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Disease management programmes in heart failure

 

Clinical bottom line

Disease management programmes for the care of patients with heart failure that involve specialised follow-up by a multidisciplinary team reduces hospital admission and is probably cost saving.


Reference

FA McAlister et al. A systematic review of randomized trials of disease management programs in heart failure. American Journal of Medicine 2001 110: 378-384.

Review

Multiple databases were searched for randomised trials of disease management programmes in heart failure. The latest searches appeared to be in 1999. For inclusion, studies had to report the effect of outpatient heart failure management programmes on mortality or hospital admission.

Results

There were eleven randomised trials included, with multiple publications for some. The control was usual care in all the trials. The follow up was from one visit, to 12 months, but mostly three or six months. Trials were not large, ranging from 98 to 1,396 patients. The mean age was 63 to 80 years.

Interventions were of two main types. Most studies (nine) assessed mutidisciplinary teams providing specialised follow up. Two investigated telephone follow up and improved communication with primary care physicians.

Multidisciplinary teams

The results for mortality were no different for mutidisciplinary teams than for usual care. Over three to 12 months 104/534 (19%) died with multidisciplinary teams compared with 121/572 (21%) with usual care.

Hospital admission was reduced by mutidisciplinary teams (Figure 1). There were 260/680 (38%) admissions with multidisciplinary teams compared with 345/686 (50%) with usual care. the relative risk was 0.77 (0.68 to 0.86), and the number needed to treat was 8.3 (5.8 to 15). This means that for every eight patients with heart failure treated by a multidisciplinary team rather than usual care, there will be one fewer hospital admission over about six months.

Figure 1: Multidisciplinary teams and hospital admissions


Telephone follow up.

Mortality was not assessed. Hospital admissions were no different between the intervention and usual care (45% and 40% respectively).

Comment

This is a fine and interesting review from some experienced folk in Canada. They comment that of the eight trials that reported the costs of the intervention, all but one reported that it was cost saving.

It is relatively rare to have randomised trials of managerial interventions, let alone a meta-analysis of randomised trials. The evidence here is good, that over six months programmes involving a multidisciplinary team providing specialised follow up will reduce hospital admissions by one for every eight patients in six months. That is roughly one admission saved for every four patients in a year.