This systematic review shows that delivering multidisciplinary interventions to patients with heart failure not only reduces hospital admission but also is an effective method for reducing mortality. Our results show that the risk of all cause admission is reduced by about 13%, mortality by as much as 20%, and heart failure admission by 30%. Results for all cause admission and mortality were little changed by a wide variety of sensitivity analyses that excluded trials on the basis of quality criteria or clustering of data. This is the first meta-analysis of this form of intervention to show a significant reduction in mortality, and it is important to note that the reduction is similar to that achieved by ACE inhibitors in heart failure.40
This study also investigated whether effectiveness varied according to where the interventions were carried out. These subgroup analyses generated less clear cut results. Home based interventions successfully reduced all cause admission, heart failure admission, and mean days in hospital. However, they led to a non-significant decrease in deaths. The latter result may simply reflect that insufficient patients have been enrolled in home based trials as yet (n
1909). In contrast, telephone interventions decreased heart failure admission and deaths but led to a non-significant decrease in all cause admission. Remote televideo or physiological monitoring provides a newer form of intervention. A few trials of these interventions have now been conducted. Although this review suggests that these interventions may have an important effect on mortality, data were not available to investigate their effect on admission. We found only three trials where interventions were solely delivered in a hospital, clinic, or general practice.24,29,30
None of these studies reported significant benefits.
Studies that we reviewed had reasonably broad inclusion criteria such that the findings are of relevance to most hospitalised patients with heart failure. However, trials tended to restrict participation to patients with no important co-morbidity, terminal disease, confusion, or residence in a long term care facility. Thus, the benefits may not extend to these groups. Equally, it should be noted that trial populations were reasonably heterogeneous, which is likely to have contributed to heterogeneity in the results.
This review has been enhanced by the provision of extra unpublished data from some authors and data from abstracts of trials presented at international conferences. Exclusion of these non-peer reviewed data within our sensitivity analysis did not change the effectiveness estimates but did broaden the confidence limits.
Eleven studies were excluded because they did not report outcome data that could be used by this review. However, eight of these reported other outcomes favouring their intervention groups, while three reported no clear differences. Funnel plots suggested little evidence of publication bias. Nonetheless, given the numbers of patients now randomly assigned (> 8000), it seems unlikely that publication of small negative studies would have an important impact on any of the effectiveness estimates.
A diverse range of interventions could have met this review’s inclusion criteria. However, in reality the trials that we found tested relatively similar interventions. Almost all interventions shared two key elements: one to one patient education concerning heart failure, medication, and diet and exercise advice; and symptom monitoring and self management advice. Education tended to be given over a number of encounters. It should be noted that 11 trials incorporated interventions that appeared to be of high intensity. Effectiveness estimates from these appeared to be only marginally greater than those of lower intensity interventions and the confidence intervals overlapped. Equally, targeting the intervention at high risk patients with heart failure did not seem important. It is also interesting to note that trial results do not appear to have changed over time despite increased use of ACE inhibitors and introduction of low dose β blockade (fig 2). This may suggest that the effectiveness of multidisciplinary interventions is mediated not solely through better compliance with modern drug treatments but also through better symptom self management and lifestyle changes.
No trial included in this review provided any form of placebo intervention. It is difficult to imagine how this would be delivered in practice. It is therefore possible that the effectiveness observed is partly due to increased social contact. A more important limitation of much of the research to date has been the use of a single highly motivated specialist team. Replicating this in other settings, particularly in rural areas where distances to specialist centres are large, is likely to be difficult. It seems important to test whether less specialised nurses or community pharmacists are as effective as these highly specialised teams.
A few studies were excluded from this review because they compared two interventions and did not include a usual care subgroup. These shed some light on the importance of intervention intensity. Benatar et al41
compared telemonitoring with frequent home visiting (nine visits over five weeks, then as needed) of 216 patients over 12 months’ follow up. This trial reported heart failure admission data and found a non-significant reduction from telemonitoring (38 admissions) compared with home visiting (63 admissions). Jerant et al42
randomly assigned 37 patients to telemonitoring, telephone follow up, or usual care (where all groups received two detailed home visits) and followed them up over six months. This study’s sample size limited its findings. In total there were nine admissions in the telemonitoring group, five in the telephone group, and 15 in the usual care group (p
0.45). Harrison et al43
randomly assigned 192 patients to receive usual home nursing care, which consisted of assessment, monitoring and health teaching, or a transitional care intervention. The transitional care intervention was a comprehensive discharge programme with evidence based counselling and education. Harrison et al43
found a non-significant decrease in the proportion of patients admitted after the transitional care intervention. Finally, Coletta et al
(in the TEN-HMS (Trans-European Network initiative–homecare management system study)),13
whose interim results are included in this review, compared usual care with two interventions: a telephone intervention and a televideo intervention. This study has found an improvement in mortality in both intervention groups, but only a small non-significant difference between these groups (13% for telemonitoring v
15% for telephone). With the exception of the study of Jerant et al
these studies suggest a small incremental effect of intensive interventions, in line with the finding from our review comparing high intensity interventions versus low intensity interventions. However, this difference, as well as its relative cost effectiveness, needs to be more clearly established. Ongoing trials will add to this analysis over the next three years including the large COACH (coordinating study evaluating outcomes of advising and counselling in heart failure) trial,44
which is randomly assigning 1050 patients to either usual care, basic education and support, or intensive education and support, as well as final results from the TEN-HMS study.13
In conclusion, it is apparently possible to achieve major reductions in admissions and deaths of patients with heart failure by implementing post-discharge interventions delivering patient education and symptom self management. These interventions appear to be particularly effective when they are at least partly delivered in a patient’s own home through visits, telephone calls, or more advanced televideo techniques.