Nurse-Led Case Management Cuts HF Readmissions, Mortality



For patients discharged after hospitalization for heart failure, case-management interventions led by a specialist nurse reduce HF-related readmissions, HF-related mortality, and all-cause mortality, according to an update published online Sept. 11 in the Cochrane Database of Systematic Reviews.

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"There is now strong evidence that case-management interventions are associated with a substantial, statistically significant reduction in all-cause mortality."

The initial Cochrane Review that addressed the effectiveness of three different types of follow-up care (case-management, clinic-based, and multidisciplinary) after hospitalization for HF was published in 2005, and found mixed and inconclusive results for all three (Cochrane Database Syst. Rev. 2005 8;(2):CD002752).

Since then, several new clinical trials have been performed, and "there is now strong evidence that case-management interventions are associated with a substantial, statistically significant reduction in all-cause mortality" as well as HF mortality and rehospitalization, said Dr. Andrea Takeda of Queen Mary University, London, and her associates in the Cochrane Collaboration.

In contrast, the evidence doesn’t support interventions in which the major component is follow-up in a hospital HF clinic. And the evidence for multidisciplinary interventions is too sparse to be conclusive because only two high-quality studies have examined these approaches, the investigators wrote (Cochrane Database of Systematic Reviews 2012 [doi:101002/14651858.CD002752.pub3]).

Case-management programs led by personnel other than nurses specializing in HF, such as hospital-based or community pharmacists, nonspecialist nurses, or interdisciplinary teams, were not as successful as those led by specialist nurses, they added.

Dr. Takeda and her colleagues reviewed 25 randomized clinical trials of at least 6 months’ duration that compared the three types of interventions against usual care in 5,942 adults who had been hospitalized for HF. They excluded interventions that focused on patient education only, exercise only, telemedicine (which was examined in a separate Cochrane Review), or cardiac rehabilitation.

Most of the clinical trials had 100-350 study subjects, but some had fewer than 100 and one had over 1,000 subjects. They were conducted in Europe, the United States, Canada, Australia, and China.

Seventeen studies assessed case-management interventions. Pooling the results demonstrated that these interventions produced a substantial and highly significant reduction in all-cause mortality, HF-related mortality, and HF-related rehospitalization at 12 months. Although the overall impact of the interventions on inpatient days was "not clear," the researchers wrote, there was "a strong suggestion" that these interventions decreased hospital length of stay.

However, case-management interventions did not appear to improve event-free survival. They also did not appear to improve health-related quality of life, but few studies examined this outcome and those that did suffered from high dropout rates, so the data were inconclusive.

Only six clinical trials involving 1,486 patients assessed clinic-based interventions. They showed no reduction in readmissions, mortality, inpatient days, event-free survival, or health-related quality of life.

Only two clinical trials involving 403 patients assessed multidisciplinary programs. The data were inadequate to establish conclusive results, Dr. Takeda and her associates wrote.

In a post hoc analysis, the intensity of various interventions did not appear to influence their effectiveness. Studies of the most intensive, moderately intensive, and low-intensity interventions all showed some reductions in mortality and rehospitalization, the researchers added.

No financial conflicts of interest were reported.

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