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Editor,—Stromberg’s recent editorial highlighted the increasing prevalence of congestive cardiac failure (CCF) in the Western world and made the point that the cost of frequent hospital admissions with decompensated CCF consumes a large and growing proportion of health service budgets.1 Several studies have demonstrated the effectiveness of various complex interventions in reducing the number of admissions with decompensated CCF compared to usual care—for example, through the use of nurse practitioners specialising in heart failure and dedicated heart failure clinics.2-4 As well as reducing the morbidity associated with CCF—an important goal in itself—such interventions have the potential to reduce total costs, but only where the cost of the intervention is less than the saving produced. At least one study in the last year has acknowledged the importance of assessing the cost effectiveness of interventions to reduce admissions with decompensated CCF as well as their clinical effectiveness,5 and in an age of limited resources we think it is appropriate to look for effective interventions that are as simple as possible. We report our early experience with a very simple intervention that we believe may have potential.
Since November 1997 it has been our practice to identify all our patients with CCF (New York Heart Association grades III and IV) who are readmitted with acute decompensation, and for whom only medical treatment is indicated. If they are cognitively intact, well motivated, and self caring, we instruct them about the pre-admission clinical indicators of decompensation: a rapid increase in weight of 1 kg or more within a few days, increased breathlessness on exertion, unexpected breathlessness at night, breathlessness in their usual sleeping position, and increased swelling of their ankles. They are advised that, on recognising any of these indicators, they should take metolazone 2.5 mg bid (morning and lunchtime) in addition to their regular diuretics until the indicators disappear, to a maximum of four doses. These instructions take 20 to 30 minutes at discharge, and are repeated on a simple advice sheet, which also contains a box in which the patient fills in their weight in underwear, measured on their own scales as soon as they get home.
They are advised to contact their general practitioner or our team (the number is on the advice sheet) if they have any problems, and a copy of the advice sheet is sent to the general practitioner with the discharge letter. They are also asked to record when and why they take extra diuretics.
We identified all 14 patients admitted in the six months to April 1998 under our firm—the “index” admission—and instructed as above before discharge. Four patients died at home within six months of discharge, a mortality rate of 29% over six months, which is comparable to that seen in large trials involving patients with severe CCF,6 and is an overestimate as there have been no further deaths at the time of writing. Two patients had been lost to follow up. The remaining eight patients were reviewed in clinic and asked how useful the advice had been (table 1). Among the eight patients reviewed there were no admissions in the six months after their index admissions compared to three admissions in the six months beforehand. Five of these patients had used extra diuretics on 92 occasions. None of the patients reported any problems understanding or following the advice and all were still monitoring their weight regularly. Five patients had found the advice useful of whom two were certain that taking extra diuretics had prevented their admission on one and two occasions, respectively. Our practice appears safe, well tolerated, and effective in comparison to usual practice. It is also very quick and simple, and we believe it warrants more formal assessment.
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