Heart Failure in Southern Sweden (HISS)

Heart Failure in Southern Sweden - Improving the Quality of Diagnosis and Treatment Through a Educational Intervention in Primary Care

The aim of the study is to optimize diagnosis and treatment for patients with heart failure in Swedish primary care. Patient with the diagnose heart failure registered in the electronic medical record (EMR) at seventeen primary health care centers (PHCCs) will be invited to to participate in the study. Blood testing and electrocardiography will be performed. Data on diagnosis and medical treatment will be collected from the EMR. An educational visit with a cardiologist will be performed at the PHCC, in order to discuss evidence-based diagnoses and treatment of heart failure. Data on drug therapy and health care consumption will be collected after six and twelve months.

Study Overview

• Status: Completed
• Conditions: Drug Use; Heart Failure，Congestive; Patient Care
• Intervention / Treatment: Behavioral: Educational outreach visit

Detailed Description

Background Congestive heart failure is one of the most common chronic diseases worldwide, with a prevalence of 2% of the population. With approximately 30000 affected patients, congestive heart failure is also one the most common reasons for hospital admissions in people over 65 years in southern Sweden. Heart failure means lower quality of life, a larger need for hospital care due to shortness of breath and leg swelling, risk for life threatening arrhythmia and high mortality. Several evidence-based treatment modalities have demonstrated good effect on life quality and mortality. In Sweden, there are large geographical differences in compliance to treatment guidelines. According to statistics from the National Board for Health and Welfare, in the Southern part of Sweden, Skåne, only 55% of the patients with congestive heart failure are treated with the combination of angiotensin converting enzyme inhibitors or angiotensin receptor blockers along with beta blockers. The national guidelines are recommending a target level of 65%.

The aim of this study is to assess to which extent an outreach educational program involving a cardiologist in primary care can raise the number of patients with congestive heart failure receiving evidence-based treatment, to study the cost-effectiveness of the intervention and to create a biobank for future studies in the field.

Methods The study design is prospective observational, with two patient cohorts followed over time. One cohort of patients will participate in an educational/AUDIT intervention including a cardiologist and the primary care physicians responsible for the patients. The control group will be the rest of the population in Southern Sweden, receiving usual care.

Settings Patients with a heart failure diagnosis registered in the electronic medical record (EMR) in different primary health care centers (PHCCs) will be invited to participate in the intervention group. Blood tests and electrocardiography will be performed. Blood samples for a biobank will be saved following well- regulated procedures.

Data collection Data will be collected from the EMRs in a Case Report Form (CRF). Primary outcome variable is the change in the proportion of patients receiving treatment with the combination of angiotensin converting enzyme inhibitors or angiotensin receptor blockers along with beta blockers, six months after the educational intervention.

Secondary outcome variables are the change between the groups in health care consumption and mortality as well as evidence-based treatment one year from the base line.

Data analysis The power estimation indicates that 850 patients will be required to the intervention group. Data will be analyzed with descriptive statistics and group comparison analysis for the primary outcome variable (McNemar's test and/or conditional logistic regression). Secondary outcome variables will be analyzed with group comparison for independent groups (Mann-Whitney or Student's T-test). In order to adjust for different confounders, we will use regression models. Generalized estimations equations will be used since patients are clustered within the PHCCs and can therefore not be labeled as independent.

• Study Type: Observational
• Enrollment (Actual): 563

Contacts and Locations

Study Locations

• Sweden
  • Malmö, Sweden
    • Vårdcentralen Granen

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

Patients who meet the inclusion criteria and left informed consent, at Swedish PHCCs that have previously agreed to participate in the study. All invited PHCCs are located in the Region of Skane, Southern Sweden.

Description

Inclusion Criteria:

• patients with ICD diagnose I50, I11.0, I42 and I43 in the electronic medical journal and who have left informed consent to participate in the study

Exclusion Criteria:

• patients with ICD diagnose I42.1, I42.2
• patients where the heart failure diagnose is set on wrong grounds according to the information in the electronic medical journal, as normal NT-proBNP or/and normal ecocardiogram.

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Intervention; The patients are registered at PHCCs who agreed to participate into the study, the patients have provided an informed consent. The PHCCs (seventeen according to the power calculation) will receive an educational outreach visit by a cardiologist, discussing evidence-based treatment. The physician will decide afterwords if the treatment will be adjusted. Blood samples and electrocardiography will be collected before the intervention, data from the EMR will be collected before and after the intervention.	Behavioral: Educational outreach visit; Two-four hours of discussion between a cardiologist and the primary care physicians at the PHCC encompassing evidence-based treatment guidelines and counseling upon specific patient cases and their diagnose and treatment for congestive heart failure.
Control; The control group will be the rest of the patients with heart failure in Southern Sweden. Data from the regional data base on medication and heath care consumption will be collected at base line and 6 and 12 months after.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Medication change	Change in proportion of patients treated with the combination angiotensin conversion enzyme-inhibitors(ACEi) or angiotensin receptor blockers (ARB) and betablockers	6 months after inclusion

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in health care consumption	Difference between the groups in change in number of visits in hospitals or primary care	One year after the intervention
Change in mortality rate	Difference between the groups in change in number of visits in hospitals or primary care	One year after the intervention
Change in medication	Difference between the groups in change of medication with mineral receptor antagonists (MRA), cardiac resynchronisation therapy (CRT), other implantable devices for treatment of heart failure (ICD) and intravenous iron for patients with iron deficiency	Six months after the intervention
Change in diagnostics	Difference between groups in change for proportion of patients getting the diagnosis with ecocardiogram and NYHA classification	Six months after the intervention

Collaborators and Investigators

• Sponsor: Region Skane

Study record dates

Study Major Dates

• Study Start (Actual): May 26, 2021
• Primary Completion (Actual): January 31, 2024
• Study Completion (Actual): January 31, 2024

Study Registration Dates

• First Submitted: October 15, 2019
• First Submitted That Met QC Criteria: October 15, 2019
• First Posted (Actual): October 17, 2019

Study Record Updates

• Last Update Posted (Estimated): February 29, 2024
• Last Update Submitted That Met QC Criteria: February 27, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Heart Failure
• Other Study ID Numbers: 1111

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No