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Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical
David B Bekelman1, Mary E Plomondon2, Evan P Carey2
1Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Denver-Seattle Center of Innovatio.
Insights
A patient-centered disease management intervention for heart failure (HF) did not improve overall health status. However, it did reduce mortality and improve depression symptoms in HF patients.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Heart failure (HF) significantly impacts patients' quality of life, symptom burden, and functional capacity.
- Effective disease management strategies are crucial for improving patient outcomes in HF.
Purpose of the Study:
- To evaluate the effectiveness of a collaborative, patient-centered disease management (PCDM) intervention for improving the health status of patients with HF.
- To assess the impact of PCDM on mortality, hospitalization rates, and depressive symptoms in HF patients.
Main Methods:
- A multisite randomized clinical trial involving 392 HF patients with compromised health status (Kansas City Cardiomyopathy Questionnaire [KCCQ] score < 60).
- The intervention group received collaborative care from a multidisciplinary team, home telemonitoring, self-management support, and depression screening/treatment.
- The control group received usual care. Outcomes were measured over 1 year using KCCQ scores, mortality, hospitalization data, and depressive symptom scores (Patient Health Questionnaire 9).
Main Results:
- The PCDM intervention did not lead to significant improvements in KCCQ overall summary scores compared to usual care at 1 year (mean change of 13.5 points in both groups).
- The intervention group experienced significantly fewer deaths at 1 year (4.3% vs. 9.6%, P=.04).
- Patients in the intervention group with positive depression screening showed greater improvement in depressive symptoms (P=.01), with no significant difference in hospitalization rates.
Conclusions:
- A multifaceted, collaborative patient-centered disease management intervention did not improve the overall health status of heart failure patients.
- The intervention showed a potential benefit in reducing mortality and improving depressive symptoms among specific patient subgroups.
- Further research may be needed to refine PCDM interventions for optimal impact on heart failure management.
Importance:
Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life.
Objective:
To determine the effectiveness of a collaborative care patient-centered disease management (PCDM) intervention to improve the health status of patients with HF.
Design, Setting, And Participants:
The Patient-Centered Disease Management (PCDM) trial was a multisite randomized clinical trial comparing a collaborative care PCDM intervention with usual care in patients with HF. A population-based sample of 392 patients with an HF diagnosis from 4 Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of less than 60 (heavy symptom burden and impaired functional status and quality of life) were enrolled between May 2009 and June 2011.
Interventions:
The PCDM intervention included collaborative care by a multidisciplinary care team consisting of a nurse coordinator, cardiologist, psychiatrist, and primary care physician; home telemonitoring and patient self-management support; and screening and treatment for comorbid depression.
Main Outcomes And Measures:
The primary outcome was change in the KCCQ overall summary score at 1 year (a 5-point change is clinically significant). Mortality, hospitalization, and depressive symptoms (Patient Health Questionnaire 9) were secondary outcomes.
Results:
There were no significant differences in baseline characteristics between patients randomized to the PCDM intervention (n=187) vs usual care (n=197); baseline mean KCCQ overall summary scores were 37.9 vs 36.9 (P=.48). There was significant improvement in the KCCQ overall summary scores in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (P=.97). The intervention was not associated with greater improvement in the KCCQ overall summary scores when the effect over time was estimated using 3-month, 6-month, and 12-month data (P=.74). Among secondary outcomes, there were significantly fewer deaths at 1 year in the intervention arm (8 of 187 [4.3%]) than in the usual care arm (19 of 197 [9.6%]) (P = .04). Among those who screened positive for depression, there was a greater improvement in the Patient Health Questionnaire 9 scores after 1 year in the intervention arm than in the usual care arm (2.1 points lower, P=.01). There was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs 29.9%, P=.87).
Conclusions And Relevance:
This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care.
Trial Registration:
clinicaltrials.gov Identifier: NCT00461513.
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