Randomized, controlled evaluation of short- and long-term benefits of heart failure disease management within a
Carey Kimmelstiel1, Daniel Levine, Kathleen Perry
1Division of Cardiology, Tufts-New England Medical Center, and Tufts University School of Medicine, Boston, Mass 02111, USA.
Insights
Disease management (DM) significantly reduced heart failure (HF) hospitalizations and days in hospital within 90 days. However, long-term benefits require sustained intervention, even for stable patients.
Area of Science:
- Cardiology
- Health Services Research
- Clinical Trials
Background:
- Previous heart failure (HF) disease management (DM) studies had limitations.
- These included small sample sizes, lack of concurrent randomized controls, and restricted settings.
- Low baseline use of effective medications was also a common limitation.
Purpose of the Study:
- To assess the effectiveness of a 90-day HF DM intervention.
- To evaluate DM in a diverse provider network and heterogeneous population.
- To examine outcomes in patients with high baseline use of HF pharmacotherapy.
Main Methods:
- Prospective, randomized assessment of 200 HF patients.
- Intervention group received 90-day HF DM.
- Control group received standard care; follow-up averaged 283 days.
Main Results:
- DM patients had fewer HF hospitalizations (RR 0.48, P=0.027) and HF-related hospital days (RR 0.54, P<0.001) at 90 days.
- Cardiovascular hospitalizations and days in hospital also decreased significantly.
- Long-term follow-up showed attrition of benefits, with only cardiac hospital days remaining significantly reduced.
Conclusions:
- A 90-day HF DM intervention improved short-term clinical outcomes in a diverse population with high medication use.
- Sustained benefits require ongoing, active chronic care, even for clinically stable patients.
- Uniform delivery across varied sites demonstrated feasibility.
Background:
Several trials support the usefulness of disease management (DM) for improving clinical outcomes in heart failure (HF). Most of these studies are limited by small sample size; absence of concurrent, randomized controls; limited follow-up; restriction to urban academic centers; and low baseline use of effective medications.
Methods And Results:
We performed a prospective, randomized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy. During a 90-day follow-up, patients randomized to DM experienced fewer hospitalizations for HF [primary end point, 0.55+/-0.15 per patient-year alive versus 1.14+/-0.22 per patient-year alive in control subjects; relative risk (RR), 0.48, P=0.027]. Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF (4.3+/-0.4 versus 7.8+/-0.6 days hospitalized per patient-year; RR, 0.54; P<0.001), cardiovascular hospitalizations (0.81+/-0.19 versus 1.43+/-0.24 per patient-year alive; RR, 0.57; P=0.043), and days in hospital per patient-year alive for cardiovascular cause (RR, 0.64; P<0.001). Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days. On long-term (mean, 283 days) follow-up, there was substantial attrition of the 3-month gain in outcomes, with sustained significant reduction only in days in hospital for cardiac cause.
Conclusions:
In a population with high background use of standard HF therapy, a DM intervention, uniformly delivered across varied clinical sites, produced significant short-term improvement in HF-related clinical outcomes. Longer-term benefit likely requires more active chronic intervention, even among patients who appear clinically stable.
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