Physician-level intervention provided them with evidence-based HF guidelines in the form of a brochure summarising the 2005 American College of Cardiology/American selleck chem Heart Association (ACC/AHA) recommendations with updates from the 2009 guidelines, which were current at the time of our study.10 11 Physicians also received summary reports of their patient’s medication use at baseline, 1 and 4 months, as obtained from medical records and patient self-reports. These reports were accompanied by standardised personal notes from our study cardiologist (JEC) outlining patient-specific recommendations,

such as possible medication changes, that could optimise adherence to evidence-based therapy as defined by class I ACC/AHA recommendations. This being a feasibility study with a short follow-up time, we addressed only evidence-based medication classes but not optimal medication dosing. No feedback to the personal notes was solicited or tracked. Patient-level intervention provided to each enrolled patient a tailored HF self-management kit.12 The kit included brochures featuring patient-friendly HF education material and a variety of self-management tools (scale, measuring bottle, educational materials and pillboxes). Patients were coached on use of the

kit during one-on-one contacts timed to occur 3 days post hospital discharge, then once weekly for 1 month and every 2 weeks thereafter for another 3 months, totalling 11 intervention contacts. The patient contacts were performed in person or via telephone at the patient’s discretion. These contacts were conducted by a trained nurse who followed a problem-solving format in which patients were encouraged to articulate barriers to their adherence and

to use a variety of self-management strategies to overcome them.13 Simple metaphors were used to educate patients about their HF. The heart was equated to a ‘workhorse’ carrying a ‘load’ (blood and water) throughout the body via the ‘road’ (arteries). ‘Water pills’ (diuretics) ‘lighten the load’ and ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) ‘widen the road’, making it easier for the workhorse to pump. The importance of adhering to prescribed medications, a low sodium diet, daily weighing, regular physical activity, smoking cessation, Carfilzomib and regular follow-up with providers was emphasised. Stress reduction strategies were also discussed. Patient comprehension of these components was assessed at each contact and their knowledge reinforced whenever gaps were identified. Outcomes, measures, and data analyses The impact of the dual-level intervention on physician adherence to evidence-based therapy focused specifically on appropriate use of an ACE-I or ARB, β-blocker and aldosterone antagonist. Data on physician adherence were gathered by chart audit at baseline and at 5 months for each patient enrolled. Only patients who remained in the study for the 5 month evaluation were included in these analyses.