Clinical service organisation following hospital discharge for adults with chronic heart failure

Chronic heart failure (CHF) is a serious condition, mainly affecting elderly patients. It is becoming increasingly common as the population ages, and carries high risks of emergency hospitalisation and death. This is an update of an earlier review, including clinical trials published since the previous version.

We examined 25 clinical trials with nearly 6000 patients that tested different methods of organising the care of CHF patients after leaving hospital. Although the quality of reporting was unclear in about a third of the trials, most appeared to be of high quality so confidence can be placed in their results.  We classified these into three models: 1) case-management interventions, where patients were intensively monitored by telephone calls and home visits, usually by a specialist nurse; 2) clinic interventions involving follow up in a specialist CHF clinic; 3) multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team). Where possible, we combined studies to find the overall effect on a larger group of patients.

Seventeen studies reported a case-management intervention. Patients who received this had less all cause mortality a year after discharge than patients who received usual care. There was no real difference between groups in deaths related to heart failure (HF), although few studies reported this.  Case management patients were less likely to be readmitted to hospital for HF six months after discharge. They were also less likely to be readmitted for HF a year after discharge, although the studies reporting this were not similar enough to draw strong conclusions from the combined data. A year after discharge, case management patients were less likely to be readmitted to hospital for any reason than people who received usual care. Telephone follow-up by a specialist nurse was a common feature of more successful programs.

Six studies looked at heart failure clinics, and there was no real difference in all cause mortality, readmissions for HF or between patients who attended a clinic and those who received usual care. Only two studies looked at multidisciplinary interventions. There were slightly fewer deaths from any cause in the treatment group than in the usual care group, and both all cause and heart failure related readmissions were substantially lower for patients receiving multidisciplinary care.

No studies reported any adverse events associated with the interventions.

 

Authors' conclusions: 

Amongst CHF patients who have previously been admitted to hospital for this condition there is now good evidence that case management type interventions led by a heart failure specialist nurse reduces CHF related readmissions after 12 months follow up, all cause readmissions and all cause mortality.  It is not possible to say what the optimal components of these case management type interventions are, however telephone follow up by the nurse specialist was a common component.

Multidisciplinary interventions may be effective in reducing both CHF and all cause readmissions. There is currently limited evidence to support interventions whose major component is follow up in a CHF clinic.

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Background: 

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

Objectives: 

To update the previously published review which assessed the effectiveness of disease management interventions for patients with CHF.

Search strategy: 

A number of databases were searched for the updated review: CENTRAL, (the Cochrane Central Register of Controlled Trials) and DARE, on The Cochrane Library, ( Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-January 2009); AMED (1985-January 2009). For the original review (but not the update) we had also searched: Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research Register (2003) and NHS Economic Evaluations Database (2001). We also searched reference lists of included studies for both the original and updated reviews.

Selection criteria: 

Randomised controlled trials (RCTs) with at least six months follow up, comparing disease management interventions specifically directed at patients with CHF to usual care.

Data collection and analysis: 

At least two reviewers independently extracted data and assessed study quality. Study authors were contacted for further information where necessary. Data were analysed and presented as odds ratios (OR) with 95% confidence intervals (CI).

Main results: 

Twenty five trials (5,942 people) were included. Interventions were classified by: (1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the ‘usual care’ comparator provided in different trials.

Case management interventions were associated with reduction in all cause mortality at 12 months follow up, OR 0.66 (95% CI 0.47 to 0.91, but not at six months. No reductions were seen for deaths from CHF or cardiovascular causes. However, case management type interventions reduced CHF related readmissions at six month (OR 0.64, 95% CI 0.46 to 0.88, P = 0.007) and 12 month follow up (OR 0.47, 95% CI 0.30 to 0.76). Impact of these interventions on all cause hospital admissions was not apparent at six months but was at 12 months (OR 0.75, 95% CI 0.57 to 0.99, I2 = 58%).   

CHF clinic interventions (for six and 12 month follow up) revealed non-significant reductions in all cause mortality, CHF related admissions and all cause readmissions. 

Mortality was not reduced in the two studies that looked at multidisciplinary interventions. However, both all cause and CHF related readmissions were reduced (OR 0.46, 95% CI 0.46-0.69, and 0.45, 95% CI 0.28-0.72, respectively). 

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