 % ( 73 pts ) in UC group ( RR=0.49 , 95 % [ CI ] : 0.31 - 0.76 ; p=0.0001 ) . No significant difference was found on cardiovascular mortality between groups . Mean cost for hospital readmission was significantly lower in HBT group ( euro 843+/-1733 ) than in UC group ( euro 1298+/-2322 ) , ( -35 % , p<0.01 ) . CONCLUSIONS This study suggests that one-year HBT programme reduce hospital readmissions and costs in CHF patients OBJECTIVES We compared the longer-term impact of the two most commonly applied forms of post-discharge management design ed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure ( CHF ) . METHODS We followed a multi-center r and omized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days . Blinded endpoints included event-free survival from all-cause emergency hospitalization or death , all-cause mortality and rate of all-cause hospitalization and stay . RESULTS 280 patients ( 73 % male , aged 71 ± 14 years and 73 % left ventricular systolic dysfunction ) were initially r and omized to home-based ( n=143 ) or clinic-based ( n=137 ) intervention . During extended follow-up ( complete for 274 patients ) , 1139 all-cause hospitalizations ( 7477 days of hospital stay ) and 121 ( 43.2 % ) deaths occurred . There was no difference in the primary endpoint ; 20 ( 14.0 % ) home-based versus 13 ( 7.4 % ) clinic-based patients remained event-free ( adjusted HR 0.89 , 95 % CI 0.70 to 1.15 ; p=0.378 ) . Significantly fewer home-based ( 51/143 , 35.7 % ) than clinic-based intervention ( 71/137 , 51.8 % ) patients died ( adjusted HR 0.62 , 95 % CI 0.42 to 0.90 : p=0.012 ) . Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations ( p=0.087 ) associated with 3067 ( median 4.0 , IQR 2.0 to 6.8 ) versus 4410 ( 6.0 , IQR 3.0 to 12.0 ) days of hospital stay ( p<0.01 for rate and duration of hospital stay ) . CONCLUSIONS Relative to clinic-based intervention , home-based intervention was not associated with prolonged event-free survival  . Home-based intervention was , however , associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term . TRIAL REGISTRATION Australian New Zeal and Clinical Trials Registry number 12607000069459 ( http://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=81803 ) BACKGROUND The Support , Education , and Research in Chronic Heart Failure ( SEARCH ) study was design ed to assess the impact of a mindfulness-based psychoeducational intervention on clinical outcomes , depression , and quality of life in patients with chronic heart failure ( CHF ) . Although research has shown that psychosocial factors including depression are important risk factors for adverse events in patients with CHF , no large clinical trials have investigated the efficacy of psychosocial interventions to reduce these factors in this population . METHODS This was a prospect i ve cohort study of 208 adults with left ventricular ejection fraction < or = 40 % and CHF geographically assigned to treatment or control groups with follow-up at 3 , 6 , and 12 months . Treatment groups met weekly for 8 consecutive weeks for training in mindfulness meditation , coping skills , and support group discussion . RESULTS Subjects had a mean age of 61 years , left ventricular ejection fraction 26 % , and median New York Heart Association class II . The majority were treated with angiotensin-converting enzyme inhibitors ( 80 % ) and beta-blockers ( 86 % ) . At baseline , patients in the treatment group had more severe CHF with higher New York Heart Association class ( P = .0209 ) and more severe psychological distress ( Center of Epidemiology - Depression , Profile of Mood States ; P < .05 ) . When compared with controls , treatment result ed in lower anxiety ( Profile of Mood States , P = .003 ) , depression ( Center of Epidemiology - Depression , P = .05 ) , improved symptoms ( Kansas City Cardiomyopathy Question naire symptom scale , P = .033 ) and clinical scores ( Kansas City Cardiomyopathy Question naire clinical score , P = .024 ) over time . There were no treatment effects on death/rehospitalization at 1 year . CONCLUSIONS An 8-week mindfulness-based psychoeducational intervention reduced anxiety and depression ; this effect was attenuated at 1 year . Importantly , the intervention led to significantly better symptoms of CHF at 12 months compared to control subjects . Our results suggest that interventions of this type might have a role in optimal therapy for CHF Background — Patients with heart failure ( HF ) who live in rural areas have less access to cardiac services than patients in urban areas . We conducted a r and omized , clinical trial to determine the impact of an educational intervention on the composite end point of HF rehospitalization and cardiac death in this population . Methods and Results — Patients ( n=602 ; age , 66±13 years ; 41 % female ; 51 % with systolic HF ) were r and omized to 1 of 3 groups : control ( usual care ) , Fluid Watchers LITE , or Fluid Watchers PLUS . Both intervention groups included a face-to-face education session delivered by a nurse focusing on self-care . The LITE group received 2 follow-up phone calls , whereas the PLUS group received biweekly calls ( mean , 5.3±3.6 ; range , 1–19 ) until the nurse judged the patient to be adequately trained . Over 2 years of follow-up , 35 % of patients ( n=211 ) experienced cardiac death or hospitalization for HF , with no difference among the 3 groups in the proportion who experienced the combined clinical outcome ( P=0.06 ) . Although patients in the LITE group had reduced cardiac mortality compared with patients in the control group over the 2 years of follow-up ( 7.5 % and 17.7 % , respectively ; P=0.003 ) , there was no significant difference in cardiac mortality between patients in the PLUS group and the control group . Conclusions — A face-to-face education intervention did not significantly decrease the combined end point of cardiac death or hospitalization for HF . Increasing the number of contacts between the patient and nurse did not significantly improve outcome . Clinical Trial Registration — http://www . clinical trials.gov . Unique identifier : NCT00415545
target: Main Findings : The results indicate that an intervention involving any human factor principles may nearly double an individual ’s probability of not being readmitted .
  Principal Conclusions : Interventions with human factor principles reduce readmissions among HF patients .
background: Background : Human factors play an important role in health-care outcomes of heart failure ( HF ) patients .
  A systematic review and meta- analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies .
  Purpose : To investigate how the 8 guiding principles of choice , rest , environment , activity , trust , interpersonal relationships , outlook , and nutrition reduce HF readmissions .