Methods, Results and/or Applicability in Practice
Controlled trials have widely been applied in studies assessing what approach between multidisciplinary education approach and use of standard heart failure education in primary settings is effective in reducing readmissions of CHF patients. Most of the studies have supported the use of standard heart failure education as multidisciplinary education has been found to yield no results sometimes. An example is Dracup et al. (2014) used a randomized control trial to determine the efficiency, as well as, effectiveness that is attached to self-care education on patients diagnosed with heart failure in rural areas. One of the intervention groups was followed-up using two phone calls; while the control groups received biweekly calls until the nurses were satisfied that, they had adequate training. With a 2-years follow up, the number of hospitalized cardiac patients was 35% with the group, which received education on self-care having low rates of hospitalization. As such, Dracup et al. (2014) concluded that patient education, which is designed towards optimizing self-care in HF patients, should be embraced. The education should focus on aspects such as medication adherence, weight monitoring, and appropriate diet.
A randomized control trial was also used by Luttik et al. (2014) in a study of 189 patients. The participants were tasked to follow-up programs in HF clinic (n=92) or in primary care (n=97). 12 months later, “no differences between the two groups with respect to hospital readmissions for direct cardiovascular issues were observed” (Luttik et al., 2014). As such, Luttik et al. (2014) concluded that HF patients who are discharged to primary care should be exposed to long periods of follow-up to foster adherence to management guidelines. GPs in primary care should for instance focus on helping the patients adhere to medication to reduce co-morbidities, which accompany HF.
Peters-Klimm et al. (2010) conducted a study aimed at evaluating the effectiveness of case management in HF patients in primary care. The randomized control trial consisted of 31 doctor assistants and GPs. Patients diagnosed with HF were case managed (n=99) through home visits, and telephone monitoring while (n=100) were managed through usual care. The study supports the effectiveness of primary care mechanisms to instill self-care in HF patients and consequently stabilize these patients. In examining the effectiveness of outpatient follow-up for patients with CHF, Schou et al. (2013) used a sample of 921 patients. Follow-up was done for two and a half years. Results depicted that follow-up had no significant benefit in reducing hospital readmission.
Stewart et al. (2014) “used a multi-center randomized controlled trial on patients who were hospitalized with CHF and who were initially put under clinic-based and home-based intervention for a period of 1368 ± 216 days. The results showed that unlike clinic-based intervention, the home-based intervention had a significant impact in reducing the level of deaths as well as the hospitalization of HF patients, especially in the long term. Vaillant-Roussel et al. (2014)’s study was aimed at improving the life quality of HF patients using GP education in primary care. Using a cluster-controlled trial, four areas were studied where control and intervention groups were compared. The education sessions were scheduled at 1, 4, 7, 10, 13 and 19 months after the trial started. The results of the study showed that patient education in primary care settings played a major role in improving the life quality of HF patients and thus reduced their readmission.
Present Gaps in Knowledge
Following the review of the existing studies on how to reduce readmission of HF patients, a gap still exists on why multidisciplinary education approach is less effective in reducing CHF readmissions. Studies which have previously examined the effectiveness of the multidisciplinary approaches have shown that it is ineffective but do not go to the extent of why. An example is a study conducted by Riley and Masters (2016), and it shows that multidisciplinary teams have the potential to lower HF readmissions but does not explore the effectiveness of the approach. As identified by Sato (2015), multidisciplinary education is mostly oriented towards changing the behavior of CF patients and their families with an aim of improving their life quality. Since different parties are involved including nurses and other health professionals, there lacks clear identification of whether the ineffectiveness of multidisciplinary education in reducing HF emanates from the failure of these parties. As such, it is difficult to give a clear conclusion on what makes the approach ineffective in reducing HF readmissions.
The Iowa model will be used to guide the application of research findings. The model helps health practitioners to easily translate findings from a research into practical practice to improve patients’ outcome. The first step in this model is the identification of a problem, which may require evidence-based practice. In this case, the problem is the readmission of CHF patients. The second step is the formation of a team, which will determine whether the problem is worth looking at. The determination will be based on the cost or resources needed, and the team can also decide on practice areas which need to be changed. Evidence retrieval is the third step, which begins with the team identifying available sources and terms to guide evidence search. The evidence is then graded in the fourth step through assessment of the overall strength of individual research studies. This will ensure that the research findings, which are translated into clinical practices, yield the best-desired results (Doody & Doody, n.d.).
The fifth step is the development of EBP standards, which is initiated when team members set practice recommendations. The recommendations are made based on risks and benefits, which accrue to the patients, as the EBP is largely patient-centered. In the sixth step, evidence-based practice is implemented. For proper implementation, key aspects such as guidelines, procedures, and written policy are considered to ensure that the changes brought by the EBP are positive. Finally, evaluation is done to determine whether EBP is of any value. Data obtained prior to implementation of the practice is crucial as it shows the extent to which evidence has enhanced patient care (Doody & Doody, n.d.).
Present Conclusions, Limitations, and Suggestions for Future Research
Currently, there is no clear conclusion on which approach between multidisciplinary education and standard heart failure education in the primary care setting is effective in reducing readmission of HF patients. However, it can be concluded that standard heart failure education in primary care settings is effective than multidisciplinary education approach. Through education in primary care, it is possible to educate people on appropriate behavior change to improve prognosis as well as life quality that prevent readmission. Based on the current studies, multidisciplinary education especially follow-ups have been found to be unsuccessful, sometimes yielding no difference between patients who are subjected to it and those who are not subjects to it. However, in standard education on HF, readmissions reduce because people are informed on appropriate self-care practices. As such, patients are able to embrace measures, which can lower readmissions.
However, present studies have limitations. One is that assessment of the effectiveness of multidisciplinary approaches, which consist of follow-ups, may require a long period, of up to 2 years. As such, where conclusions are made within a short time period like six months, the results may not be valid. Secondly, it may be difficult to enroll a large number of patients for a study since the majority of them may not have encountered any of the approaches in question. As such, generalizability is limited. Additionally, where GPs and other health practitioners are involved in the education, there is a risk of bias since they may not conduct the education uniformly to all patients.
Future research should focus on why the multidisciplinary education approach especially follow-ups is ineffective in reducing readmission of HP patients. Given that it involves frequent communication between a health practitioner and a HF patient/family, it would be expected that the patient’s health would improve. Where the opposite happens, it implies that communication does necessarily assess the aspects it is supposed to. As such, there is a need for further research to be done on where the problem arises. Such research will mend the gap in the multidisciplinary approach and ensure that whenever it is applied, readmission of HF patients is reduced.
Present Implications for Nursing Practice, Education, Administration, and Research
The findings challenge Nurse Practitioners to embrace standard heart failure education in primary care settings. In such education, patients need to be informed on the appropriate care practices to improve their health outcome. Their families should also be involved to assist them to adhere to the right prevention and management practices. Additionally, administrators need to consider organizing training programs, where nurses are taught on appropriate multidisciplinary education to help in lowering HF readmissions. During such programs, nurses should be informed on how they need to go about follow-up such that the health outcome of patients is improved, and readmission is prevented. For instance, they should be informed that follow-up is not just about assessing how the patient is doing but paying personal visits to physically assess their performance, medication adherence, and adherence to other care practices.
Since home-based care has been found to improve HF patient’s health outcome, administrators have a role in equipping their practitioners with necessary skills to carry out such care. As for nursing education, the results depict the need to incorporate elements of the multidisciplinary approach in the curriculum. Such elements will equip nursing practitioners with necessary skills to spearhead education for prevention of HF patients’ readmission. As for research, more attention needs to be shifted on how to make multidisciplinary education more effective in reducing readmission of CHF patients