Effectiveness of a multidimensional home nurse led heart failure disease management program—A French nationwide time-series comparison
Introduction
Age-standardized mortality rates due to heart failure (HF) have declined by 40% in European countries over the past two decades [13]. However, HF still represents the primary cause of hospitalization for patients over the age of 65 in Europe, and the death rate following discharge from a HF hospitalization is as high as 25% in the first year [18]. The cost of HF is estimated to account for 1% to 2% of total healthcare expenditures, and it is largely driven by hospitalization [27]. Therefore, preventing HF hospitalizations is a major health care objective. Dedicated multidimensional disease management programs (DMP) across diverse health care systems are associated with lower hospitalizations and prolonged survival [9], [28], [31]. Therefore, DMPs are strongly recommended in heart failure guidelines based on the highest level of evidence [10], [17]. Most studies evaluating the effectiveness of DMPs [4], [6], [8], [9], [11], [16], [23], [25], [31] were prospective, randomized, controlled studies that enrolled patients in select settings. Whether DMPs are effective in “real-world” population-based settings (i.e., unselected patients, enrolled in general health care centers, receiving a non-standardized and flexible health care delivery) is unknown.
The Insuffisance CARdiaque en LORraine (ICALOR) program is a multidimensional DMP established in 2006. Its goal is to prolong survival and reduce the rate of hospital readmissions in HF patients living in the French administrative region of Lorraine, an area of over 2 million inhabitants. The objective of this study was to assess the effectiveness and budget impact of this holistic, multidimensional, HF specific, “real world” DMP.
Section snippets
Study design
A prospective, observational, cohort study of the patients enrolled in ICALOR from 2006 to 2010 with complete follow-up was used to describe the features and implementation of the DMP.
A national comprehensive database was used to compare the heart failure hospitalization rate among patients of the Lorraine region to those throughout France from 1999 to 2010, in order to assess the impact of the DMP at a population level.
The study was reviewed and approved by the local institutional review board
Description of ICALOR implementation
The sample population in this study consisted of the 1223 patients recruited between January 1st, 2006 and January 1st, 2010 from the 19 centers participating in the DMP; 1222 of them had complete follow-up data as of December 31st, 2010 (Fig. 1). The median length of follow-up for survival ascertainment, corresponding to the length of time patients participated in the program, was 552 days (IR 240–871 days), totaling 2043.5 patient-years of follow-up. Considering the total number of patients
Discussion
The main finding of our study was that a population-based, subsidized HF DMP including coordinated home-nurse visits and a computerized monitoring system, implemented at a regional level, decreased substantially, persistently, and cost-effectively the number of HF hospitalizations and estimated costs. These findings provide translational evidence of effectiveness for DMPs in real world setting, and they extend the applicability of results beyond trials and meta-analyses that demonstrated
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