Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure.
BACKGROUND
Few studies have examined the potential benefits of specialist nurse-led programs of care involving home and clinic-based follow-up to optimise the post-discharge management of chronic heart failure (CHF).


OBJECTIVE
To determine the effectiveness of a hybrid program of clinic plus home-based intervention (C+HBI) in reducing recurrent hospitalisation in CHF patients.


METHODS
CHF patients with evidence of left ventricular systolic dysfunction admitted to two hospitals in Northern England were assigned to a C+HBI lasting 6 months post-discharge (n=58) or to usual, post-discharge care (UC: n=48) via a cluster randomization protocol. The co-primary endpoints were death or unplanned readmission (event-free survival) and rate of recurrent, all-cause readmission within 6 months of hospital discharge.


RESULTS
During study follow-up, more UC patients had an unplanned readmission for any cause (44% vs. 22%: P=0.019, OR 1.95 95% CI 1.10-3.48) whilst 7 (15%) versus 5 (9%) UC and C+HBI patients, respectively, died (P=NS). Overall, 15 (26%) C+HBI versus 21 (44%) UC patients experienced a primary endpoint. C+HBI was associated with a non-significant, 45% reduction in the risk of death or readmission when adjusting for potential confounders (RR 0.55, 95% CI 0.28-1.08: P=0.08). Overall, C+HBI patients accumulated significantly fewer unplanned readmissions (15 vs. 45: P<0.01) and days of recurrent hospital stay (108 vs. 459 days: P<0.01). C+HBI was also associated with greater uptake of beta-blocker therapy (56% vs. 18%: P<0.001) and adherence to Na restrictions (P<0.05) during 6-month follow-up.


CONCLUSIONS
This is the first randomised study to specifically examine the impact of a hybrid, C+HBI program of care on hospital utilisation in patients with CHF. Its beneficial effects on recurrent readmission and event-free survival are consistent with those applying either a home or clinic-based approach.
Thompson
David R
DR
Chinese University of Hong Kong, Hong Kong.
Roebuck
Alun
A
Stewart
Simon
S
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D004232:Diuretics / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000451:nursing* / Q000628:therapy; D006699:Home Care Services; D006760:Hospitalization; D006801:Humans; D008297:Male; D009722:Nurse Practitioners; D010044:Outpatient Clinics, Hospital; D010343:Patient Admission / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D011788:Quality of Life; D013148:Spironolactone / Q000627:therapeutic use; D013997:Time Factors
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D004232:Diuretics; D013148:Spironolactone