Mode of Action and Effects of Standardized Collaborative Disease Management on Mortality and Morbidity in Patients With Systolic Heart Failure

Abstract

Background— Trials investigating efficacy of disease management programs (DMP) in heart failure reported contradictory results. Features rendering specific interventions successful are often ill defined. We evaluated the mode of action and effects of a nurse-coordinated DMP (HeartNetCare-HF, HNC). Methods and Results— Patients hospitalized for systolic heart failure were randomly assigned to HNC or usual care (UC). Besides telephone-based monitoring and education, HNC addressed individual problems raised by patients, pursued networking of health care providers and provided training for caregivers. End points were time to death or rehospitalization (combined primary), heart failure symptoms, and quality of life (SF-36). Of 1007 consecutive patients, 715 were randomly assigned (HNC: n=352; UC: n=363; age, 69±12 years; 29% female; 40% New York Heart Association class III-IV). Within 180 days, 130 HNC and 137 UC patients reached the primary end point (hazard ratio, 1.02; 95% confidence interval, 0.81–1.30; P =0.89), since more HNC patients were readmitted. Overall, 32 HNC and 52 UC patients died (1 UC patient and 4 HNC patients after dropout); thus, uncensored hazard ratio was 0.62 (0.40–0.96; P =0.03). HNC patients improved more regarding New York Heart Association class ( P =0.05), physical functioning ( P =0.03), and physical health component ( P =0.03). Except for HNC, health care utilization was comparable between groups. However, HNC patients requested counseling for noncardiac problems even more frequently than for cardiovascular or heart-failure–related issues. Conclusions— The primary end point of this study was neutral. However, mortality risk and surrogates of well-being improved significantly. Quantitative assessment of patient requirements suggested that besides (tele)monitoring individualized care considering also noncardiac problems should be integrated in efforts to achieve more sustainable improvement in heart failure outcomes. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN23325295.

Intervenções não farmacológicas para melhor qualidade de vida na insuficiência cardíaca: revisão integrativa

“…Regarding year of publication, nine articles were dated 2012 (15)(16)18,(20)(21)(22)(29)(30)(31) , followed by years 2011 (n=6) (11)(12)(13)17,19,23,33) , 2010 (n=4) de la salud que tratan de personas con insuficiencia cardiaca. Futuras revisiones sistemáticas con meta-análisis son necesarias para identificar las intervenciones más eficaces para mejorar la calidad de vida de estos individuos.…”

“…Regarding year of publication, nine articles were dated 2012 (15)(16)18,(20)(21)(22)(29)(30)(31) , followed by years 2011 (n=6) (11)(12)(13)17,19,23,33) , 2010 (n=4) (24)(25)32,34) , 2013 (n=3) (14,(27)(28) and 2008 (n=1) (26) . The articles were published in General Cardiology journals (12)(13)(16)(17)(18)20,22,(24)(25)(28)(29)(30)(31)(32)34) , followed by General Clinical journals (14)(15)(26)(27)33) . Two articles were published in Nursing journals (19,23) and one was published in a Nutrition journal (21) (Chart 1).…”

“…As for languages, all articles were published in English. The selected studies were performed in the following countries: USA (n=8) (12,15,17,19,(24)(25)(32)(33) , Sweden (n=2) (18,23) , Germany (n=2) (22,34) , Brazil (n=2) (21,26) , Australia (n=2) (28)(29) , United Kingdom (n=2) (14,31) , Italy (n=2) (16,30) , Spain (n=1) (13) , Taiwan (n=1) (19) and Iran (n=1) (27) . Nurses were the professionals performing the interventions in most studies (12,(14)(15)(19)(20)32) .…”

“…Nurses were the professionals performing the interventions in most studies (12,(14)(15)(19)(20)32) . Another study was performed by nurses in partnership with physical therapists (24) or physicians (22) , followed by nurses working with physical therapists, physicians and occupational therapists (18) . Six studies did not describe which professionals performed the interventions (13,(26)(27)(28)(29)34) .…”

Heart Failure Clinics Are Still Useful (More Than Ever?)

“…Recent large-scale studies show that not all models are equally successful to improve outcomes (17,18). These results indicate that a sophisticated approach to HF management is needed and questions remain on the optimal 'dose' and format of follow-up.…”