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Case management in a heterogeneous congestive heart failure population: a randomized controlled trial
Ann S Laramee1, Susan K Levinsky, Jesse Sargent
1Department of Quality and Care Management, Fletcher Allen Health Care Office of Patient Oriented Research, University of Vermont/Fletcher Allen Health Care, Burlington,VT 05401, USA.
Insights
Congestive heart failure (CHF) case management (CM) did not reduce 90-day readmissions in a diverse patient group. However, CM improved medication adherence and reduced healthcare costs for CHF patients.
Area of Science:
- Cardiology
- Health Services Research
- Clinical Trials
Background:
- Previous studies linked congestive heart failure (CHF) case management (CM) to reduced readmissions in homogeneous settings.
- The effectiveness of CHF CM in heterogeneous populations remained unclear.
Purpose of the Study:
- To evaluate the impact of CHF CM on 90-day readmission rates in a heterogeneous patient population.
- To assess the effect of CM on healthcare costs and treatment adherence.
Main Methods:
- A randomized controlled trial involving 287 patients hospitalized with CHF.
- Intervention included discharge planning, patient education, telephone follow-up, and medication optimization.
- Comparison was made against usual care.
Main Results:
- No significant difference in 90-day readmission rates between CM and usual care groups (37%).
- The CM group experienced a 14% reduction in total costs and a 26% reduction in readmission costs.
- CM patients showed better adherence to the overall treatment plan, though not specifically to medication dosages.
Conclusions:
- The generalizability of improved CHF outcomes with CM is limited in heterogeneous settings.
- Lack of coordinated care and accessibility issues in non-networked settings may hinder CM effectiveness.
- Subgroup analysis indicated potential benefit for local patients seeing a cardiologist.
Background:
Both randomized and nonrandomized controlled studies have linked congestive heart failure (CHF) case management (CM) to decreased readmissions and improved outcomes in mostly homogeneous settings. The objective of this randomized controlled trial was to test the effect of CHF CM on the 90-day readmission rate in a more heterogeneous setting.
Methods:
A total of 287 patients admitted to the hospital with the primary or secondary diagnosis of CHF, left ventricular dysfunction of less than 40%, or radiologic evidence of pulmonary edema for which they underwent diuresis were randomized. The intervention consisted of 4 major components: early discharge planning, patient and family CHF education, 12 weeks of telephone follow-up, and promotion of optimal CHF medications.
Results:
The 90-day readmission rates were equal for the CM and usual care groups (37%). Total inpatient and outpatient median costs and readmission median cost were reduced 14% and 26%, respectively, for the intervention group. Patients in the CM group were more likely to be taking CHF medication at target doses, but dosages did not increase significantly throughout 12 weeks. Although both groups took their medications as prescribed equally well, the rest of the adherence to treatment plan was significantly better in the CM group. Subgroup analysis of patients who lived locally and saw a cardiologist showed a significant decrease in CHF readmissions for the intervention group (P =.03).
Conclusions:
These results suggest several limitations to the generalizability of the CHF CM-improved outcome link in a heterogeneous setting. One explanation is that the lack of coordinated system supports and varied accessibility to care in an extended, nonnetworked physician setting limits the effectiveness of the CM.