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

doi:10.1016/j.cardfail.2006.03.003

Journal of Cardiac Failure

Volume 12, Issue 7, September 2006, Pages 554-567

https://doi.org/10.1016/j.cardfail.2006.03.003 Get rights and content

Abstract

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 β-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.

Section snippets

Literature Search

We performed a MEDLINE search on articles appearing from 1966 through December 2005, using the extended range of Medical Subject Headings terms “congestive heart failure,” “disease management program,” “case management,” “early intervention,” “clinical protocol,” “patient care planning,” “nurse led clinics,” “home care service,” “patient care team,” and “outpatient clinics” to cover the inconsistency in the definition of DMPs. Additional studies were identified from bibliographies of retrieved

Included Studies

Our electronically literature search resulted in 1851 hits, which included 346 RCTs. Thirty-three of these studies met our inclusion criteria.7, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 Five studies7, 22, 36, 38, 46 were excluded because their data were reported in other studies included in our analysis. Eight additional studies meeting our inclusion criteria50, 51, 52, 53, 54, 55, 56, 57 were identified in

Discussion

Our meta-analysis suggests that DMPs have favorable effects on complications associated with CHF, including a significant reduction in all-cause mortality and rehospitalization. The pooled DMP-related absolute mortality reduction was 3%; that is, 33 patients must be treated to prevent 1 death during a relatively modest median time horizon of 6 months. In addition, the pooled DMP-related absolute reduction in hospitalization was 8% for the first rehospitalization and 19% for subsequent

Conclusion

Our findings suggest that DMPs reduce all-cause mortality as well as first and subsequent hospitalizations in patients with CHF. Age, severity of disease, β-blocker therapy, intervention team composition, intervention mode, and length of follow-up were identified as relevant factors explaining heterogeneity. Future studies should directly compare the effect of different postdischarge contact modes and other DMP features.

Acknowledgment

Dr. Göhler was supported by the Charité Research Grant for Young Scientists. We thank Dr. Turid Piening, Dr. Vera Zietemann, MPH, and Dr. Theo Steijnen for their helpful comments on this manuscript.

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Transitional care interventions that bridge the care gap from hospital to home have proven to be effective in lessening the burden of healthcare systems by reducing hospital readmissions. Yet, the effects of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress remains unclear.
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Systematic review with random-effects meta-analysis, meta-regression, and dose-response analysis of randomized controlled trials comparing transitional care interventions with usual care in adult people hospitalized with heart failure.
Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL were systematically searched from January 1, 2000 to June 31, 2020.
Authors independently reviewed the retrieved articles based on inclusion and exclusion criteria, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2.0. We pooled data from each study using random-effects meta-analysis and performed meta-regression to explore the impact of pre-specified trial-level factors. Dose-response meta-analysis was conducted to examine the relationship between the intensity (i.e., frequency and duration of interventions) and complexity (i.e., number of intervention components) of transitional care interventions and the treatment effects.
Data were synthesized from 42 trials covering a total of 10,784 people with heart failure. Comparing to usual care, transitional care interventions achieved pooled evidence of a mean 18% risk reduction on mortality (0.82, 95% CI 0.71 to 0.95, P = 0.009) and better improvement in quality of life (-4.37, 95% CI -7.20 to -1.54, P = 0.002). There were insufficient data to determine with certainty the effects on anxiety and depression. Meta-regression showed greater efficacy in trials that delivered the intervention by a multidisciplinary team. Dose-response analyses demonstrated that mortality and quality of life were improved with increased intensity and complexity of the transitional care interventions.
Transitional care interventions were effective in reducing mortality and improving quality of life for adult people with heart failure. The effects on emotional distress were inconclusive due to insufficient data, highlighting the need for further research.
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Several trials have evaluated the effect of disease management programs in heart failure (HF) with diverse results. The aim of this study was to develop a simple nurse-led clinic intervention program for patients with HF and assess whether this intervention positively affects the prognosis of patients, their care costs and perceived quality of life (QoL).
Between 2011 and 2013, 127 patients with reduced ejection fraction were prospectively randomly allocated (1:2) to standard care or intervention program. Primary composite endpoint was all-cause mortality and hospital readmissions. Secondary endpoints were all-cause mortality, all-cause hospital readmissions, readmissions for HF, time to first readmission and QoL improvements assessed by “Minnesota Living with Heart Failure Questionnaire” (MLHFQ). An intention-to-treat analysis was performed.
After a median follow-up of 2-years, no differences were found in the primary composite endpoint. Likewise, there were no differences between groups in the predefined secondary endpoints of mortality and readmissions from any cause. However, in the intervention group, readmissions for HF were significantly reduced (35% vs. 18%; p = 0.04) and QoL significantly improved (MLHFQ ± SD: 2.29 ± 14 vs. 10.9 ± 14.75; p = 0.04).
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Se han publicado múltiples ensayos sobre programas de gestión de enfermedades en la insuficiencia cardiaca (IC) con resultados muy heterogéneos. El objetivo de este estudio fue desarrollar un sencillo programa de intervención clínica dirigido por enfermería en pacientes con IC y evaluar si dicha intervención afecta positivamente sobre el pronóstico de los pacientes, sus costes de atención y la calidad de vida percibida.
Entre 2011 y 2013, 127 pacientes con fracción de eyección reducida fueron aleatorizados (1:2) a manejo estándar o al programa de intervención. El objetivo primario compuesto fue mortalidad y reingresos hospitalarios por cualquier causa. Los criterios de valoración secundarios fueron mortalidad por cualquier causa, reingresos hospitalarios por cualquier causa, reingresos hospitalarios por IC, tiempo hasta el primer ingreso y mejoría de la calidad de vida evaluado por el Minnesota Living with Heart Failure Questionnaire (MLHFQ).
Tras un seguimiento medio de 2 años, no se encontraron diferencias en el criterio de valoración compuesto primario. Igualmente, no hubo diferencias en la mortalidad o los reingresos por cualquier causa. Sin embargo, en el grupo de intervención, los reingresos por IC se redujeron (35 vs. 18%; p = 0,04) y la calidad de vida percibida mejoró de forma significativa (MLHFQ ± DE: 2,29 ± 14 vs. 10,9 ± 14,75; p = 0,04).
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Review ArticleA Systematic Meta-Analysis of the Efficacy and Heterogeneity of Disease Management Programs in Congestive Heart Failure

Abstract

Background

Methods and Results

Conclusion

Section snippets

Literature Search

Included Studies

Discussion

Conclusion

Acknowledgment

J Am Coll Cardiol

Control Clin Trials

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

J Card Fail

J Card Fail

J Card Fail

J Card Fail

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiac Fail

The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis

Eur Heart J

Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study

Arch Intern Med

Heart failure: a growing public health problem

J Intern Med

The health care costs of heart failure in Sweden

J Intern Med

Clinical epidemiology of heart failure: public and private health burden

Eur Heart J

Team management of patients with heart failure: a statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association

Circulation

Home-based intervention in congestive heart failure: long-term implications on readmission and survival

Circulation

Care management interventions for older patients with congestive heart failure

Am J Manag Care

The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports

Eur Heart J

Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis

JAMA

Measuring inconsistency in metaanalyses

BMJ

Advanced methods in meta-analysis: multivariate approach and meta-regression

Stat Med

Operating characteristics of a rank correlation test for publication bias

Biometrics

Bias in meta-analysis detected by a simple, graphical test

BMJ

Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis

Biometrics

Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study

J Gen Intern Med

A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure

N Engl J Med

Cost effective management programme for heart failure reduces hospitalisation

Heart

Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure

Eur Heart J

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