[Value of basic and intensive management of patients with heart failure; results of a randomised controlled clinical trial].

Universitair Medisch Centrum Groningen, afd. Cardiologie, Postbus 30.001, 9700 RB Groningen.
Nederlands tijdschrift voor geneeskunde 10/2008; 152(37):2016-21.
Source: PubMed

ABSTRACT To determine the efficacy of 2 nurse-directed programmes of different intensity for the counselling and follow-up of patients hospitalised for heart failure, compared with standard care by a cardiologist.
Multicentre randomised clinical trial ( NCT 98675639).
A total of 1023 patients were randomized after hospitalisation for heart failure to 1 of 3 treatment strategies: standard care provided by a cardiologist, follow-up care from a cardiologist with basic counselling and support by a nurse specialising in heart failure, or follow-up care from a cardiologist with intensive counselling and support by a nurse specialising in heart failure. Primary end points were the time to rehospitalisation due to heart failure or death and the number of days lost to rehospitalisation or death during the 18-month study period. Data were analysed on an intent-to-treat basis.
Mean patient age was 71 years, 38% were women, 50% had mild heart failure and 50% had severe heart failure. During the study, 411 patients (40%) were rehospitalised due to heart failure or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (differences not significant). The time to rehospitalisation or death was similar in the 3 groups: hazard ratios for the basic and intensive support groups versus the control group were 0.96 (95% CI: 0.76-1.21; p = 0.73) and 0.93 (95% CI: 0.73-1.17; p = 0.53), respectively. The number of days lost to rehospitalisation or death was 39,960 in the control group; this number was 15% less in the intervention groups, but the difference was not significant. However, there was a trend toward lower mortality in the intervention groups. In all 3 groups, more visits occurred than planned, which may have had a considerable effect on care, notably in the control group.
The results of this study indicated that the provision of additional counselling and support by a nurse specialising in heart failure as an adjuvant to intensive follow-up care provided by a cardiologist does not always lead to a reduction in rehospitalisation frequency.

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    ABSTRACT: Unplanned admissions for heart failure are common and some are considered preventable. Undertake a systematic literature review and meta-analysis to evaluate the effectiveness of specialist clinics in reducing unplanned hospital admissions in people with heart failure. 18 databases were searched from inception to June 2010. Relevant websites and reference lists of included studies were checked for additional publications. Randomised controlled trials in Organisation for Economic Co-operation and Development countries that evaluated the effectiveness of specialist clinic interventions for heart failure compared with usual care, where unplanned heart failure admissions or readmissions were an outcome. Data were extracted by one reviewer and checked by a second reviewer. 10 of 17 randomised controlled trials met the inclusion criteria. Specialist clinics showed a reduction in unplanned admissions at 12 months (pooled risk ratio (RR) for five studies 0.51 (95% CI 0.33 to 0.76); absolute risk reduction 16 per 100 (95% CI 12 to 20)). Studies with initial frequent (weekly/fortnightly) appointments reducing in frequency over the study duration demonstrated a 58% RR reduction in unplanned admissions (pooled RR for three studies 0.42 (95% CI 0.27 to 0.65); absolute risk reduction 14 per 100 (95% CI 7 to 20)). Clinics conducted on a monthly or 3 monthly basis throughout or tailored to the individual patients did not show an effect. Specialist clinics for patients with heart failure can reduce the risk of unplanned admissions; these were most effective when there was a high intensity of clinic appointments close to the time of discharge which then reduced over the follow-up period.
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