Nurse-led case management may reduce HF readmissions

Among chronic heart failure (CHF) patients who have previously been admitted to the hospital for this condition there is now good evidence that case management type interventions led by a HF specialist nurse reduces CHF related readmissions after one year of follow-up, all-cause readmissions and all-cause mortality, according to a large study published online Sept. 12 in The Cochrane Library.

For the study, Andrea Takeda, MD, of Queen Mary University of London, Barts & The London School of Medicine, and colleagues searched a number of databases for the updated review: the Cochrane Central Register of Controlled Trials and DARE on the Cochrane Library (Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-January 2009); and AMED (1985-January 2009). For the original review (but not the update), the researchers had searched the Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research Register (2003) and NHS Economic Evaluations Database (2001).

Ultimately, the researchers chose randomized controlled trials with at least six months follow-up, comparing disease management interventions specifically directed at patients with CHF to usual care. At least two reviewers independently extracted data and assessed study quality.

In total, they included 25 trials (5,942 people), and classified interventions by:

1. Case management interventions (intense monitoring of patients following discharge often involving telephone follow-up and home visits);
2. Clinic interventions (follow-up in a CHF clinic); and
3. Multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the ‘usual care’ comparator provided in different trials.

Case management interventions were associated with reduction in all-cause mortality at 12 months follow-up, but not at six months. No reductions were seen for deaths from CHF or cardiovascular causes.

However, case management type interventions reduced CHF related readmissions at six month and 12 month follow-up. Impact of these interventions on all cause hospital admissions was not apparent at six months but was at 12 months.   

Takeda and colleagues also found that CHF clinic interventions (for six and 12 month follow-up) revealed non-significant reductions in all-cause mortality, CHF-related admissions and all-cause readmissions. Mortality was not reduced in the two studies that looked at multidisciplinary interventions. However, both all-cause and CHF-related readmissions were reduced. 

While there was no real difference between groups in deaths related to HF, case management patients were less likely to be readmitted to the hospital for HF six months after discharge, according to the study authors.

“They were also less likely to be readmitted for HF a year after discharge, although the studies reporting this were not similar enough to draw strong conclusions from the combined data,” the researchers wrote. “A year after discharge, case management patients were less likely to be readmitted to hospital for any reason than people who received usual care.” They added that telephone follow-up by a specialist nurse was a common feature of more successful programs.