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A systematic review of randomized trials of disease management programs in heart failure
F A McAlister1, F M Lawson, K K Teo
1Divisions of General Internal Medicine, University of Alberta Hospital, Edmonton, Canada.
Insights
Disease management programs for heart failure patients, especially those with multidisciplinary follow-up, reduce hospitalizations and are cost-saving. Mortality data remain inconclusive, requiring further research into program components.
Area of Science:
- Cardiology
- Health Services Research
- Evidence-Based Medicine
Background:
- Chronic diseases like heart failure necessitate effective management strategies.
- Disease management programs (DMPs) are frequently recommended for chronic disease care.
- The efficacy of DMPs in heart failure (HF) patient outcomes requires systematic evaluation.
Purpose of the Study:
- To systematically review randomized clinical trials (RCTs) on DMPs for heart failure patients.
- To determine if DMPs improve patient outcomes in heart failure management.
- To identify specific DMP components that influence outcomes.
Main Methods:
- Searched multiple databases (Medline, Embase, Cinahl, Sigle, Cochrane) for RCTs from 1966-1999.
- Included studies involving heart failure patients and DMPs.
- Extracted data independently and calculated summary risk ratios (RR) with 95% confidence intervals (CI) using random and fixed effects models.
Main Results:
- Eleven trials involving 2,067 patients were analyzed.
- DMPs reduced hospitalizations (RR=0.87, 95% CI: 0.79-0.96) and were cost-saving in most trials.
- Specialized multidisciplinary follow-up significantly reduced hospitalization risk (RR=0.77, 95% CI: 0.68-0.86).
Conclusions:
- DMPs involving specialized multidisciplinary follow-up are effective in reducing heart failure hospitalizations.
- These programs demonstrate cost-saving potential.
- Current data on mortality reduction are inconclusive, necessitating further investigation into specific program elements.
Purpose:
Disease management programs are often advocated for the care of patients with chronic disease. This systematic review was conducted to determine whether these programs improve outcomes for patients with heart failure.
Methods:
Randomized clinical trials of disease management programs in patients with heart failure were identified by searching Medline 1966 to 1999, Embase 1980 to 1998, Cinahl 1982 to 1999, Sigle 1980 to 1998, the Cochrane Controlled Trial Registry, the Cochrane Effective Practice and Organization of Care Study Registry, and the bibliographies of published studies. We also contacted experts in the field. Studies were selected and data extracted independently by two investigators, and summary risk ratios (RR) and 95% confidence intervals (CI) were calculated using both the random and fixed effects models.
Results:
A total of 11 trials (involving 2,067 patients with heart failure) were identified. Disease management programs were cost saving in 7 of the 8 trials that reported cost data and also appeared to have beneficial effects on prescribing practices. Hospitalizations (RR = 0.87, 95% CI: 0.79 to 0.96) but not all-cause mortality (RR = 0.94, 95% CI: 0.75 to 1.19) were reduced by the programs. However, there were considerable differences in the effects of various interventions on hospitalization rates; specialized follow-up by a multidisciplinary team led to a substantial reduction in the risk of hospitalization (RR = 0.77, 95% CI 0.68 to 0.86, n = 1366), whereas trials employing telephone contact with improved coordination of primary care services failed to find any benefit (RR = 1.15, 95% CI 0.96 to 1.37, n = 646).
Conclusion:
Disease management programs for the care of patients with heart failure that involve specialized follow-up by a multidisciplinary team reduce hospitalizations and appear to be cost saving. Data on mortality are inconclusive. Further studies are needed to establish the incremental benefits of the different elements of these programs.