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?

Abstract

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...