title: Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis.
abstract: OBJECTIVE
  To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics.
  
  
  METHODS
  We searched MEDLINE (1966-November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure.
  
  
  METHODS
  Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized.
  
  
  RESULTS
  Six trials were selected (N=949, mean age 73 years [range 62-79], men 58%, LVEF 34% [27-41], and average follow-up of 8.5 months [3-12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient -0.26 [-0.49,-0.02] vs. 0.09 [-1.17, 1.34].
  
  
  CONCLUSIONS
  HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. chr_phi@yahoo.com
authors.forename: Christopher O
authors.initials: CO
authors.lastname: Phillips
authors.forename: Ramesh M
authors.initials: RM
authors.lastname: Singa
authors.forename: Haya R
authors.initials: HR
authors.lastname: Rubin
authors.forename: Tiny
authors.initials: T
authors.lastname: Jaarsma
mesh_terms: D000368:Aged; D002985:Clinical Protocols; D002986:Clinical Trials as Topic; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000451:nursing / Q000628:therapy*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009720:Nurse Clinicians; D011788:Quality of Life; D012044:Regression Analysis