A multicenter disease management program for hospitalized patients with heart failure

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Effective technologies for noninvasive remote monitoring in heart failure

BACKGROUND

Trials of new technologies to remotely monitor for signs and symptoms of worsening heart failure are continually emerging. The extent to which technological differences impact the effectiveness of noninvasive remote monitoring for heart failure management is unknown. This study examined the effect of specific technology used for noninvasive remote monitoring of people with heart failure on all-cause mortality and heart failure-related hospitalizations.

MATERIALS AND METHODS

A subanalysis of a large systematic review and meta-analysis was conducted. Studies were stratified according to the specific type of technology used, and separate meta-analyses were performed. Four different types of noninvasive remote monitoring technologies were identified, including structured telephone calls, videophone, interactive voice response devices, and telemonitoring.

RESULTS

Only structured telephone calls and telemonitoring were effective in reducing the risk of all-cause mortality (relative risk [RR]=0.87; 95% confidence interval [CI], 0.75-1.01; p=0.06; and RR=0.62; 95% CI, 0.50-0.77; p<0.0001, respectively) and heart failure-related hospitalizations (RR=0.77; 95% CI, 0.68-0.87; p<0.001; and RR=0.75; 95% CI, 0.63-0.91; p=0.003, respectively). More research data are required for videophone and interactive voice response technologies.

CONCLUSIONS

This subanalysis identified that only two of the four specific technologies used for noninvasive remote monitoring in heart failure improved outcomes. When results of studies that involved these disparate technologies were combined in previous meta-analyses, significant improvements in outcomes were identified. As such, this study has highlighted implications for future meta-analyses of randomized controlled trials focused on evaluating the effectiveness of remote monitoring in heart failure.

Is age a factor in the success or failure of remote monitoring in heart failure? Telemonitoring and structured telephone support in elderly heart failure patients

BACKGROUND

There are few data regarding the effectiveness of remote monitoring for older people with heart failure. We conducted a post-hoc sub-analysis of a previously published large Cochrane systematic review and meta-analysis of relevant randomized controlled trials to determine whether structured telephone support and telemonitoring were effective in this population.

METHODS

A post hoc sub-analysis of a systematic review and meta-analysis that applied the Cochrane methodology was conducted. Meta-analyses of all-cause mortality, all-cause hospitalizations and heart failure-related hospitalizations were performed for studies where the mean or median age of participants was 70 or more years.

RESULTS

The mean or median age of participants was 70 or more years in eight of the 16 (n=2659/5613; 47%) structured telephone support studies and four of the 11 (n=894/2710; 33%) telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63-1.00) and telemonitoring (RR 0.56; 95% CI=0.41-0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67-0.99).

CONCLUSION

Despite a systematic bias towards recruitment of individuals younger than the epidemiological average into the randomized controlled trials, older people with heart failure did benefit from structured telephone support and telemonitoring. These post-hoc sub-analysis results were similar to overall effects observed in the main meta-analysis. While further research is required to confirm these observational findings, the evidence at hand indicates that discrimination by age alone may be not be appropriate when inviting participation in a remote monitoring service for heart failure.

Remote care costs for congestive heart failure: a systematic review and meta-analysis of randomized controlled trials in the United States comparing remote versus more intensive care settings

It has been assumed that less intense levels of care for managing heart failure result in a lowering of the overall costs for this care in the United States. The objective of this review was to determine whether this assumption is correct. A systematic review was performed using Medline, technology assessment Web sites, and relevant cardiovascular and heart failure journals from the year 2000 to the present. US randomized controlled trials where costs were evaluated as one of the endpoints were included. Data were collected using Cochrane Review characteristics of included studies and risk of bias assessment forms. Cost data from each trial were converted to a uniform cost definition and year. Meta-analysis was performed where appropriate. Ten trials were identified evaluating costs at various time points (3, 6, and 12 months). Meta-analysis of trials demonstrated no difference in costs for care, no matter the patient condition or settings. In high-quality trials examining costs, there may be a shifting in costs from more expensive care settings to less expensive care settings without savings to the healthcare system. Larger and longer-term trials should be undertaken to understand this issue.

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

OBJECTIVE

To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.

DATA SOURCES

Reviews and primary studies that evaluated chronic care management interventions.

STUDY DESIGN

A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.

PRINCIPAL FINDINGS

Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72-0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76-0.93) and improves quality of life by 7.14 points (95 percent CI: -9.55 to -4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.

CONCLUSION

Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.

Targeting cardiovascular medication adherence interventions

OBJECTIVES

To determine whether adherence interventions should be administered to all medication takers or targeted to nonadherers.

DATA SOURCES AND STUDY SELECTION

Systematic search (Medline and Embase, 1966-2009) of randomized controlled trials of interventions to improve adherence to medications for preventing or treating cardiovascular disease or diabetes.

DATA EXTRACTION

Articles were classified as (1) broad interventions (targeted all medication takers), (2) focused interventions (targeted nonadherers), or (3) dynamic interventions (administered to all medication takers; real-time adherence information targets nonadherers as intervention proceeds). Cohen's d effect sizes were calculated.

DATA SYNTHESIS

We identified 7,190 articles; 59 met inclusion criteria. Broad interventions were less likely (18%) to show medium or large effects compared with focused (25%) or dynamic (32%) interventions. Of the 33 dynamic interventions, 6 used externally generated adherence data to target nonadherers. Those with externally generated data were less likely to have a medium or large effect (20% vs. 34.8% self-generated data).

CONCLUSION

Adherence interventions targeting nonadherers are heterogeneous but may have advantages over broad interventions. Dynamic interventions show promise and require further study.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To update the previously published review which assessed the effectiveness of disease management interventions for patients with CHF.

SEARCH METHODS

A number of databases were searched for the updated review: CENTRAL, (the Cochrane Central Register of Controlled Trials) and DARE, on The Cochrane Library, ( Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-January 2009); AMED (1985-January 2009). For the original review (but not the update) we had also searched: Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research Register (2003) and NHS Economic Evaluations Database (2001). We also searched reference lists of included studies for both the original and updated reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least six months follow up, comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data and assessed study quality. Study authors were contacted for further information where necessary. Data were analysed and presented as odds ratios (OR) with 95% confidence intervals (CI).

MAIN RESULTS

Twenty five trials (5,942 people) were included. Interventions were classified by: (1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the 'usual care' comparator provided in different trials.Case management interventions were associated with reduction in all cause mortality at 12 months follow up, OR 0.66 (95% CI 0.47 to 0.91, but not at six months. No reductions were seen for deaths from CHF or cardiovascular causes. However, case management type interventions reduced CHF related readmissions at six month (OR 0.64, 95% CI 0.46 to 0.88, P = 0.007) and 12 month follow up (OR 0.47, 95% CI 0.30 to 0.76). Impact of these interventions on all cause hospital admissions was not apparent at six months but was at 12 months (OR 0.75, 95% CI 0.57 to 0.99, I(2) = 58%).   CHF clinic interventions (for six and 12 month follow up) revealed non-significant reductions in all cause mortality, CHF related admissions and all cause readmissions. Mortality was not reduced in the two studies that looked at multidisciplinary interventions. However, both all cause and CHF related readmissions were reduced (OR 0.46, 95% CI 0.46-0.69, and 0.45, 95% CI 0.28-0.72, respectively). 

AUTHORS' CONCLUSIONS

Amongst CHF patients who have previously been admitted to hospital for this condition there is now good evidence that case management type interventions led by a heart failure specialist nurse reduces CHF related readmissions after 12 months follow up, all cause readmissions and all cause mortality.  It is not possible to say what the optimal components of these case management type interventions are, however telephone follow up by the nurse specialist was a common component.Multidisciplinary interventions may be effective in reducing both CHF and all cause readmissions. There is currently limited evidence to support interventions whose major component is follow up in a CHF clinic.

Transitional care programs: who is left behind? A systematic review

OBJECTIVE

Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support.

DESIGN

Systematic review.

SETTING

Hospital to home.

PARTICIPANTS

Older hospitalized adults.

MEASUREMENTS

For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based.

RESULTS

Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization.

CONCLUSIONS

These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.

Costs and benefits of personalized healthcare for patients with chronic heart failure in the care and education program "Telemedicine for the Heart"

OBJECTIVE

A health economic analysis was conducted to evaluate the program "Telemedicine for the Heart," which the German Foundation for the Chronically Ill organizes for the Techniker Krankenkasse, one of the biggest German statutory health insurance funds. The program consists of nurse-calls to motivate patients to perform regular self-measurements (blood pressure, pulse, weight) with either their own or telemedical measuring devices provided by the program. In the case of measured values outside of set limits, calls to treating physicians were placed to allow for the initiation of therapy adjustments where applicable.

MATERIALS AND METHODS

To evaluate the program, a retrospective matched-pairs analysis was performed. Program participants (n=281) and regularly insured patients (n=843) were matched for demographics and morbidity status and compared according to their use of resources.

RESULTS

Significant cost differences in favor of the study group of up to 25% in relation to total costs could be detected, particularly in the group of New York Heart Association (NYHA) classification II patients (persons with mild symptoms and slight limitation according to the NYHA classification for the extent of heart failure). In the more severe NYHA stages III and IV the cost relation differed and showed a slight cost disadvantage for the program group. Mortality was 35.1% lower in the program group than in the control group. Quality of life measures were almost constant over the observation time, compatible with a positive impact of the program on the highly impaired patient group.

CONCLUSIONS

The findings suggest that, besides a reduction of costs, by participating in "Telemedicine for the Heart" patients with chronic heart failure experienced a reduced number of hospital stays, optimized medical therapy, better quality of life, and reduced mortality.

Concordance between observer reports and patient survey reports of pharmacists' communication behaviors

BACKGROUND

Assessing the quantity and quality of pharmacist-patient communication is important to create strategies for improving communication. Findings from studies on pharmacist-patient communication differ on the extent of communication by pharmacists. This disagreement could be because of different methods of data collection, samples, and concepts used to measure communication.

OBJECTIVES

This research compared findings from 2 widely used methods of data collection (survey and observation) to identify: (1) the extent to which pharmacists ask questions to patients and provide information on directions, side effects, and adverse effect, (2) agreement between observation and patient report data on pharmacist information giving and question asking, and (3) how patient perceptions of question asking vary according to the structure of the question asked.

METHODS

A cross-sectional fieldwork design was used to collect data from a stratified random sample of 30 community pharmacies in Southeast and South-central Wisconsin. At each pharmacy, the dispensing pharmacist and 12 patients filling prescriptions were recruited. Each patient was observed for their interaction with the pharmacist and completed a survey while exiting the pharmacy. Both the survey and the observation tool consisted of items pertaining to recording of pharmacist information provision related to direction, side effects, and interactions, and pharmacist's question-asking behaviors. Descriptive analyses and correlations are reported.

RESULTS

There was good agreement between the 2 methods regarding pharmacist information provision behaviors (r=0.091, P<.001), this was less true of question asking (r=0.28, P=.034). Certain types of questions showed greater concordance with the observed pharmacist questions. Patients were less likely to report having been asked a question when it took the form of a nonspecific closed-ended questions, that is, "Do you have any questions?"

CONCLUSIONS

One of the most frequent questions pharmacists ask patients may not be either remembered or perceived by patients as a serious question, let alone an invitation to raise a concern. Secondly, during the selection of a specific method of data collection, researchers need to weigh strengths and weaknesses of various methods. Multimethod studies are encouraged.

Newsletters and adherence to a weekly home spirometry program after lung transplant

CONTEXT

Newsletters are a common intervention for patients in clinical trials. However, it is not clear whether newsletters are associated with increased adherence to the health regimen, and if so, which aspects of the newsletter are reported as most helpful to patients.

OBJECTIVE

To examine the association between patients' ratings of worthwhileness of a quarterly newsletter and adherence with a home spirometry regimen.

DESIGN

Patients (n=48) were in a research-based spirometry program after lung transplant and had received at least 1 newsletter; 24 (50%) returned completed surveys via postal mail.

MAIN OUTCOME MEASURES

Adherence for forced vital pulmonary function tests for respondents versus nonrespondents, number of weeks they were adherent, ratings they gave the newsletter, and which components of the newsletters were helpful to the respondents.

RESULTS

Respondents had more forced vital capacity pulmonary function tests ("blows") overall, blew more times weekly, and blew more consistently from week to week than did nonrespondents. Although it was not statistically significant, a mild correlation was found between the number of weeks that the respondents were adherent and their ratings of the newsletter (r = 0.36, P = .08). Most respondents reported that newsletter length was "about right", and 86% reported that newsletters helped encourage regular spirometer use, maintain interest in the study, educate about general health, and alert readers to seasonal health risks.

IMPLICATIONS FOR PRACTICE

High ratings for newsletters used to encourage participation among adults in our home spirometry study were associated with higher adherence.

Newsletters and adherence to a weekly home spirometry program after lung transplant

CONTEXT

Newsletters are a common intervention for patients in clinical trials. However, it is not clear whether newsletters are associated with increased adherence to the health regimen, and if so, which aspects of the newsletter are reported as most helpful to patients.

OBJECTIVE

To examine the association between patients' ratings of worthwhileness of a quarterly newsletter and adherence with a home spirometry regimen.

DESIGN

Patients (n=48) were in a research-based spirometry program after lung transplant and had received at least 1 newsletter; 24 (50%) returned completed surveys via postal mail.

MAIN OUTCOME MEASURES

Adherence for forced vital pulmonary function tests for respondents versus nonrespondents, number of weeks they were adherent, ratings they gave the newsletter, and which components of the newsletters were helpful to the respondents.

RESULTS

Respondents had more forced vital capacity pulmonary function tests ("blows") overall, blew more times weekly, and blew more consistently from week to week than did nonrespondents. Although it was not statistically significant, a mild correlation was found between the number of weeks that the respondents were adherent and their ratings of the newsletter (r = 0.36, P = .08). Most respondents reported that newsletter length was "about right", and 86% reported that newsletters helped encourage regular spirometer use, maintain interest in the study, educate about general health, and alert readers to seasonal health risks.

IMPLICATIONS FOR PRACTICE

High ratings for newsletters used to encourage participation among adults in our home spirometry study were associated with higher adherence.

What are the basic self-monitoring components for cardiovascular risk management?

BACKGROUND

Self-monitoring is increasingly recommended as a method of managing cardiovascular disease. However, the design, implementation and reproducibility of the self-monitoring interventions appear to vary considerably. We examined the interventions included in systematic reviews of self-monitoring for four clinical problems that increase cardiovascular disease risk.

METHODS

We searched Medline and Cochrane databases for systematic reviews of self-monitoring for: heart failure, oral anticoagulation therapy, hypertension and type 2 diabetes. We extracted data using a pre-specified template for the identifiable components of the interventions for each disease. Data was also extracted on the theoretical basis of the education provided, the rationale given for the self-monitoring regime adopted and the compliance with the self-monitoring regime by the patients.

RESULTS

From 52 randomized controlled trials (10,388 patients) we identified four main components in self-monitoring interventions: education, self-measurement, adjustment/adherence and contact with health professionals. Considerable variation in these components occurred across trials and conditions, and often components were poorly described. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted.

CONCLUSIONS

The components of self-monitoring interventions are not well defined despite current guidelines for self-monitoring in cardiovascular disease management. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted. We propose a checklist of factors to be considered in the design of self-monitoring interventions which may aid in the provision of an evidence-based rationale for each component as well as increase the reproducibility of effective interventions for clinicians and researchers.

Physician effectiveness in interventions to improve cardiovascular medication adherence: a systematic review

BACKGROUND

Medications for the prevention and treatment of cardiovascular disease save lives but adherence is often inadequate. The optimal role for physicians in improving adherence remains unclear.

OBJECTIVE

Using existing evidence, we set the goal of evaluating the physician's role in improving medication adherence.

DESIGN

We conducted systematic searches of English-language peer-reviewed publications in MEDLINE and EMBASE from 1966 through 12/31/2008.

SUBJECTS AND INTERVENTIONS

We selected randomized controlled trials of interventions to improve adherence to medications used for preventing or treating cardiovascular disease or diabetes.

MAIN MEASURES

Articles were classified as either (1) physician "active"-a physician participated in designing or implementing the intervention; (2) physician "passive"-physicians treating intervention group patients received patient adherence information while physicians treating controls did not; or (3) physicians noninvolved. We also identified studies in which healthcare professionals helped deliver the intervention. We did a meta-analysis of the studies involving healthcare professionals to determine aggregate Cohen's D effect sizes (ES).

KEY RESULTS

We identified 6,550 articles; 168 were reviewed in full, 82 met inclusion criteria. The majority of all studies (88.9%) showed improved adherence. Physician noninvolved studies were more likely (35.0% of studies) to show a medium or large effect on adherence compared to physician-involved studies (31.3%). Among interventions requiring a healthcare professional, physician-noninvolved interventions were more effective (ES 0.47; 95% CI 0.38-0.56) than physician-involved interventions (ES 0.25; 95% CI 0.21-0.29; p < 0.001). Among physician-involved interventions, physician-passive interventions were marginally more effective (ES 0.29; 95% CI 0.22-0.36) than physician-active interventions (ES 0.23; 95% CI 0.17-0.28; p = 0.2).

CONCLUSIONS

Adherence interventions utilizing non-physician healthcare professionals are effective in improving cardiovascular medication adherence, but further study is needed to identify the optimal role for physicians.

The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure

Background

Despite applications of models of care and organizational or system-level interventions to improve patient outcomes for chronic disease, consistent improvements have not been achieved. This may reflect a mismatch between the interventions and the nature of the settings in which they are attempted. The application of complex adaptive systems (CAS) framework to understand clinical systems and inform efforts to improve them may lead to more successful interventions. We performed a systematic review of interventions to improve outcomes of patients with congestive heart failure (CHF) to examine whether interventions consistent with CAS are more likely to be effective. We then examine differences between interventions that are most effective for improving outcomes for patients with CHF versus previously published data for type 2 diabetes to explore the potential impact of the nature of the disease on the types of interventions that are more likely to be effective.

Methods

We conducted a systematic review of the literature between 1998 and 2008 of organizational interventions to improve care of patients with CHF. Two independent reviewers independently assessed studies that met inclusion criteria to determine whether each reported intervention reflected one or more CAS characteristics. The effectiveness of interventions was rated as either 0 (no effect), 0.5 (mixed effect), or 1.0 (effective) based on the type, number, and significance of reported outcomes. Fisher's exact test was used to examine the association between CAS characteristics and intervention effectiveness. Specific CAS characteristics associated with intervention effectiveness for CHF were contrasted with previously published data for type 2 diabetes.

Results and discussion

Forty-four studies describing 46 interventions met eligibility criteria. All interventions utilized at least one CAS characteristic, and 85% were either 'mixed effect' or 'effective' in terms of outcomes. The number of CAS characteristics present in each intervention was associated with effectiveness (p < 0.001), supporting the idea that interventions consistent with CAS are more likely to be effective. The individual CAS characteristics associated with CHF intervention effectiveness were learning, self-organization, and co-evolution, a finding different from our previously published analysis of interventions for diabetes. We suggest this difference may be related to the degree of uncertainty involved in caring for patients with diabetes versus CHF.

Conclusion

These results suggest that for interventions to be effective, they must be consistent with the CAS nature of clinical systems. The difference in specific CAS characteristics associated with intervention effectiveness for CHF and diabetes suggests that interventions must also take into account attributes of the disease.

Structured telephone support or telemonitoring programmes for patients with chronic heart failure

BACKGROUND

Specialised disease management programmes for chronic heart failure (CHF) improve survival, quality of life and reduce healthcare utilisation. The overall efficacy of structured telephone support or telemonitoring as an individual component of a CHF disease management strategy remains inconclusive.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or telemonitoring compared to standard practice for patients with CHF in order to quantify the effects of these interventions over and above usual care for these patients.

SEARCH STRATEGY

Databases (the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database (HTA) on The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED and Science Citation Index Expanded and Conference Citation Index on ISI Web of Knowledge) and various search engines were searched from 2006 to November 2008 to update a previously published non-Cochrane review. Bibliographies of relevant studies and systematic reviews and abstract conference proceedings were handsearched. No language limits were applied.

SELECTION CRITERIA

Only peer reviewed, published RCTs comparing structured telephone support or telemonitoring to usual care of CHF patients were included. Unpublished abstract data was included in sensitivity analyses. The intervention or usual care could not include a home visit or more than the usual (four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

Data were presented as risk ratio (RR) with 95% confidence intervals (CI). Primary outcomes included all-cause mortality, all-cause and CHF-related hospitalisations which were meta-analysed using fixed effects models. Other outcomes included length of stay, quality of life, acceptability and cost and these were described and tabulated.

MAIN RESULTS

Twenty-five studies and five published abstracts were included. Of the 25 full peer-reviewed studies meta-analysed, 16 evaluated structured telephone support (5613 participants), 11 evaluated telemonitoring (2710 participants), and two tested both interventions (included in counts). Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI 0.54 to 0.81, P < 0.0001) with structured telephone support demonstrating a non-significant positive effect (RR 0.88, 95% CI 0.76 to 1.01, P = 0.08). Both structured telephone support (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) and telemonitoring (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008) reduced CHF-related hospitalisations. For both interventions, several studies improved quality of life, reduced healthcare costs and were acceptable to patients. Improvements in prescribing, patient knowledge and self-care, and New York Heart Association (NYHA) functional class were observed.

AUTHORS' CONCLUSIONS

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

Assessment of the clinical outcomes and cost-effectiveness of the management of systolic heart failure in Chinese patients using a home-based intervention

This study was designed to assess the clinical effect of a home-based telephone intervention in Chinese heart failure patients. A total of 550 Chinese heart failure patients were enrolled into either (i) a group that received the usual standard of care (UC group); or (ii) a group that received a home-based heart failure centre management programme using nursing specialist-led telephone consultations (HFC group). The impact of the home-based intervention on admission rate, admission length and medical costs over 6 months was measured. Although the mean left ventricular ejection fraction in HFC patients was 29.3% compared with 34.8% in UC patients, the home-based intervention resulted in a significantly lower all-cause admission rate per person (HFC 0.60 +/- 0.77 times/person; UC 0.96 +/- 0.85 times/person), a shorter all-cause hospital stay (reduced by 8 days per person) and lower total 6-month medical costs (reduced by US$2682 per patient). These results suggest that the home-based intervention with nursing specialist-led telephone consultations may improve the clinical outcome and provide cost-savings for Chinese patients with heart failure.

Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review

OBJECTIVE

This review examined the effectiveness of self-management interventions compared to usual care on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

METHODS

A systematic review was performed. MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched between 1996 and 2009. Randomized controlled trials were selected evaluating self-management interventions designed for patients with chronic heart failure. Outcomes of interest are mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life.

RESULTS

Nineteen randomized controlled trials were identified. The effectiveness of heart failure management programs initiating self-management interventions in patients with chronic heart failure indicate a positive effect, although not always significant, on reduction of numbers of all-cause hospital readmitted patients and due to chronic heart failure, decrease in mortality and increasing quality of life.

CONCLUSION

This systematic review found that current available published studies show methodological shortcomings impairing validation of the effectiveness of self-management interventions on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

PRACTICE IMPLICATIONS

Further research should determine independent effects of self-management interventions and different combinations of interventions on clinical and patient reported outcomes.

Home telemonitoring in patients with chronic heart failure: a chance to improve patient care?

BACKGROUND

Telemonitoring can improve the medical care, quality of life, and prognosis of chronically ill patients. This review article summarizes the current status of health services research on telemonitoring, focusing on patients with chronic congestive heart failure.

METHOD

The Medline database was selectively searched for articles appearing from June 2001 to May 2008, with an emphasis on randomized, controlled trials.

RESULTS

The available scientific data on vital signs monitoring are limited, yet there is evidence for a positive effect on some clinical endpoints, particularly mortality. Nonetheless, any possible improvement of patient-reported outcomes, such as the quality of life, still remains to be demonstrated.

CONCLUSIONS

The data suggest that telemonitoring is effective, yet there is no evidence for superior outcomes with any particular model of care incorporating telemonitoring (i.e., monitoring of vital signs versus structured telephone monitoring). A valid criticism is that the individual components of home telemonitoring have not yet been separately tested in order to compare their individual effects.

Chronic Heart Failure: Developments and Perspectives

OBJECTIVE

To describe the clinical presentation, diagnosis, and contemporary treatment of chronic heart failure (CHF) while emphasizing the important role of the pharmacist.

DATA SOURCES

English-language articles from MEDLINE pertinent to CHF.

STUDY SELECTION AND DATA EXTRACTION

All relevant publications addressing CHF management were considered, including prospective comparative trials, epidemiological studies, guideline statements, review articles, and editorials. Particular focus occurred on the primary literature published after the release of noted guidelines. The Heart Failure Society of America (HFSA), and the European Society of Cardiology (ESC).

DATA SYNTHESIS

Heart failure is a common disorder, especially in the elderly. To determine appropriate pharmacotherapy, one must establish the type of dysfunction (systolic versus diastolic) as well as characterize the patient's disease state according to the New York Heart Association (NYHA) functional classification system and from the American College of Cardiology (ACC)/American Heart Association (AHA), stage of diseases. Although most patients have systolic dysfunction ([ejection fraction] less than 40%), the prevalence of diastolic dysfunction (a normal to elevated ejection fraction) is rising and it accounts for at least one-third of all cases. Six drugs/drug classes are contemporary treatments in systolic heart failure, depending on NYHA functional class: angiotensin-converting-enzyme inhibitors, diuretics, beta-blockers, aldosterone antagonists, angiotensin II receptor-blockers, and digoxin. Clinicians should be aware that studies demonstrate all these drugs/drug classes prolong survival in systolic heart failure, except diuretics and digoxin. Some patients with systolic dysfunction also may be candidates for the combination of hydralazine/isosorbide dinitrate as well as nonpharmacological approaches with biventricular pacemakers and/or implantable cardioverter defibrillators. Treatment of diastolic heart failure is less evidence-based, and speculative treatments focus on control of blood pressure, tachycardia, volume overload, and myocardial ischemia.

CONCLUSIONS

CHF treatment remains a therapeutic challenge. Pharmacists have an essential role in the care of these patients by avoiding drugs known to exacerbate the disease, promoting optimal pharmacotherapy, and ensuring compliance with prescribed drugs and dietary modifications.

A cost-effectiveness model comparing endovascular repair to open surgical repair of abdominal aortic aneurysms in Canada

OBJECTIVES

The primary risk of abdominal aortic aneurysms (AAAs) is rupture, which is associated with a high mortality rate. Elective surgical options for AAA include open repair (OR) and endovascular aneurysm repair (EVAR). EVAR is less invasive than OR, and therefore may have less surgical risk than OR. However, the graft used for EVAR is much more expensive then the graft used for OR.

METHODS

A decision model with a 10-year time horizon was used to assess the cost-effectiveness of EVAR versus OR. The primary outcome measure was quality-adjusted life-years (QALYs). The model incorporated the costs and benefits of both perioperative outcomes and postoperative outcomes. A systematic review was conducted to derive clinical outcome rates. Cost and utility model variables were based on various literature sources and data from a recent Canadian observational study. Parameter uncertainty was assessed using probabilistic sensitivity analysis.

RESULTS

In the base-case model, the incremental cost per QALY of EVAR was estimated to be $268,337, whereas the incremental cost per life-year was found to be $444,129. The incremental cost per QALY of EVAR remained above $295,715 under different assumptions of cohort age and model time horizon.

CONCLUSIONS

Based on commonly quoted willingness-to-pay thresholds, EVAR was not found to be cost-effective compared to OR.

Metformin treatment in diabetes and heart failure: when academic equipoise meets clinical reality

Objective

Metformin has had a 'black box' contraindication in diabetic patients with heart failure (HF), but many believe it to be the treatment of choice in this setting. Therefore, we attempted to conduct a pilot study to evaluate the feasibility of undertaking a large randomized controlled trial with clinical endpoints.

Study Design

The pilot study was a randomized double blinded placebo controlled trial. Patients with HF and type 2 diabetes were screened in hospitals and HF clinics in Edmonton, Alberta, Canada (population ~1 million). Major exclusion criteria included the current use of insulin or high dose metformin, decreased renal function, or a glycosylated hemoglobin <7%. Patients were to be randomized to 1500 mg of metformin daily or matching placebo and followed for 6 months for a variety of functional outcomes, as well as clinical events.

Results

Fifty-eight patients were screened over a six month period and all were excluded. Because of futility with respect to enrollment, the pilot study was abandoned. The mean age of screened patients was 77 (SD 9) years and 57% were male. The main reasons for exclusion were: use of insulin therapy (n = 23; 40%), glycosylated hemoglobin <7% (n = 17; 29%) and current use of high dose metformin (n = 12; 21%). Overall, contraindicated metformin therapy was the most commonly prescribed oral antihyperglycemic agent (n = 27; 51%). On average, patients were receiving 1,706 mg (SD 488 mg) of metformin daily and 12 (44%) used only metformin.

Conclusion

Despite uncertainty in the scientific literature, there does not appear to be clinical uncertainty with regards to the safety or effectiveness of metformin in HF making a definitive randomized trial virtually impossible.

Trial registration

ClinicalTrials.gov Identifier: NCT00325910

Systematic reviews of pharmacy practice research: methodologic issues in searching, evaluating, interpreting, and disseminating results

Although there has been a large number of trials on pharmacist care, often demonstrating clinically significant benefits, the trials generally have not changed practice or healthcare policy. What is needed are focused evidence syntheses, such as a systematic review. A systematic review is defined as a summary that addresses a focused clinical question, using methods to reduce the likelihood of bias. These reviews, which are the highest level of evidence, can help to impact policy by bringing together results of various trials. However, systematic reviews of practice research pose some unique methodologic challenges, including issues with searching, interpreting, and evaluating the available research. Well-conducted systematic reviews of pharmacist interventions could go a long way toward changing pharmacy practice and healthcare policy to recognize the important impact that pharmacists could have in the healthcare system.

The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review

OBJECTIVES

To review studies on the cost consequences of compliance and/or persistence in cardiovascular disease (CVD) and related conditions (hypertension, dyslipidaemia, diabetes and heart failure) published since 1995, and to evaluate the effects of noncompliance on healthcare expenditure and the cost-effectiveness of pharmaceutical interventions.

METHODS

English language papers published between January 1995 and February 2007 that examined compliance/persistence with medication for CVD or related conditions, provided an economic evaluation of pharmacological interventions or cost analysis, and quantified the cost consequences of noncompliance, were identified through database searches. The cost consequences of noncompliance were compared across studies descriptively.

RESULTS

Of the 23 studies identified, 10 focused on hypertension, seven on diabetes, one on dyslipidaemia, one on coronary heart disease, one on heart failure and three covered multiple diseases. In studies assessing drug costs only, increased compliance/persistence led to increased drug costs. However, increased compliance/persistence increased the effectiveness of treatment, leading to a decrease in medical events and non-drug costs. This offset the higher drug costs, leading to savings in overall treatment costs. In studies evaluating the effect of compliance/persistence on the cost-effectiveness of pharmacological interventions, increased compliance/persistence appeared to reduce cost-effectiveness ratios, but the extent of this effect was not quantified.

CONCLUSIONS

Noncompliance with cardiovascular and antidiabetic medication is a significant problem. Increased compliance/persistence leads to increased drug costs, but these are offset by reduced non-drug costs, leading to overall cost savings. The effect of noncompliance on the cost-effectiveness of pharmacological interventions is inconclusive and further research is needed to resolve the issue.

Heart failure disease management programs: a cost-effectiveness analysis

BACKGROUND

Heart failure (HF) disease management programs have shown impressive reductions in hospitalizations and mortality, but in studies limited to short time frames and high-risk patient populations. Current guidelines thus only recommend disease management targeted to high-risk patients with HF.

METHODS

This study applied a new technique to infer the degree to which clinical trials have targeted patients by risk based on observed rates of hospitalization and death. A Markov model was used to assess the incremental life expectancy and cost of providing disease management for high-risk to low-risk patients. Sensitivity analyses of various long-term scenarios and of reduced effectiveness in low-risk patients were also considered.

RESULTS

The incremental cost-effectiveness ratio of extending coverage to all patients was $9700 per life-year gained in the base case. In aggregate, universal coverage almost quadrupled life-years saved as compared to coverage of only the highest quintile of risk. A worst case analysis with simultaneous conservative assumptions yielded an incremental cost-effectiveness ratio of $110,000 per life-year gained. In a probabilistic sensitivity analysis, 99.74% of possible incremental cost-effectiveness ratios were <$50,000 per life-year gained.

CONCLUSIONS

Heart failure disease management programs are likely cost-effective in the long-term along the whole spectrum of patient risk. Health gains could be extended by enrolling a broader group of patients with HF in disease management.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure--2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies

Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Impact of heart failure on hospital activity and healthcare costs in Belgium

Heart failure (HF) is a serious public health problem worldwide. It has a high prevalence, affects mainly the elderly and causes high mortality or disability with high economic costs. The aim of the present study was to calculate the number of admissions for HF, the total in-hospital stay, the mean length of in-hospital stay and the in-hospital costs due to HF in Belgium. Retrospective analysis of data from the national hospital registration system provided the following results. In 2001, there were 19,398 admissions with HF as a primary diagnosis, with a total in-hospital stay of 286,938 days. The mean in-hospital stay for HF was 14.8 days. The total in-hospital cost of HF as a primary diagnosis was euro 94,113,827, representing 1.8% of the total hospital expenditure. The limitations of this study are its mere focus on admissions and their characteristics in 2001, and the use of a retrospective analysis. Nevertheless, it led to the conclusion that HF was responsible for a significant number of in-hospital days, with a significant impact on healthcare costs in Belgium.

Weight and symptom diary for self-monitoring in heart failure clinic patients

BACKGROUND

For people with chronic heart failure, self-monitoring has been linked with improved body awareness and better communication with health professionals. Cognitive theory and the concept of somatic awareness help explain self-monitoring behaviors. This study compares the clinical and hospital outcomes of heart failure patients who are using and not using a diary to record weight, vital signs and, symptoms and evaluates the diary format.

METHODS

All patients enrolling in an outpatient heart failure clinic were given a Heart Health Diary. Seventy patients used the diary and 54 did not. A review of these 124 patients (82 men and 42 women) was completed 6 months after enrollment.

RESULTS

Diary nonusers were more likely to be younger women with a lower ejection fraction and worse functional status. Those using a diary had 35% and 47% more contacts via telephone and clinic, respectively. Both groups had significant functional and B-type natriuretic peptide improvement. If hospitalized after enrollment in the heart failure clinic, average length of stay for all hospital admissions for diary users decreased by 58% (P < .002) and average cost per case decreased by 56% (P < .011). Length of stay and cost per case did not significantly change for those not using diaries.

CONCLUSION

Diary users showed evidence of improved clinical and hospital outcomes. Further investigation is needed to clarify the characteristics of a diary user and the effect of diary use on self-management and outcomes.

Multidisciplinary team for enhancing care for patients with acute myocardial infarction or heart failure

PURPOSE

Pharmacists' involvement in a disease management program for the improvement of care of patients with acute myocardial infarction (MI) or heart failure (HF) is described.

SUMMARY

Beginning in 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented evidence-based measures in several performance areas, including MI and HF. In 2003, a multidisciplinary team consisting of physicians, clinical pharmacists, nurses, cardiac rehabilitation specialists, nutrition specialists, and case managers was established at Allegheny General Hospital. As of January 2004, hospitals were required to select three core measure sets in order to meet JCAHO accreditation requirements. Pharmacists provided medication evaluation and education for patients in an effort to augment adherence with the JCAHO core measures. These services were facilitated by pharmacists' participation in the development of preprinted orders, clinical pathways, patient-evaluation forms, and written educational materials. Patients targeted for intervention were admitted with a principal diagnosis of MI or HF. JCAHO core measure data for MI and HF were presented from first quarter (Q1) fiscal year (FY) 2005 through Q1 FY 2006. For MI, a consistent improvement in performance to 100% was demonstrated for four of the six criteria. For HF, increases were demonstrated for left ventricular (LV) function assessment, angiotensin-converting-enzyme inhibitor for LV systolic dysfunction, and smoking-cessation counseling. Despite documentation issues regarding discharge instructions, results overall compared favorably with the referenced standard.

CONCLUSION

A multidisciplinary team that included pharmacists improved JCAHO core measures for hospitalized patients with MI or HF.

Difficulty taking medications, depression, and health status in heart failure patients

BACKGROUND

Little is known about medication nonadherence in heart failure populations. We evaluated the association between 1 aspect of medication nonadherence, patient-reported difficulty taking medications as directed, and health status among heart failure outpatients, and then examined whether this association was explained by depression.

METHODS AND RESULTS

A total of 522 outpatients with left ventricular ejection fraction <0.40 completed clinical evaluation, Kansas City Cardiomyopathy Questionnaire (KCCQ), Medical Outcomes Study-Depression questionnaire, and categorized their difficulty taking medications (5-level Likert-scale question). Multivariable regression was used to evaluate the cross-sectional association between difficulty taking medications and health status, with incremental adjustment for medical history and depressive symptoms. Patients with difficulty taking medications (n = 64; 12.2%) had worse health status (8.2 +/- 2.7 point lower mean KCCQ summary scores; P = .008) and more depressive symptoms (43.8% versus 27.1%; P = .006). Adjusting for demographic and clinical factors had little effect on the association between difficulty taking medications and health status (8.0 +/- 3.2 point lower KCCQ scores; P = .01); however, the relationship was attenuated with adjustment for depressive symptoms (4.7 +/- 2.9 point lower KCCQ scores; P = .11).

CONCLUSIONS

Among heart failure outpatients, difficulty taking medications is associated with worse health status. This association appears to be explained, in part, by coexistent depression. Future studies should evaluate interventions such as depression treatment to improve medication adherence and health status.

A Systematic Meta-Analysis of the Efficacy and Heterogeneity of Disease Management Programs in Congestive Heart Failure

BACKGROUND

We sought to systematically combine the evidence on efficacy of disease management programs (DMPs) in the treatment of congestive heart failure (CHF), to identify and explain heterogeneity of results from prior studies of DMPs, and to assess potential publication bias from these studies.

METHODS AND RESULTS

We conducted a systematic literature search on randomized clinical trials investigating the effect of DMPs on CHF outcomes and performed meta-analyses and meta-regressions comparing DMPs and standard care for mortality and rehospitalization. We included 36 studies from 13 different countries (with data from 8341 patients). Our meta-analysis yielded a pooled risk difference of 3% (95% confidence interval [CI] 1-6%, P < .01) for mortality and of 8% (95% CI 5-11%, P < .0001) for rehospitalization, both favoring DMP. Factors explaining heterogeneity between studies included severity of disease, proportion of beta-blocker at baseline, country, duration of follow-up, and mode of postdischarge contact. No statistically significant publication bias was detected.

CONCLUSION

DMPs have the potential to reduce morbidity and mortality for patients with CHF. The benefit of the intervention depends on age, severity of disease, guideline-based treatment at baseline, and DMP modalities. Future studies should directly compare the effect of different aspects of disease management programs for different populations.

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes

AIMS

Disease management programmes (DMPs) have evolved as an innovative clinical practice system to enhance the discharge outcomes of older people with heart failure. Yet, clinical trials which have examined their effectiveness have reported inconsistent findings. This may be explained by variations in the design of DMPs. The aim is to identify the characteristics of DMPs which are crucial to reducing hospital readmission and/or mortality of older people with heart failure.

METHODS AND RESULTS

A systematic computerized search was conducted to identify randomized controlled trials of the last 10 years, which examined the effects of DMPs on hospital readmission and mortality of older people with heart failure. The identified DMPs were classified as effective and ineffective, according to statistically significant changes in discharge outcomes. Twenty-one trials were identified, 11 (52.4%) of which reported DMPs improving the discharge outcomes of older people with heart failure. The results indicate that an effective DMP should be multi-faceted and consists of an in-hospital phase of care, intensive patient education, self-care supportive strategy, optimization of medical regimen, and ongoing surveillance and management of clinical deterioration. Cardiac nurse and cardiologist should be actively involved and a flexible approach should be adopted to deliver the follow-up care.

CONCLUSION

This study defines precisely the characteristics of the care team and the organization content and delivery method of the DMP which are crucial to enhance the discharge outcomes of older people with heart failure.

Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis

BACKGROUND

Disease management programmes (DMP) have been advocated to improve long term outcomes of heart failure (HF) patients.

AIMS

To summarise the evidence supporting DMP effectiveness in improving HF clinical outcomes.

METHODS

Eligible studies were located through a systematic literature search. Only randomised controlled trials (RCTs), enrolling HF patients, and allocating them to DMP or usual care (UC), were included. Information on study setting and design, participants' characteristics and interventions tested were collected. A study quality assessment was performed. Main clinical outcomes assessed were: all-cause mortality and (re)hospitalisations, HF-related (re)hospitalisations and mortality. Meta-analysis was performed according to both Yusuf-Peto method and random effects model.

RESULTS

Thirty-three RCTs were included. Mortality was significantly reduced by DMP compared to UC: OR = 0.80 (CI 0.69-0.93, p = 0.003). All-cause and HF-related hospitalisation rates were also significantly reduced: OR = 0.76 (CI 0.69-0.94, p < 0.00001) and OR = 0.58 (CI 0.50-0.67, p < 0.00001), respectively. Different DMP approaches appeared to be equally effective (sensitivity analyses).

CONCLUSION

DMP reduce mortality and hospitalisations in HF patients. Because various types of DMP appear to be similarly effective, the choice of a specific programme depends on local health services characteristics, patient population, and resources available.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To assess the effectiveness of disease management interventions for patients with CHF.

SEARCH STRATEGY

We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary.

MAIN RESULTS

Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions.

AUTHORS' CONCLUSIONS

The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.

Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials

OBJECTIVES

The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients.

BACKGROUND

Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients.

METHODS

Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts.

RESULTS

Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving.

CONCLUSIONS

Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.