Which patients with heart failure respond best to multidisciplinary disease management?

Riegel, Bárbara; Carlson, Beverly; Glaser, Dale; Hoagland, P.

doi:10.1054/jcaf.2000.19226

Cited by 99 publications

(72 citation statements)

References 28 publications

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“…14,15 Our results differ from those of previous trials that included nonadvanced HF and were different in design, DMP intensity and complexity, time of follow-up, and sociodemographic characteristics. 15,16 Our findings are in accordance with the first report of DMP success in high-risk HF patients for early hospitalization and with the DIAL [Randomized Trial of Telephone Intervention in Chronic Heart Failure] trial that had shorter follow-up. 5,17 Our results support the role of our DMP design of long-term follow-up with high-intensity repetitive education and monitoring for the management of nonadvanced HF outpatients who are already being treated by a cardiologist.…”

Section: Discussionsupporting

confidence: 89%

Long-Term Prospective, Randomized, Controlled Study Using Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure Outpatients

Bocchi

Cruz

Guimarães

et al. 2008

Circ: Heart Failure

112

102

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Background-The effectiveness of heart failure disease management programs in patients under cardiologists' care over long-term follow-up is not established. Methods and Results-We investigated the effects of a disease management program with repetitive education and telephone monitoring on primary (combined death or unplanned first hospitalization and quality-of-life changes) and secondary end points (hospitalization, death, and adherence Key Words: heart failure Ⅲ education Ⅲ disease program management Ⅲ case management Ⅲ controlled clinical trials Ⅲ quality of life Ⅲ patient compliance R ecent disease management program (DMP) meta-analyses have reported reductions in mortality and hospitalizations of heart failure (HF) patients. 1-4 However, important issues in DMP for HF remain to be resolved. For example, few investigations include non-high-risk HF for early hospitalization managed by cardiologists or report long-term results. [3][4][5][6] No studies have reported the long-term effects of a repetitive-cyclic reeducation program. 3,4,7,8 Most DMPs have been tested in high-risk HF patients that have been discharged from the hospital, and it has been suggested that DMPs are less effective when patients are already being treated by an HF specialist. 1,3,7,9,10 Improved survival is associated with cardiologist care and with multidisciplinary teams providing specialized follow-up. 4,8 Whether both together could benefit HF is not well defined. Clinical Perspective see p 124We tested whether a DMP consisting of a long-term repetitive multidisciplinary education program and telephone monitoring could benefit HF outpatients in usual ambulatory care already under the care of a cardiologist with experience in HF. Figure 1). The first patient was randomized on October 5, 1999, and the last on January 18, 2005, in the Heart Institute of the São Paulo University Medical School. At least an 18-month follow-up from inclusion of the last patient was planned to initiate the trial analysis. Referred patients, with no exclusion criteria, were randomized in a 2:1 ratio between the intervention and control parallel groups, respectively. A computer-generated randomization list was drawn up by the statistician. The randomization 2:1 was used based on the previously published benefit of DMP in HF. The 2:1 randomization sequence was developed in blocks of 3, including 2 interventions and 1 control. The order of interventions and control within each block was also randomly assigned. To avoid deduction of the next treatment allocation and for arrangement of education classes, researchers were blinded for block size; each randomization included a number of patients in multiples of 3, with at least 15 eligible participants, except for the last group. The order of subjects in each group was randomized using a computer program. For allocation concealment, sequential, numbered, opaque, and sealed envelopes were used. Investigators ensured that the envelopes were opened sequentially only after the participants' names were written on the app...

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Section: Discussionsupporting

confidence: 89%

Long-Term Prospective, Randomized, Controlled Study Using Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure Outpatients

Bocchi

Cruz

Guimarães

et al. 2008

Circ: Heart Failure

112

102

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“…Of note, we found that the lack of cost difference persisted even in patients with higher NYHA class, suggesting that the improved survival in sicker patients was not associated with cost savings, an observation that has been reported previously. 10,24 From a conceptual viewpoint, DM will be most useful when there is a marked disparity between the best-case management for a disease and the management that is being applied. Earlier DM trials were performed when use of guideline-based therapy was less prevalent than it is currently.…”

Section: Discussionmentioning

confidence: 99%

Long-Term Healthcare and Cost Outcomes of Disease Management in a Large, Randomized, Community-Based Population With Heart Failure

et al. 2004

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Background-Because of the prevalence and expense of congestive heart failure (CHF), significant efforts have been made to develop disease management (DM) programs that will improve clinical and financial outcomes. The effectiveness of such programs in a large, heterogeneous population of CHF patients remains unknown. Methods and Results-We randomized 1069 patients (aged 70.9Ϯ10.3 years) with systolic (ejection fraction 35Ϯ9%) or echocardiographically confirmed diastolic heart failure (HF) to assess telephonic DM over an 18-month period. Data were collected at baseline and at 6-month intervals. Survival analysis was performed by Kaplan-Meier and Cox regression methods. Healthcare utilization was defined after extensive record review, with an attempt to account for all inpatient and outpatient visits, medications, and diagnostic tests. We obtained data on 92% of the patients, from nearly 53 000 health-related encounters. Total cost per patient was defined by adding estimated costs for the observed encounters, excluding the cost of the DM. Kaplan-Meier analysis showed that DM patients had a reduced mortality rate (Pϭ0.037), with DM patients surviving an average of 76 days longer than controls. Subgroup analysis showed that DM had beneficial outcomes in patients with systolic HF (hazard ratio 0.62; Pϭ0.040), which was more pronounced in NYHA classes III and IV. Although improvements in NYHA class were more likely with DM (PϽ0.001), 6-minute walk data from 217 patients in whom data were available at each visit showed no significant benefit from DM (Pϭ0.08). Total and CHF-related healthcare utilization, including medications, office or emergency department visits, procedures, or hospitalizations, was not decreased by DM. Repeated-measures ANOVA for cost by group showed no significant differences, even in the higher NYHA class groups. Conclusions-Participation in DM resulted in a significant survival benefit, most notably in symptomatic systolic HF patients. Although DM was associated with improved NYHA class, 6-minute walk test results did not improve.

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“…Several studies showed a graduation of effectiveness related to the intensity of the intervention. 33,34 In our study to improve cost-effectiveness, the intensity was linked to the patient's clinical characteristics. Thus, the intensity of intervention increased on average by 40% for each increase in risk cluster.…”

Section: Discussionmentioning

confidence: 99%

Heart failure case disease management program: a pilot study of home telemonitoring versus usual care

Capomolla

Pinna

Rovere

et al. 2004

European Heart Journal Supplements

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Background Telemonitoring care can be integrated into health care provision as a substitute for routine clinical follow-up. A telemonitoring service (TMS) integrated into the process of chronic heart failure (CHF) care has not so far been evaluated. Objectives We describe our comprehensive home TMS and evaluate its outcomes in comparison to the usual program of care after discharge from a Heart Failure Unit (HFU). Methods 133 patients discharged from a HFU, underwent risk cluster classification for cardiac events and were prospectively randomized to usual community care (n = 66) and to a management program delivered by the TMS (n = 67). Clinical outcome including re-hospitalization, cardiac death, and emergency room access, was compared in the two groups. Results Patients were clustered as at low (n = 51), moderate (n = 43) and high (n = 39) risk. The compliance to telemonitoring was 82%. The compliance to system follow-up was (81%). The mean individual access rate to the TMS was 4.6 ± 3.3 calls. Active interventions were made following 54% of the accesses. After 10 ± 6 months, 135 events had occurred: 103 in the usual care group and 32 in telemonitoring group (P < 0.001). Re-hospitalisation was 22 (TMS) vs 77 (usual care) (P < 0.009). Cluster risk classification intercepted patients' increased health care demands (low risk: 0.34 ± 0.62; moderate risk 1 ± 1.2; high risk 1.9 ± 1.5 events). Conclusion A management program delivered by a TMS can reduce health care demands by CHF patients.

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Which patients with heart failure respond best to multidisciplinary disease management?

Cited by 99 publications

References 28 publications

Long-Term Prospective, Randomized, Controlled Study Using Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure Outpatients

Long-Term Prospective, Randomized, Controlled Study Using Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure Outpatients

Long-Term Healthcare and Cost Outcomes of Disease Management in a Large, Randomized, Community-Based Population With Heart Failure

Heart failure case disease management program: a pilot study of home telemonitoring versus usual care

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