Clinical service organisation for heart failure
Chronic heart failure (CHF) is a serious condition, mainly affecting elderly people. It is becoming increasingly common as the population ages, and carries high risks of emergency hospitalisation and death. It affects around three to 20 per 1,000 of the general population, with figures rising to 10% of people aged between 80 and 89. In the UK, CHF consumes almost 2% of the National Health Service’s budget, most of the cost being linked to hospital admissions. In the US, heart failure is one of three conditions specifically targeted in the “readmissions reduction” component of the Affordable Care Act
Drug therapy is the mainstay of treatment for CHF; patients are generally managed with a combination of medications and lifestyle advice. Management has evolved over the last several years from a traditional model (emphasising crisis intervention) towards more proactive and preventative disease management models. These care models, known as “clinical service interventions”, offer "aggressive care" in hospital, home or clinic, and may also differ in components, duration, intensity and number and type of healthcare professionals involved.
A team of Cochrane researchers based in the UK and Australia first attempted in 2005 to answer the question of which clinical service organisation models were most effective in reducing hospital admissions and deaths in patients at high risk of unscheduled hospital readmission for CHF. In this update of the original review, the team has examined 25 clinical trials randomising nearly 6,000 patients. The trials selected tested three different methods of organising the care of CHF patients after they leave hospital: 1) case-management interventions (where patients were intensively monitored by telephone calls and home visits); 2) clinic interventions (involving follow-up in a specialist CHF clinic); and 3) multidisciplinary interventions (in which a team of professionals bridged the gap between hospital admission and living back at home).
The authors found that patients who received case-management intervention had less ‘all cause’ mortality a year after discharge than those receiving usual care; in fact the risk of dying compared to the risk of not dying was one-third lower amongst those receiving case management compared to usual care, although there were no differences seen at six months after discharge. Follow-up in a clinic was assessed in six trials, and for these participants there was no real difference in all-cause mortality and readmission rates compared with people receiving usual care. Only two studies looked at multidisciplinary follow-up; in these there were fewer deaths from any cause than in groups of patients given usual care.
“We weren’t able to identify the optimal components of case-management interventions, but telephone follow up by a specialist nurse was a very common element,” said Cochrane Review author Stephanie Taylor. Given the number of people who have CHF, the team also point out the need for research that deliberately compares different approaches to follow-up, in particular comparing interventions that last for only a few weeks after discharge to those that span much longer periods. They also recommend that trials look carefully at costs and cost-effectiveness of each approach.