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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
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HEART FAILURE

Multidisciplinary strategies for the management of heart failure patients at high risk for admission

A systematic review of randomized trials

Finlay A. McAlister, MD, MSc, FRCPC*,*, Simon Stewart, PhD, FESC, FAHA{dagger}, Stefania Ferrua, MD{ddagger} and John J.J.V. McMurray, MD, FESC, FACC§

* Division of General Internal Medicine, University of Alberta, Edmonton, Canada
{dagger} Division of Health Sciences, University of South Australia, Adelaide,Australia
{ddagger} 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.

Abbreviations and Acronyms
  CI = confidence interval
  HF = heart failure
  NNT = number needed to treat
  RR = risk ratio




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Heart failure management programmes: The time for action has arrived
Eur J Heart Fail, December 1, 2005; 7(7): 1077 - 1078.
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Eur J Heart FailHome page
R. Roccaforte, C. Demers, F. Baldassarre, K. K.Teo, and S. Yusuf
Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis
Eur J Heart Fail, December 1, 2005; 7(7): 1133 - 1144.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
K. D. Rasmusson, S. J. Brush, J. A. Hall, J. C. Vesty, A. G. Kfoury, and D. G. Renlund
Bridging the Resource Gap in Heart Failure Expertise and Management: The Underacknowledged Role of Nurse Specialists
J. Am. Coll. Cardiol., November 15, 2005; 46(10): 1961 - 1962.
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Eur Heart J SupplHome page
K. Swedberg and I. Ekman
Integrating heart failure guidelines into clinical practice
Eur. Heart J. Suppl., October 1, 2005; 7(suppl_J): J21 - J25.
[Abstract] [Full Text] [PDF]


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Am J Crit CareHome page
P. Davidson, G. Paull, D. Rees, J. Daly, and J. Cockburn
Activities of Home-Based Heart Failure Nurse Specialists: A Modified Narrative Analysis
Am. J. Crit. Care., September 1, 2005; 14(5): 426 - 433.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
J. McMurray, A. Cohen-Solal, R. Dietz, E. Eichhorn, L. Erhardt, F.D. R. Hobbs, H. Krum, A. Maggioni, R. S. McKelvie, I. L. Pina, et al.
Practical recommendations for the use of ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers in heart failure: Putting guidelines into practice
Eur J Heart Fail, August 1, 2005; 7(5): 710 - 721.
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CMAJHome page
A. Ducharme, O. Doyon, M. White, J. L. Rouleau, and J. M. Brophy
Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial
Can. Med. Assoc. J., July 5, 2005; 173(1): 40 - 45.
[Abstract] [Full Text] [PDF]


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CMAJHome page
M. W. Rich
Multidisciplinary heart failure clinics: Are they effective in Canada?
Can. Med. Assoc. J., July 5, 2005; 173(1): 53 - 54.
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Arch Intern MedHome page
S. Stewart, F. A. McAlister, and J. J. V. McMurray
Heart Failure Management Programs Reduce Readmissions and Prolong Survival
Arch Intern Med, June 13, 2005; 165(11): 1311 - 1311.
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HeartHome page
T. Jaarsma
Inter-professional team approach to patients with heart failure
Heart, June 1, 2005; 91(6): 832 - 838.
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Eur Heart JHome page
Authors/Task Force Members, K. Swedberg, Writing Committee:, J. Cleland, H. Dargie, H. Drexler, F. Follath, M. Komajda, L. Tavazzi, O. A. Smiseth, et al.
Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology
Eur. Heart J., June 1, 2005; 26(11): 1115 - 1140.
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Eur J Heart FailHome page
S. Stewart
Recognising the "other half" of the heart failure equation: are we doing enough for family caregivers?
Eur J Heart Fail, June 1, 2005; 7(4): 590 - 591.
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Journal of Renin-Angiotensin-Aldosterone SystemHome page
K. Swedberg
Review: Effective Implementation of the New ESC Guidelines for the Management of Chronic Heart Failure in Routine Clinical Practice
Journal of Renin-Angiotensin-Aldosterone System, June 1, 2005; 6(2_suppl): S6 - S10.
[Abstract] [PDF]


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J Am Coll CardiolHome page
J. G.F. Cleland, A. A. Louis, A. S. Rigby, U. Janssens, A. H.M.M. Balk, and TEN-HMS Investigators
Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death: The Trans-European Network-Home-Care Management System (TEN-HMS) study
J. Am. Coll. Cardiol., May 17, 2005; 45(10): 1654 - 1664.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
E. P. Havranek
Improving the Outcomes of Heart Failure Care: Putting Technology Second
J. Am. Coll. Cardiol., May 17, 2005; 45(10): 1665 - 1666.
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HeartHome page
T A McDonagh
Lessons from the management of chronic heart failure
Heart, May 1, 2005; 91(suppl_2): ii24 - ii27.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
C. O. Phillips, R. M. Singa, H. R. Rubin, and T. Jaarsma
Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis
Eur J Heart Fail, March 16, 2005; 7(3): 333 - 341.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
T. Jaarsma
Health care professionals in a heart failure team
Eur J Heart Fail, March 16, 2005; 7(3): 343 - 349.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
L. Blue and J. McMurray
How much responsibility should heart failure nurses take?
Eur J Heart Fail, March 16, 2005; 7(3): 351 - 361.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
A. Stromberg
The crucial role of patient education in heart failure
Eur J Heart Fail, March 16, 2005; 7(3): 363 - 369.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
D. R. Thompson, A. Roebuck, and S. Stewart
Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure
Eur J Heart Fail, March 16, 2005; 7(3): 377 - 384.
[Abstract] [Full Text] [PDF]


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Eur J Heart FailHome page
S. Stewart
Financial aspects of heart failure programs of care
Eur J Heart Fail, March 16, 2005; 7(3): 423 - 428.
[Abstract] [Full Text] [PDF]


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CMAJHome page
J. G.F. Cleland
Patients with treatable malignant diseases -- including heart failure -- are entitled to specialist care
Can. Med. Assoc. J., January 18, 2005; 172(2): 207 - 209.
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CirculationHome page
G. C. Fonarow
Heart Failure Disease Management Programs: Not a Class Effect
Circulation, December 7, 2004; 110(23): 3506 - 3508.
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JWatch Emergency Med.Home page
Multidisciplinary Management of Heart Failure Saves Lives
Journal Watch Emergency Medicine, October 27, 2004; 2004(1027): 2 - 2.
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