© 2005 European Society of Cardiology
Heart failure management programmes: The time for action has arrived
Department of Cardiology, University Hospital, Linköping, Sweden and Department of Medicine and Care, Nursing Science, Linköping University S-581 85 Linköping, Sweden
* Tel.: +46 13 227762; fax: +46 13 123285. E-mail address: annst{at}imv.liu.se
Received September 9, 2005; There is a time for everything and a season for every activity. A time for landmark studies designing and testing new interventions, a time for confirming studies and meta-analyses and a time for implementation of successful interventions into clinical practice.
The economic impact of heart failure and the burden of the disease to patients and their caregivers continue to increase despite advances in pharmacological therapy. Individuals with moderate to severe systolic dysfunction still have a very poor prognosis with more than one third of patients hospitalised yearly and dying within 1 year of hospitalisation [1,2]. The heart failure population consumes a large proportion of health care resources and the main cost is hospitalisations [3]. In order to improve care and reduce health care costs, heart failure management programmes have been implemented in many countries. Disease management can be defined as a multidisciplinary care approach for patients with chronic illness, an approach that coordinates care through the continuum of illness and throughout the various health care systems [4]. Heart failure management programmes involve early assessment, optimised treatment, easy access to care as well as patient education and psychosocial support. The majority of the programmes, both in research trials and in clinical settings, involve nurses and physicians specialised in heart failure, not a whole multidisciplinary team. The management programmes do not generally work throughout the continuum of illness. They mainly focus on patients that have been hospitalised and do not include the earlier stages of heart failure e.g. patients at risk and newly diagnosed patients with mild heart failure or severely ill patients in need of palliative care.
The paper presented by Roccaforte et al. [5] in this issue of the European Journal of Heart Failure is the latest contribution to support the concept that patients hospitalised due to heart failure should be referred for follow-up through a heart failure management programme after discharge. Based on this meta-analysis [5] and others recently published showing similar results [6–8], it is today the best evidence-based practice to provide these programmes for the majority of the heart failure patients since they reduce mortality and hospitalisations as well as health care costs and may also improve self-care and quality of life.
It is clear that usual care, as provided to the patients in the control groups included in these meta-analyses [5–8] as well as to most patients with heart failure in the real world, is not sufficient. Usual care means, in most countries, that patients receive acute care when needed due to escalating symptoms and no structured, health care system-initiated follow up after the initial diagnosis or after hospitalisation. It is not surprising that this approach causes problems when treatment and assessment not are optimal and education and support are not provided to newly diagnosed patients or those discharged home after a few days of intensive, acute heart failure care.
Is it possible to determine which disease management programme model is the most effective? At present, we do not know which components or organisational models are most effective, since no trial has yet tested the single components or models against each other [9]. Both clinic- and home-based nurse-managed models effectively reduce mortality and all-cause morbidity as well as costs. A previous meta-analysis by McAlister et al. [6] concluded that the home-based model may be the most effective. This might be true, especially for the population of fragile, elderly patients and those who are not mobile. Hence, for the less physically impaired elderly patients, the clinic model is probably more effective from the perspective of the health care providers since more patients can be seen in a day and hospital facilities are more readily available. Telephone follow-up is probably an important aspect of care, but probably cannot replace face-to-face contact. Even a few visits with a heart failure nurse have been shown to have a large effect on outcome [10]. In their paper, Roccaforte et al. [5] conclude that various types of programmes have similar effects and the choice of model should be based on the resources and structure of the local health care service, the patient population and their needs, as well as the local infrastructure. In the US, Australia and Europe, all models (the clinic-based, home-based, tele-care and tele-monitoring) are used, either separately or in combination. Regardless of the model chosen, however, the most important aspect of care is the inclusion of follow-up for previously hospitalised patients. The European guidelines for the management of chronic heart failure published earlier this year advocate that an organised system of specialist heart failure care should be implemented, since it improves symptoms and reduces hospitalisations (Class of recommendation I, level of evidence A) and mortality (Class of recommendation IIa, level of evidence B) [11].
Despite evidence-based recommendations in guidelines, the majority of patients hospitalised due to heart failure still do not receive this type of follow-up. It is now time to work on putting evidence into practice by encouraging national guidelines, major organisations, local decision makers and health care administrators to implement heart failure management programmes into clinical practice throughout Europe.
Data from more than 30 randomised controlled trials, including over 5000 patients with a mean age of 73 years are now available to support the implementation of disease management programmes in heart failure. The sex distribution is fairly equal with 58% women in the trials [5]. For the future research agenda, race and cultural differences need to be addressed, data on the non-white population (75% of the patients in the trials were white) and from countries in South America, Asia, Africa and former Eastern Europe, for example Russia, are still required. In addition, for very old and fragile individuals with cognitive impairment and a high number of co-morbidities, the most optimal follow up, remains uncertain. We need to evaluate extended programmes that coordinate care through the continuum of illness ranging from stable, newly diagnosed patients with mild heart failure to severely ill patients in need of palliative care, to find out which caregivers and interventions are necessary and beneficial throughout the chain of care. We also need more long-term studies with more extensive cost-effectiveness analyses.
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