LETTER TO THE EDITOR
The optimal "dose" of disease management programs in HF
T. Jaarsma, RN, PhD
Department of CardiologyThoraxcenterUniversity Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
Dirk J. van Veldhuisen, MD, PhD, FACC
t.Jaarsma{at}thorax.azg.nl
Dr. Krumholz and his colleagues are to be congratulated with their effects of a targeted education and support intervention on the rate of readmission or death and hospital cost in patients with heart failure (HF) (1). This study adds to the understanding that education and support should be a component of an intervention program for HF patients. As noted by the investigators, there is evidence that multidisciplinary HF programs may improve patient outcomes in respect to health care utilization, costs and quality of life (2). Key components recognized by the American Heart Association include education and advice, availability of health care providers, counselling after discharge and optimal medical therapy (3). Studies that established the effect of separate components are scarce, and Krumholz et al. (1) showed that education and support alone can substantially improve outcome. Most groups, however, argue that both components (i.e., pharmacologic and nonpharmacologic HF management strategies) are required (4).
In the Krumholz et al. study (1), patients were educated in an hour-long face-to-face session, with intensive monitoring after discharge. Previous data indicate that intensive education during hospitalization with only one outpatient follow-up visit is not sufficient to reduce rehospitalization (5). In a similar study with two follow-up outpatient visits, however, Cline et al. (6) were able to demonstrate a significant benefit from the intervention.
The question then is this: How intense should an HF program be? To date, there are no studies that compare the relative effectiveness of different programs. For this reason, we have recently started a multicenter randomized trial in the Netherlands that will include 1,050 HF patients. In this Coordinating study evaluating Outcomes of Advising and Counseling in Heart Failure (COACH), patients are randomized into three arms: 1) care as usual, 2) basic education and support, and 3) intensive education and support; patients will be followed for at least two years. Outcomes of this study are time to first major event (HF hospitalizations and death), quality of life and costs. With this trial we aim to derive insight into the optimal dose of an HF intervention, enabling us to make rational and responsible choices in the future on which components of an HF management program should be expanded and which components can perhaps be deleted. In the meantime, studies similar to those by Krumholz et al. (1) are awaited, thus adding importantly to our understanding.
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References
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1. Krumholz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol. 2002;39:83–89[Abstract/Free Full Text]
2. McAlister FA, Lawson FM, Teo KK, Armstrong PW. A systematic review of randomized trials of disease management programs in heart failure. Am J Med. 2001;110:378–384[CrossRef][Medline]
3. Grady KL, Dracup K, Kennedy G, et al. Team management of patients with heart failure; a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation. 2000;102:2443–2456[Free Full Text]
4. Cunningham SL, Mayet J. Modern management of heart failure: education as well as medication. Eur Heart J. 2002;23:101–102[Free Full Text]
5. Jaarsma T, Halfens R, Huijer ASH, et al. Effects of education and support on self-care and resource utilization in patients with heart failure. Eur Heart J. 1999;20:673–682[Abstract/Free Full Text]
6. Cline CMJ, Israelsson BYA, Willenheimer RB, et al. Cost-effective management program for heart failure reduces rehospitalisation. Heart. 1998;80:442–446[Abstract/Free Full Text]
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