Elsevier

The Lancet

Volume 354, Issue 9184, 25 September 1999, Pages 1077-1083
The Lancet

Commentary
Effects of a multidisciplinary, home-based intervention on planned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study

https://doi.org/10.1016/S0140-6736(99)03428-5Get rights and content

Summary

Background

Hospital admissions among patients with congestive heart failure (CHF) are a major contributor to health-care costs. Previous investigations suggest that the therapeutic efficacy of pharmacotherapy in CHF may be improved by strategies incorporating home visits to identify and address factors precipitating deterioration and resultant readmission.

Methods

Chronic CHF patients discharged home after acute hospital admission were randomly assigned usual care (n=100) or a multidisciplinary, home-based intervention (n=100), consisting of a home visit by a cardiac nurse 7–14 days after discharge. The primary endpoint of the study was frequency of unplanned readmission plus out-of-hospital death within 6 months.

Findings

During 6 months' follow-up there were 129 primary endpoint events in the usual-care group and 77 in the intervention group (p=0·02). More intervention-group than usual-care patients remained event-free (38 vs 51; p=0·04). Overall, there were fewer unplanned readmissions (68 vs 118; p=0·03) and associated days in hospital (460 vs 1173; p=0·02) among intervention-group patients. Hospital-based costs were Australian $490 300 for the intervention group and A$922 600 for the usual-care group (p=0·16); the mean cost of the intervention was A$350 per patient, and other community-based costs were similar for both groups.

Interpretation

A home-based intervention has the potential to decrease the rate of unplanned readmissions and associated health-care costs, prolong event-free and total survival, and improve quality of life among patients with chronic CHF.

Introduction

Despite the introduction of more effective treatments, such as inhibitors of angiotensin-converting enzyme1 and β-adrenoceptor antagonists,2 chronic congestive heart failure (CHF) remains a common cause of disability and death.3, 5 The extensive requirement for hospital admission associated with severe CHF4, 5 represents a major burden to health-care systems; such admissions account for about two-thirds of total costs of management of CHF, and for 1–2% of overall health-care expenditure.6 A major component is recurrent hospital admissions; studies of CHF patients have reported all-cause readmission rates as high as 47% within 3 months7 and 54% within 6 months8 of discharge from acute hospital admission. The cost of managing CHF in the USA alone is estimated to be at least US$10 billion per year. Data suggest that hospital admissions attributable to CHF continue to increase.9

The current limits of response to pharmacotherapy provide an impetus for development of possible adjunctive non-pharmacological treatment regimens. Several randomised controlled studies have examined strategies that incorporate a postdischarge, multidisciplinary intervention to address common precipitants of unplanned hospital admission.10, 12 Results of these studies have been promising in terms of limiting hospital use among such patients. Moreover, such strategies might be particularly cost-effective if targeted towards higher-risk patients. However, previous studies have been limited by factors such as small sample size,10 limited duration of follow-up,11 and low event rates due to selection of low-risk patients.12

We previously found, in a randomised study, that a multidisciplinary, home-based intervention decreased the frequency of unplanned readmissions plus out-of-hospital deaths in a group of older patients with various chronic illnesses.13 This intervention seemed to be particularly cost-effective among a subset of high-risk CHF patients.10, 14 This study prospectively tested the null hypothesis that there would be no difference in the frequency of unplanned readmission plus out-of-hospital-death, during a minimum of 6 months of follow-up, among patients with chronic CHF discharged home after acute admission between those exposed or not exposed to a CHF-specific, multidisciplinary, home-based intervention in addition to usual care.

Section snippets

Participants

The study was apporved by the institutional ethics of human research committee. All participating patients gave written informed consent.

Patients admitted to a tertiary referral hospital under the care of a cardiologist were eligible if they were 55 years or be discharged home, and had CHF (left-ventricular ejection fraction <55%, and New York Hert Associtaation Class II, III, or IV) and at least one previous admission for acute heart failure (pulmonary congestion or oedema for evident on chest

Results

4055 cardiology inpatients were screened over a period of 14 months from March, 1997. Of these, 285 (7%) met the clinical criteria for study entry. However, 59 (21%) met one of the exclusion criteria and 26 (11%) refused to participate or died before discharge (figure 1). The baseline characteristics of participating patients were similar to those of the subset of eligible patents who refused to take part in the study.

200 patients were therefore recruited and assigned usual care or the

Discussion

The results of this study suggest that an inexpensive, non-pharmacological intervention improves the efficacy of pharmacotherapy in limiting readmission to hospital and death in a group of patients with severe CHF over a period of at least 6 months.

As in previous studies of patients admitted to hospital with CHF,4, 5, 8 the participants were elderly and frail. Readmission and survival rates in the usual-care group were similar to those in previous studies. Worsening heart failure precipitated

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