© 2005 European Society of Cardiology
Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis
a Brigham and Women's Hospital, Harvard Medical School Boston, MA, United States
b Johns Hopkins University School of Medicine, Quality of Care Research and General Internal Medicine Baltimore, MD, United States
c Johns Hopkins University Bloomberg School of Public Health Baltimore, MD, United States
d University Hospital of Groningen Groningen, The Netherlands
* Corresponding author. Section of Hospital Medicine, E13, Department of General Internal Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA. Tel.: +1 216 444 0933; fax: +1 216 445 5632. E-mail address: chr_phi{at}yahoo.com
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Abstract |
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Objectives: To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics.
Data sources and study selection: We searched MEDLINE (1966–November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure.
Data extraction: Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized.
Data synthesis: Six trials were selected (N=949, mean age 73 years [range 62–79], men 58%, LVEF 34% [27–41], and average follow-up of 8.5 months [3–12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient –0.26 [–0.49,–0.02] vs. 0.09 [–1.17, 1.34].
Conclusions: HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.
Key Words: Heart failure • Specialist heart failure nurse • Heart failure clinics • Meta-regression analysis
Received May 18, 2004; Revised January 10, 2005; Accepted January 18, 2005
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