Cost-effectiveness of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort — The WHICH? study (Which Heart Failure Intervention Is Most Cost-Effective &amp; Consumer Friendly in Reducing Hospital Care)

Self Cite

This article refers to 'Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis' by H.G.C. Van Spall et al., published in this issue on pages 1427-1443.Along with an evolving armoury of pharmacological agents and devices, predominantly nurse-led heart failure (HF) management programmes represent important cogs in the wheel of effective management of patients hospitalized with the syndrome. 1 Indeed, if we were to take the analogy further, we could argue that these programmes represent the 'lubricant' that ensures that each cog of effective HF management (including the health professionals who deliver care) work smoothly together and for the best interests of the patient. It's now been 20 years since the formative randomized trials of HF management (of varying types) were conducted and more than a decade since a definitive systematic review and meta-analysis of the available evidence confirmed that the application of multidisciplinary programmes was associated with both reduced risk for rehospitalization and prolonged survival in hospitalized individuals. 2 Remarkably, however, the application of post-discharge HF management programmes remains inconsistent and their inherent value has been questioned. This scenario defies expert recommendations for their routine application and a plethora of systematic reviews and meta-analyses that are consistently positive overall, 3 whilst noting the consistent inconsistency of evidence to support the application of remote management techniques. 3,4 In reality, the translation of evidence in favour of HF management programmes has been complicated by a number of persistent issues that have both shaped and impeded their application.Firstly, the nomenclature used to describe the overall nature and components of HF management programmes is both broad and inconsistent.The opinions expressed in this article are not necessarily those of the of the wide range of options for application of the same framework of integrated care, the interventions used to build the case for HF management programmes are inherently heterogeneous, including in their modes of delivery (e.g. remote vs. face-to-face care), personnel (single-person vs. multidisciplinary team) and the intensity and frequency of programme-to-patient contact over the short to longer term. Thirdly, the individual components of non-pharmacological management (from exercise to self-care strategies) are often open to interpretation and it is difficult to determine which combination works best in individual cases.Fourthly, there is a continued push to simplify an inherently complex intervention into a formula or strategy that is easier to understand and apply, which explains the continued focus on the development of remote management techniques and monitoring devices.Finally, the HF patient population is inherently diverse and its needs, according to each patient's age and socioeconomic profile, clinical complexity and the health c...

supporting

confidence: 90%

mentioning

confidence: 99%

Home is where the heart is when it comes to transitional care in heart failure, but is it the only way to improve health outcomes?

Stewart¹

2017

Self Cite

“…While there are often financial arguments against the implementation of healthcare services that entail upfront costs, the present study demonstrates that there are transitional care services that can improve both clinical and cost outcomes, at least within the context of RCTs. Our results are consistent with a systematic review of HF management programmes, in which interventions that reduced hospital admissions appeared to result in favourable cost outcomes …”

Section: Discussionmentioning

confidence: 99%

Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta‐analysis

Spall

Rahman

Mytton

et al. 2017

292

256

“…Patients with worsening heart failure are increasingly being managed in non‐hospitalized settings (e.g. emergency departments, specialized clinics, observation units, hospital‐at‐home services), which is among other reasons, motivated by an effort to contain healthcare costs . The draft EMA Guideline addressed this trend by proposing that events of worsening of heart failure without hospitalization may be used as an additional endpoint.…”

Section: Assessment Of Efficacymentioning

confidence: 99%

New medicinal products for chronic heart failure: advances in clinical trial design and efficacy assessment

Cowie

Filippatos

Garcia

et al. 2017

Despite the availability of a number of different classes of therapeutic agents with proven efficacy in heart failure, the clinical course of heart failure patients is characterized by a reduction in life expectancy, a progressive decline in health-related quality of life and functional status, as well as a high risk of hospitalization. New approaches are needed to address the unmet medical needs of this patient population. The European Medicines Agency (EMA) is undertaking a revision of its Guideline on Clinical Investigation of Medicinal Products for the Treatment of Chronic Heart Failure. The draft version of the Guideline was released for public consultation in January 2016. The Cardiovascular Round Table of the European Society of Cardiology (ESC), in partnership with the Heart Failure Association of the ESC, convened a dedicated two-day workshop to discuss three main topic areas of major interest in the field and addressed in this draft EMA guideline: (i) assessment of efficacy (i.e. endpoint selection and statistical analysis); (ii) clinical trial design (i.e. issues pertaining to patient population, optimal medical therapy, run-in period); and (iii) research approaches for testing novel therapeutic principles (i.e. cell therapy). This paper summarizes the key outputs from the workshop, reviews areas of expert consensus, and identifies gaps that require further research or discussion. Collaboration between regulators, industry, clinical trialists, cardiologists, health technology assessment bodies, payers, and patient organizations is critical to address the ongoing challenge of heart failure and to ensure the development and market access of new therapeutics in a scientifically robust, practical and safe way.