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Conclusion
Living with HF is a challenge to the sufferers of this condition.
It also represents a significant burden for the caregivers. The
effective management of HF is achieved through optimal medical
therapy. In addition, current emphasis has been geared toward
a comprehensive and proactive support for self-management utilizing
delivery models before, during, and after hospitalizations. These
self-management models use multiple intervention components of
comprehensive patient education, self care behaviors, medication
review, proactive nurse followup, and increased access to providers.
This report identified 49 randomized controlled trials that
evaluated interventions utilizing various combinations of individual
components initiated in three different settings. We included
studies published since 1990 — the time point associated
with rapid advances in the medical management of HF, and changing
health needs of the patients and changes in the practice patterns.
The majority of the included studies reported readmissions as
the primary outcome of interest. A few studies also evaluated
combined endpoint of readmissions or death as the primary outcome
of interest. In general, studies were not adequately powered
to evaluate the clinical outcome of mortality. We performed meta-analysis
and subgroup analyses to address the key question of the effectiveness
of interventions of post-discharge support to prevent readmissions.
Our report used lax inclusion criteria, thereby reviewing a large
body of literature. We identified those interventions that utilized
increased clinic visits, home visits, and multidisciplinary care
to reduce the risk of readmissions in the intervention group
compared with the usual care group. Often these interventions
utilized a combination of secondary components, with telephone
followup being the most common across the studies; however, when
telephone followup was utilized alone, it did not demonstrate
a significant difference in all cause readmissions compared with
usual care.
In our subgroup analyses, the characteristics of intermediate-
to long-term followup (>6 month and >12 month), interventions
initiated in the inpatient setting, and patient age greater than
75 years had a statistically significant impact on the all cause
readmissions in the intervention group. Inpatient setting benefits
may be explained due to better transition care from the inpatient
to home care in the intervention group. Generally studies did
not report adequate information about the transition of care
coordination in the usual care group. Improvements with longer
followup suggest increased compliance and motivation.
Compared to usual care, one-quarter of the 20 studies reported
a significant reduction in all-cause mortality when interventions
were initiated during an index hospitalization. Similar significantly
decreased length of stay during readmissions was reported when
interventions were initiated during an index hospitalization.
Individual studies were not adequately powered to ascertain meaningful
differences between the interventions and usual care groups for
mortality outcomes; however, there was no distinct combination
of intervention components and improved outcomes of QOL changes,
and miscellaneous clinical outcomes (costs, and composite endpoint
of mortality or readmission).
Eighteen randomized controlled trials compared self-management
delivery models beginning after discharge from an index hospitalization.
Only one of 18 studies suggested decreased event rates in mortality,
readmissions, and reduction in length of hospital stay during
readmissions with interventions. Also, the evidence was sparse
for interventions beginning in the outpatient clinics.
The studies were heterogeneous with regard to intervention components,
intervention duration, followup duration, and components of usual
care. In addition, some studies utilized components of usual
care along with their intervention components. The studies were
performed in a range of settings, in patients with a wide range
of HF severity, across various countries, over a long time period
during which the standards of HF care have changed considerably,
and in patients with different underlying risks of clinical events.
Studies often utilized several different combinations of intervention
components, resulting in considerable heterogeneity that was
difficult to dissect and ascertain the effects of individual
components.
The consistency of results in the settings of diverse studies
adds credibility to the conclusion that patient outcomes can
be improved with optimized transition of care coordination between
the inpatient settings to home care, and a combination of interventions
that increase access to providers. However, there was no easily
discernable pattern based on a particular intervention component,
time period (year), intervention duration, and specific coexisting
medical illnesses. Across studies, similar rates of coexisting
medical illnesses, and proportions of patients who received ACE
inhibitors, beta-blockers, and/or diuretics were reported at
baseline among patients in the intervention and control group.
Of note, no studies evaluated or provided data on adverse effects
due to the interventions.
Additional limitations of the studies include small sample size
and short followup durations, and a substantial number of the
studies reported a composite endpoint of mortality or readmission
as their primary outcome. It is well-acknowledged that the use
of a composite endpoint can erroneously attribute reductions
in mortality to interventions that do not actually reduce deaths.72 The
relative effectiveness of the individual components of interventions
remains unknown, since none of the studies compared one intervention
component with each other. This lack of clarity on the necessary
combination of components of a HF management program may be answered
by the future publications. Future research with long-term followup
is needed to determine which individual components, if any, in
what settings and circumstances, may benefit. A determination
should be made as to which patients are most likely to benefit
from which combinations of intervention components, and then
studies focused on these patients should be conducted. Any future
studies should continue to focus primarily on clinical benefits,
as short-term intermediate outcomes or composite endpoints are
inadequate surrogates for clinically important outcomes.