PCORI funds implementation projects to increase awareness and promote the use of PCORI-funded research findings to improve healthcare practices and health outcomes. This project focuses on implementing findings from the following completed PCORI-funded research project: Examining Whether a Self-Care Program Reduces Healthcare Use and Improves Health among Patients with Acute Heart Failure -- The GUIDED HF Study.
1. What were the results from the original PCORI-funded research study?
Over 25 percent of patients with acute heart failure (AHF) experience unplanned 30-day readmission or mortality after hospital discharge. Further, patients who are unable to see their doctor in the first week after hospital discharge are at increased risk for readmissions. Improving transitions of care for inpatients with AHF is a well-established strategy to improve these outcomes; however, patients with AHF discharged after emergency department (ED)–based management have not been included in these initiatives. Recognizing this unmet need, in our original PCORI-funded study, we determined the impact of our self-care intervention (GUIDED-HF) on clinical and patient-oriented outcomes at 30 and 90 days in patients with AHF discharged from 15 geographically diverse EDs. We observed a sustained non–statistically significant 4 percent improvement in HF events favoring our intervention at both 30 and 90 days (36 percent vs. 32 percent). At day 30 of our intervention, patients saw significant improvements in our primary HF outcome, resulting in reduced ED visits and hospital admissions. In addition, they also had statistically and clinically significant improvements in HF knowledge and quality of life (QOL) compared with the usual care arm. This finding is vitally important for patients, providers, and health systems. Readmissions and HF events in the first 30 days after hospitalization have become a critical quality improvement metric and overwhelming financial issue for hospitals and health systems. This randomized trial filled in a critical gap in knowledge while demonstrating the feasibility and effectiveness of our GUIDED-HF intervention in improving outcomes for patients with AHF who are discharged from the ED.
2. Why is this research finding important?
GUIDED-HF specifically addresses the safe transition of patients discharged from the ED to home to improve HF outcomes, QOL, and HF knowledge. Patients discharged from the inpatient setting who effectively engage in self-care interventions have lower hospitalization rates and mortality risk, better QOL and functional status, and decreased healthcare costs. In 3,166 HF patients involved in various self-care interventions, the majority reported significantly higher levels of HF knowledge and self-care behaviors, including regular weighing, medication adherence, and dietary sodium restriction. However, none of these interventions were tested in the ED setting. Our results demonstrate that a self-care intervention can be extended to the ED setting and improve HF-related events. Our findings inform this overall body of literature regarding self-care transition interventions. Readmissions over 30 days not only impact patients but have also become a critical quality improvement metric and financial issue for hospitals and health systems.
3. What is the goal of this project?
The primary objective of this project is to implement and evaluate the impact of our HF self-care coaching strategy on 30-day AHF events through ongoing formative and summative evaluation informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework in four EDs representing two large integrated health systems. To accomplish this objective, we will address the following aims over the three years of the study:
- Aim 1. Engage stakeholders to tailor GUIDED-HF implementation to an approach that is practical and feasible and embeds GUIDED-HF into routine ED discharge practices (months 0–4). We hypothesize that we will identify solutions to local barriers and streamline implementation based on survey and focus group data, as well as our prior experience with GUIDED-HF and our implementation team’s expertise.
- Aim 2. Implement and evaluate the effectiveness of GUIDED-HF implementation using the RE-AIM framework in diverse clinical settings impacting approximately 2,800 patients (months 5–36). We hypothesize that utilizing the tailored and streamline implementation approach will lead to implementation effectiveness and sustained results in improvements in patient-centered outcomes.
4. What is the project team doing?
Drawing from the Expert Recommendations for Implementation Change taxonomy of implementation strategies and our collective experience, we developed an implementation approach for GUIDED-HF consisting of evidence-based implementation strategies. Using a mixed-methods approach in aim 1, we will involve all stakeholders (providers, nurses, patients, caregivers, self-care coaches, and hospital administrators) to refine and formalize the implementation approach using surveys and focus group interviews. The Consolidated Framework for Implementation Research will guide discussions about barriers and facilitators. Based on perceived barriers and solutions from aim 1, in months 5–6 of aim 2 we will train sites on the GUIDED-HF toolkit and implement this into usual practice at each site. Patients will then be offered GUIDED-HF at each site for 24 months, leaving six months for analysis at the end of year 3. The self-care coaches at each site will approach each subject regarding their interest in participating in the GUIDED-HF program, consisting of (1) an initial/ED visit to introduce GUIDED-HF, assist with arranging outpatient provider follow-up, and assist with scheduling the virtual/home visit; (2) a virtual/home visit with the self-care coach utilizing the GUIDED-HF self-care toolkit; and (3) biweekly coaching calls to continue working on mastering HF self-care utilizing the GUIDED-HF toolkit. We expect to reach approximately 2,800 patients with AHF discharged from the four EDs over the three-year study period. Our GUIDED-HF toolkit provides sustainable self-care strategies that lead to improvements in HF outcomes, QOL, and knowledge.
5. How is the team evaluating this project?
We will be using the RE-AIM metrics for the outcomes evaluation of aim 2. This focus on reach (proportion and representativeness of eligible patients for whom GUIDED-HF was used), effectiveness (proportion of AHF events at 30 days after the intervention), adoption (proportion and representativeness of providers willing to use GUIDED-HF), implementation (consistency and acceptability of GUIDED-HF), and maintenance (continued adoption and effectiveness).
6. How is the team involving patients and others in ensuring the findings reach people who can use them?
Our team of stakeholders has contributed to this project and will continue to do so throughout the preparatory, execution, and translation phases. The list of stakeholders includes our caregiver and patient (Cheryl Walsh and Chad Robichaux), the American Heart Association (AHA), and the PCORnet STAR network. In the preparatory and execution phase of this proposal, the AHA will obtain feedback about the project via its citizen scientist think tank and online social media presence. The research team has reviewed the project with our patient and caregiver. During the execution and translation phase, the AHA and STAR CRN (part of PCORnet) will assist with the important dissemination of key study findings to patients, clinicians, investigators, and the nonmedical community.
7. How will this project help ensure future uptake and use of findings from patient-centered outcomes research?
This project will ensure future uptake by disseminating the results of the implementation project at four diverse EDs. The GUIDED-HF implementation approach will provide a roadmap to effectively scale up GUIDED-HF to other US hospitals and will be amenable to multicomponent care transition interventions in other complex disease processes managed in the ED, such as diabetes, chronic pain, and chronic pulmonary disease. Dissemination of the research results through PCORnet and the AHA, and future study-related publications and presentations, will enhance reaching targeted audiences and settings on a large scale.
Initial PCORI-funded Research Study
This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Examining Whether a Self-Care Program Reduces Healthcare Use and Improves Health among Patients with Acute Heart Failure -- The GUIDED HF Study