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BackgroundPatients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone–based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital. ObjectiveThe objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation. MethodsA multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes. ResultsPatient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020. ConclusionsThis RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation. Trial RegistrationClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303 International Registered Report Identifier (IRRID)DERR1-10.2196/15753

BACKGROUND: There is limited international agreement on defining care quality for the millions of people hospitalized with heart failure worldwide. Our objective was to compare and measure agreement across existing internationally published quality indicators (QIs) for the care of adults hospitalized for heart failure. METHODS: Systematic review and evidence gap map of internationally published articles reporting on QIs for adults hospitalized for heart failure, using PubMed, MEDLINE, EMBASE, and TRIP from inception to July 18, 2022. Narrative synthesis and descriptive statistics characterized included articles and QIs using the Donabedian Framework of Structural, Process, and Outcomes. The methodological quality of QI sets was assessed using the Appraisal of Indicators through Research and Evaluation instrument. Agreement about QIs was defined as having at least 3 different cardiovascular societies recommend its use. An evidence gap map displayed each QI according to its clinically relevant category, methodological quality, and reporting articles. RESULTS: Fourteen articles from 11 societies reported 75 unique QIs; 53 QIs were process, 16 were structural, and 7 were outcome measures. There was limited agreement on individual QIs across sets as a minority were recommended by ≥3 societies (12%; 9/75 QIs). The most common QIs included postdischarge follow-up (73%, 8/11 societies), specific pharmacotherapy (64%, 7/11 societies), patient education (45%, 5/11 societies), assessment of left ventricular ejection fraction (45%, 5/11 societies), 30-day readmission rate (45%, 5/11 societies), cardiac rehabilitation (36%, 4/11 societies), and multidisciplinary management (27%, 3/11 societies). CONCLUSIONS: There was little agreement on defining high-quality care and limited agreement on measures including postdischarge follow-up, specific pharmacotherapies, patient education, assessment of left ventricular ejection fraction, 30-day readmission, cardiac rehabilitation, and multidisciplinary management. These measures may define high-quality care and highlight opportunities to improve the quality of care for adults hospitalized for heart failure. [ABSTRACT FROM AUTHOR]

Background: Prior studies show significant gaps in the informed decision-making process, a central goal of surgical care. These studies have been limited by their focus on low-risk decisions, single visits rather than entire consultations, or both. Our objectives were, first, to rate informed decision-making for major elective vascular surgery based on audiotapes of actual physician-patient conversations and, second, to compare ratings of informed decision-making for first visits to ratings for multiple visits by the same patient over time. Methods: We prospectively enrolled patients for whom vascular surgical treatment was a potential option at a tertiary care outpatient vascular surgery clinic. We audio-taped all surgeon--patient conversations, including multiple visits when necessary, until a decision was made. Using an existing method, we evaluated the transcripts for elements of decision-making, including basic elements (e.g., an explanation of the clinical condition), intermediate elements (e.g., risks and benefits) and complex elements (e.g., uncertainty around the decision). Results: We analyzed 145 surgeon--patient consultations. Overall, 45% of consultations contained complex elements, whereas 23% did not contain the basic elements of decision-making. For the 67 consultations that involved multiple visits, ratings were significantly higher when evaluating all visits (50% complex elements) compared with evaluating only the first visit (33% complex elements, p < 0.001.) Conclusion: We found that 45% of consultations contained complex elements, which is higher than prior studies with similar methods. Analyzing decision-making over multiple visits yielded different results than analyzing decision-making for single visits. Contexte : Des etudes anterieures revelent des lacunes importantes dans le processus de prise de decisions eclairees, objectif central des soins chirurgicaux. Ces etudes ont ete limitees par leur convergence sur les decisions a faible risque, les consultations ponctuelles plutot que les consultations completes, ou les deux. Nous voulions d'abord evaluer la prise de decisions eclairees portant sur des interventions en chirurgie vasculaire electives importantes en nous fondant sur des enregistrements de conversations reelles entre medecin et patient. Nous voulions ensuite comparer des evaluations de la prise de decisions eclairees portant sur les premieres consultations a celles de decisions reliees a de multiples visites effectuees par le meme patient au fil du temps. Methodes : Nous avons inscrit de facon prospective des patients pour lesquels la chirurgie vasculaire constituait une option possible a une clinique de chirurgie vasculaire en soins tertiaires fournis en service externe. Nous avons enregistre toutes les conversations entre chirurgien et patient, y compris celles qui ont eu lieu au cours de multiples consultations au besoin, jusqu'a ce qu'une decision soit prise. Nous avons utilise une methode existante pour evaluer les comptes rendus afin de determiner les elements de la prise de decisions, y compris les elements de base (par exemple, une explication de l'etat clinique), les elements intermediaires (par exemple, risques et avantages) et les elements complexes (par exemple, incertitude entourant la decision). Resultats : Nous avons analyse 145 consultations chirurgien-patient. Dans l'ensemble, 45 % des consultations comportaient des elements complexes, tandis que 23 % ne contenaient pas les elements fondamentaux de la prise de decisions. Dans le cas des 67 consultations comportant de multiples visites, les cotes ont ete beaucoup plus elevees lorsqu'on a evalue toutes les visites (50 % d'elements complexes) comparativement a celles qu'a produites l'evaluation de la premiere visite seulement (33 % d'elements complexes, p< 0,001.) Conclusion : Nous avons constate que 45 % des consultations comportaient des elements complexes, proportion plus elevee que celle qu'ont revelee des etudes anterieures realisees au moyen de methodes semblables. L'analyse de la prise de decisions etalees sur de multiples visites a produit des resultats differents de celle de la prise de decisions reliees aux visites ponctuelles., Informed decision-making is based on the legal concept of informed consent but applies more broadly to all decisions, including consent to major procedures, recommendations for conservative or nonsurgical therapy and [...]