Hi everyone this is windy alonso presenting to you my intervention proposal for stat 507 improving heart failure related mortality in rural pennsylvania an overview for my presentation today i’m going to discuss the public health burden of heart failure risk factors for heart failure the target risk factor in my proposal my study objective my study design and methods
Anticipated outcomes and strengths and limitations of my study it’s likely that you may know someone with heart failure or if you’re a health care professional you care for someone with heart failure and that’s because they’re nearly 6 million people with heart failure in the united states and overfit 850,000 new diagnoses an annually the 2030 projections reported
Forty-six percent increase in heart failure prevalence which actually translates into over eight million people with heart failure and the united states alone by 2030 heart failure is a terminal disease with half of newly diagnosed patients dying within five years of their diagnosis heart failure is extremely costly in 2012 heart failure cost the united states 30
Point seven billion dollars would thick was sixty-eight percent of that being attributed to direct medical care costs with the increase in heart failure expected for 2030 the projections show that the total cost of heart failure will increase almost one hundred and twenty-seven percent to sixty nine point seven billion from the 2012 estimates this equates to being
Two hundred and forty four dollars per every us adult there are several things that increase your risk for developing heart failure that include lifestyle choices a good rule of thumb that the american heart association provides is that if a lifestyle choice can lead to heart attack or stroke it can lead to heart failure so some examples would be smoking obesity
Physical inactivity there are other conditions that also can increase your risk for heart failure and that list includes those things that can increase the wear and tear on the heart muscle including coronary artery disease acute mi or heart attack high blood pressure valve unit valvular abnormalities and the rest that are listed here there is evidence to suggest
That there is an influence of geography on heart failure outcomes rural patients have been found to be more likely to die have increased hospital admissions and lower self-reported health related quality of life when they’re compared to their urban counterparts worldwide additionally management disparities between rural and urban heart failure patients have been
Reported with royal patients being less likely to receive care from a specialist less likely to receive optimal medical management and when they do receive optimal medical management they are not they’re not as likely as that receive them in therapeutic doses and they’re also less likely to ever early follow-up after hospital admissions when considering the risk of
Death for rural heart failure patients i looked into the literature i found a large retrospective cohort study that was done recently in 2014 that reported rural heart failure patients had an increased risk of death at 30-day posted mission one year post admission when compared to urban counterparts after controlling for age socioeconomic status insurance status
Initial presentation and comorbidities the odds odds ratio was reported at 1.25 with a confidence interval of 1.0 62 1.48 for 30-day mortality and the hazard ratio was reported at 1.13 with a confidence interval 1 point 0 to 2 1.27 for one year one-year mortality these authors did suspect that these disparities could have been related to specialist access as it
Has been found they’re significantly more significantly more specialists are available in urban areas with one one study actually reported that when looking at 100,000 population or 1000 population excuse me though there was one point two specialists per 1,000 patients versus 10 in in urban centers so they’re significantly more specialists available to patients in
Urban urban areas and you know what’s what’s the big deal as far as having specialist follow-up well there’s a great impact with with specialist follow-up patients that were followed by a specialist in condemned conjunction with their primary care physician had improved survival to compared to those who were not followed by a specialist the odds ratio for 11 year
Mortality was 0 point 34 when the hazards ratio 0.98 after adjustment was made for frequency of follow-up appointments for patients that were seen by specialists for one-year mortality so for the proposed study the target risk factor for heart failure related deaths in rural patients i decided to go with specialist access and specialist follow-up post hospital
Admission and we do know that living raleigh please pay patients at increased risk of death for many reasons but because of what i just showed you with the odds ratio odds ratio differences with specialist access i felt that that was a significant target for the proposed study in addition there have been some previous studies that showed increasing support and
Remote monitoring have been successful in reducing death for rural heart failure patients for example there was a telephone-based support that was successful in reducing poor outcomes including death for rural heart failure patients when the groups were compared one group was telephone follow-up versus usual care there was a reduced one-year mortality the hazard
Ratio was point 7 with a confidence interval point 5 2.89 with a significant p value of 0 point 0 1 in a meta-analysis recently reported in 2014 remote patient monitoring had been shown to improve heart failure mortality in the meta-analysis remote monitoring that included a rapid intervention speed had lower risk of mortality compared to a non rapid so the relative
Risk for rapid i relative risk of death for rapid intervention was 0 point 59 verses point 88 for non rapid intervention following remote monitoring at and that was a statistically significant difference at point zero five leads me to the objective of the proposed study the objective of the proposed trial will be to determine the impact of posted mission video
Conference intervention and preventing heart failure related death in rural heart failure patients following first-time hospital admission for heart failure the aim of my study was to examine the impact of enhanced access to specialist follow-up on rural heart failure patient mortality falling index admission to the hospital using video conferencing with the
Hypothesis that patients randomized to receive video conferencing follow up with a cardiac specialized advanced practice nurse will have a decreased mortality in the year following their index indexing their first admission with heart failure compared to those patients who receive usual care a quasi-experimental design with one intervention group on one control
Group was chosen i anticipate that there will be difficulty in randomizing due to resistance to technology and older populations so that is why i chose not to do a randomized controlled trial the outcome measure for my study will be more at mortality rates at one year post index admission and like i mentioned index being that first admission with heart failure
Recruitment of participants will occur at two large hospitals in central pennsylvania known to see a significant number of rural heart failure patients potential participants will be given the choice of treatment or control groups until the desired treatment group of 200 patients is reached or intervention group be more appropriate mating the total time for study
Recruitment and one-year follow-up will be approximately two years altogether next slide includes my inclusion exclusion criteria to be included in this study that participation must be 18 years of age or older on their first admission for heart failure and have a primary residence that’s established as a rural as we’re all via zip code utilizing the rural oregon
Commuting codes of code classification patients also must be english-speaking patients will be excluded if they have comorbid cancer and stage renal disease just an anticipation that they could have a more significant cause for their death if they’re not living independently that will also impact their long-term prognosis so they’ll also be excluded patients that
Aren’t able to be discharged will be excluded or if they have unreliable internet access in order to cop to calculate a an appropriate sample size i considered the population of interest which is rural pennsylvania with heart failure there are 3.5 million rural residents in pennsylvania’s 48 rural counties seventeen percent of the rural population is over 65 years
Of age which translates to five hundred and ninety-five thousand older adults in pennsylvania after 65 years of age the incidence of heart failures reported as high as 10 and 1000 which translates to a total population estimate the 50 9,500 which is what i use to calculate my sample size used an online sample size calculator that and i use an alpha point 05 a datum
95 and using that online calculator as i mentioned and calculated a minimum sample of 382 participants i decided to set 400 as the goal for recruitment with 200 per group just to ensure that i reached that sample of 282 minimum patience the methods for my study the intervention will consist of following hospital that discharge at that index admission of the rural
Heart failure patients the intervention group will receive video conference follow over the cardiac advanced practice nurse at 37 and 14 days post-discharge and then monthly thereafter plus usual care participants will be provided with an ipad and instruction on how to access the video conferencing software during their intervention sessions the nurse will discuss
How the patient’s feeling if they’ve made their follow-up appointments if they’ve kept their follow-up appointments all those compliance issues and just in general patients have questions the nurse will provide a sounding board for those questions and allow them access to specialist care to ensure that everything is going right with their plan of treatment control
Group participants those patients will receive usual care which will include scheduling a follow-up appointment with their primary care provider within two weeks of discharge and a three-month follow-up appointment with cardiology in the heart failure clinic at the large hospital you know i’m going to analyze my data odds ratio an odds ratio will be calculated
Comparing the two this is a my sample table and i will also use a cult cox proportional hazard model anticipated outcomes in my study i anticipate that patients in the intervention group will be less likely to die in the first year following index admission when compared to the control group gender may be found as an effect modifier i anticipate that my sample
Will not be diverse enough to adequately assess the effectiveness on the intervention based on race or ethnicity i do expect that attrition among the intervention group will be limited by in sent their incentive to keep the ipad if the study is completed if all goes well and with my study i anticipate that patients in the control group will be 20 x 20 two more
Times more likely to die than patients that receive the video conferencing intervention as calculated by the odds ratio with my fictitious sample here then lastly i just want to briefly discuss the strengths of limitations of my study i believe that the adequate sample size is readily accessible i’ll be using a prospective design i’m going to follow some protocol
A successful tell telephone interventions and similar populations however i will be using that video conferencing software i expect limited study attrition due to the motivation to keep the ipad the limitations my sample is not randomized it may be better my results may be stronger if i had a second control group of non-rural heart failure patients there could be
Potentially missed effect modifiers i am unable to control for between group variability and demographics that could lead to limited generalizability and as i also mentioned i don’t expect a very diverse sample which also limits the generalizability additionally patient deaths from other causes could impact the results so that’s something that i need to keep it
Mind and be aware of and then lastly i just have my references and i thank you very much for your time and attention
Transcribed from video
Improving Heart Failure related Mortality in Rural Pennsylvania By Windy Alonso
