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J Am Coll Cardiol, 2004; 44:810-819, doi:10.1016/j.jacc.2004.05.055 © 2004 by the American College of Cardiology Foundation |
* Division of General Internal Medicine, University of Alberta, Edmonton, Canada
Division of Health Sciences, University of South Australia, Adelaide,Australia
Divisione Universitaria di Cardiologia Azienda Ospedaliera San Giovanni Battista Corso Dogliotti, Torino, Italy
Department of Cardiology, Western Infirmary, Glasgow, United Kingdom
Manuscript received January 20, 2004; revised manuscript received April 8, 2004, accepted May 11, 2004.
* Reprint requests and correspondence: Dr. Finlay A. McAlister, 2E3.24 WMC, University of Alberta Hospital, 8440 112 Street, Edmonton, Alberta, Canada T6G 2R7 (Email: Finlay.McAlister{at}ualberta.ca).
OBJECTIVES: The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients.
BACKGROUND: Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients.
METHODS: Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts.
RESULTS: Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving.
CONCLUSIONS: Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.
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