[Case management for patients with congestive heart failure under ambulatory care--a critical review]

Congestive Heart Failure (CHF) is becoming the most serious cardiac health problem after coronary heart disease (CHD). But at present, service offered to CHF patients are flawed because of the fragmentation and discontinuity of care. Case management (CM) takes responsibility for following up patients, for assessing symptoms and taking action when patients do not adhere to guideline based treatment or fail to improve. This review analyses the evidence of primary care based CM for patients with CHF.

Searches in Medline using relevant MeSH terms and hand-searching were applied to identify relevant studies. We selected RCTs and pre-post studies focussing on patient-centred CM in ambulatory settings. A five-level score (simple to complex) was generated to describe interventions and compare results.

23 of 462 identified studies (16 RCT, 7 others) that fulfilled our selection and quality criteria were included. We classified 15 studies as "complex" CM, i.e. they contained more than three elements of intervention, were strongly integrated with the process of care, involved a specialised nurse, and offered individual patient education. All studies examined the length of hospital stay: costs were investigated in 17, quality of life in 10 and mortality in 7 studies. Studies examining a "complex" CM demonstrated positive effects on mortality and quality of life in the 3-6 months of follow up. Studies with a follow up period of 12 to 18 months showed a reduction of hospital days.

Especially "complex" models of CM for patients with CHF can be effective in a primary care setting. CM can prevent the fragmentation and discontinuity of care by strengthening a close contact between patient and health care provider.