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Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart
Frank Peters-Klimm1, Stephen Campbell, Thomas Müller-Tasch
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany. frank.peters@med.uni-heidelberg.de
Insights
A multidisciplinary educational intervention for general practitioners did not improve patient quality of life in chronic heart failure (CHF). The study found no significant difference in primary outcomes, highlighting challenges in recruitment and potential biases for definitive conclusions.
Area of Science:
- Cardiology
- Primary Care Medicine
- Health Services Research
Background:
- Chronic systolic heart failure (CHF) is a prevalent and debilitating condition.
- Improving adherence to evidence-based guidelines in primary care can enhance patient outcomes.
- The Train the Trainer (TTT) intervention aimed to improve outcomes for CHF patients managed by general practitioners (GPs).
Purpose of the Study:
- To evaluate the impact of a multidisciplinary educational intervention (TTT) for GPs on patient and performance outcomes in CHF.
- To explore the effectiveness of the TTT program in improving quality of life and other secondary outcomes for CHF patients.
Main Methods:
- A randomized controlled trial involving 37 GPs and 168 patients with confirmed CHF.
- Practices were assigned to either the TTT intervention (educational meetings on guidelines and pharmacotherapy) or a control group.
- Primary outcome: patient-reported quality of life (SF-36 Physical Functioning scale) at seven months. Secondary outcomes included quality of life measures, mortality, hospital admissions, and biomarker levels.
Main Results:
- No significant difference was observed between the TTT intervention and control groups for the primary outcome (SF-36 Physical Functioning scale).
- A significant increase in the prescribing of aldosterone antagonists was noted in the TTT intervention group compared to the control group (42% vs. 24%).
- Recruitment targets for both practices and patients were not met, necessitating an exploratory analysis.
Conclusions:
- The TTT educational intervention did not demonstrate effectiveness in improving the primary outcome or most secondary outcomes for CHF patients.
- Under-recruitment and potential selection bias limit the ability to draw definitive conclusions about the intervention's efficacy.
- Lessons learned from this trial provide valuable insights for the design and conduct of future confirmatory trials in primary care settings.
Background:
Chronic (systolic) heart failure (CHF) is a common and disabling condition. Adherence to evidence-based guidelines in primary care has been shown to improve health outcomes. The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners (GPs) (Train the trainer = TTT) on patient and performance outcomes.
Methods:
This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial. Primary care practices were randomly assigned to the TTT intervention or to the control group. 37 GPs (18 TTT, 19 control) were randomised and 168 patients diagnosed with ascertained CHF (91 TTT, 77 control) were enrolled. GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback. The primary outcome was patient self-reported quality of life at seven months, using the SF-36 Physical Functioning scale. Secondary outcomes included other SF-36 scales, the Kansas City Cardiomyopathy Questionnaire (KCCQ), total mortality, heart failure hospital admissions, prescribing, depressive disorders (PHQ-9), behavioural change (European Heart Failure Self-Care Behaviour Scale), patient-perceived quality of care (EUROPEP) and improvement of heart failure using NT-proBNP-levels. Because recruitment targets were not achieved an exploratory analysis was conducted.
Results:
There was high baseline achievement in both groups for many outcomes. At seven months, there were no significant mean difference between groups for the primary outcome measure (-3.3, 95%CI -9.7 to 3.1, p = 0.30). The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group, with significant between group differences at follow-up (42 vs. 24%, adjusted OR = 4.0, 95%CI 1.2-13; p = 0.02).
Conclusion:
The intervention did not change the primary outcome or most secondary outcomes. Recruitment targets were not achieved and the under-recruitment of practices and patients alongside a selection bias of participating GPs, prohibit definite conclusions, but the CI indicates a non-effectiveness of the intervention in this sample. We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care.
Trial Registration:
ISRCTN08601529.
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