QUARTERLY FOCUS ISSUE: HEART FAILURE: VIEWPOINT
What Is the Strength of Evidence for Heart Failure Disease-Management Programs?
Alexander M. Clark, PhD*,*,
Lori A. Savard, BSc* and
David R. Thompson, PhD
* University of Alberta, Edmonton, Alberta, Canada
Department of Health Sciences and Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
Manuscript received March 1, 2009;
revised manuscript received April 6, 2009,
accepted April 14, 2009.
* Reprint requests and correspondence: Dr. Alexander M. Clark, University of Alberta, Level 3, Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada (Email: alex.clark{at}ualberta.ca).
Heart failure (HF) disease-management programs are increasingly common. However, some large and recent trials of programs have not reported positive findings. There have also been parallel recent advances in reporting standards and theory around complex nonpharmacological interventions. These developments compel reconsideration in this Viewpoint of how research into HF-management programs should be evaluated, the quality, specificity, and usefulness of this evidence, and the recommendations for future research. Addressing the main determinants of intervention effectiveness by using the PICO (Patient, Intervention, Comparison, and Outcome) approach and the recent CONSORT (Consolidated Standards of Reporting Trials) statement on nonpharmacological trials, we will argue that in both current trials and meta-analyses, interventions and comparisons are not sufficiently well described; that complex programs have been excessively oversimplified; and that potentially salient differences in programs, populations, and settings are not incorporated into analyses. In preference to more general meta-analyses of programs, adequate descriptions are first needed of populations, interventions, comparisons, and outcomes in past and future trials. This could be achieved via a systematic survey of study authors based on the CONSORT statement. These more detailed data on studies should be incorporated into future meta-analyses of comparable trials and used with other techniques such as patient-based outcomes data and meta-regression. Although trials and meta-analyses continue to have potential to generate useful evidence, a more specific evidence base is needed to support the development of effective programs for different populations and settings.
Key Words: chronic • health promotion • self care • disease management • CHF
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Abbreviations and Acronyms
| | AHA = American Heart Association | | CONSORT = Consolidated Standards of Reporting Trials | | HF = heart failure | | PICO = Patient, Intervention, Comparison, Outcome |
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