Management of high-risk heart failure

Systematic review
Results
Comment

Disease management programmes for the care of patients with heart failure that involve specialised follow-up by a multidisciplinary team reduce hospital admission and are probably cost saving. This is the finding of an updated systematic review [1] that examined all the relevant randomised trials. It found benefits in mortality, all cause and heart failure-related hospital admissions, and is probably cost effective.

Systematic review

Six electronic databases were searched for randomised trials of management programmes in heart failure, as well as bibliographies. For inclusion trials had to report on the impact of outpatient-based multidisciplinary management strategies on mortality or hospital admission rates in patients with heart failure.

Three groups of treatment were defined:

Multidisciplinary heart failure clinic, or a multidisciplinary team providing specialised follow-up but not in a hospital or practice clinic.
Telephone follow-up and enhanced communication with primary care physician.
Educational programmes designed to enhance patient self care activities.

Outcomes were mortality, patients with at least one hospital admission for any reason or for heart failure, and the total number of hospital admissions for any cause or for heart failure (to include multiple admissions).

Results

Twenty-nine randomised trials were identified, reporting at least one outcome of interest. In all of them the control was usual care, which was not well defined. Average age of patients in the trials was usually over 70 years, and follow up was between three and 30 months, though most were of 6-12 months duration.

Results for the three main outcomes of all-cause mortality, all-cause hospital admission, and heart failure admission, are shown in Table 1. Because some trials were small, and others of short duration, a sensitivity analysis includes trials with at least 100 patients, and trials of at least six and 12 month duration, though only 12 month data are shown in Table 1. Though relative risks were similar for all of these, longer duration trials had higher event rates, and so lower (better) NNTs.

Table 1: All-cause mortality, all-cause and heart failure admission results

	Number of		Event rate (%) with
Outcome and trials	Trials	Patients	Intervention	Contol	Relative risk (95% CI)	NNT (95% CI)
All-cause mortality
All trials	23	3781	15	18	0.8 (0.7 to 0.9)	30 (18 to 107)
All trials of at least 12 months	9	1236	21	29	0.7 (0.6 to 0.9)	13 (9 to 37)
Mutidisciplinary clinics or teams	12	2129	17	24	0.7 (0.6 to 0.9)	17 (11 to 38)
Telephone follow up	7	1193	10	11	0.9 (0.7 to 1.3)	not calculated
Enhanced self care	3	459	17	14	1.2 (0.8 to 1.8)	not calculated
All-cause admission
All trials	23	4313	40	47	0.9 (0.8 to 0.93)	16 (11 to 30)
All trials of at least 12 months	7	1120	45	55	0.8 (0.7 to 0.9)	10 ( 6 to 22)
Mutidisciplinary clinics or teams	14	2273	41	51	0.8 (0.7 to 0.9)	10 (7 to 16)
Telephone follow up	6	1581	42	42	1.0 (0.9 to 1.2)	not calculated
Enhanced self care	3	459	31	42	0.7 (0.6 to 0.9)	9 (5 to 38)
Heart failure admission
All trials	19	3008	25	34	0.7 (0.6 to 0.8)	11 (8 to 16)
All trials of at least 12 months	6	785	30	46	0.7 (0.6 to 0.8)	6 (5 to 11)
Mutidisciplinary clinics or teams	9	1416	27	38	0.7 (0.6 to 0.8)	9 (6 to 17)
Telephone follow up	6	1024	20	27	0.8 (0.6 to 0.95)	15 (8 to 59)
Enhanced self care	4	568	27	40	0.7 (0.5 to 0.9)	8 (5 to 19)

Multidisciplinary clinics or teams contributed the largest amount of evidence and had evidence for the largest effect (Table 1). For every 100 patients with heart failure in such a multidisciplinary team instead of a usual control for 6-12 months, 10 would avoid at least one admission to hospital, and at least five would avoid dying.

Over the wide range of event rates seen for hospital admission in just the trials on multidisciplinary interventions, there appeared to be a larger effect at lower event rates (Figure 1). This might imply that very severe cases of heart failure present much more difficult challenges, even for these overall effective teams. Telephone follow up and enhanced self care were represented in fewer trials. Telephone follow up was not effective in reducing hospital admission or mortality, and appeared to be the least favoured option.

Figure 1: All-cause hospital admission with multidisciplinary programmes versus control

Other outcomes were reported. The total number of hospital admissions and total heart failure admissions was reduced by all three strategies, and total heart failure admissions were reduced by 43%. Adherence rates to medicines was higher in the intervention programmes, nine of 18 studies reported better quality of life with the programmes, and 15 of 18 trials reporting costs of interventions concluded that the interventions were cost effective.

Comment

This is a welcome update of a previous review [2], incorporating 18 new trials. The direction of the results has not changed, but more evidence means we can be even more confident that outpatient-based multidisciplinary heart failure management programmes are effective and cost effective. This review confirms that care pathways based on good evidence can deliver better care to patients at lower cost.

References:

FA McAlister et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. Journal of the American College of Cardiology 2004 44: 810-819.
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.

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