title: Impact of home versus clinic-based management of chronic heart failure: the WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care) multicenter, randomized trial.
abstract: OBJECTIVE
  The goal of this study was to make a head-to-head comparison of 2 common forms of multidisciplinary chronic heart failure (CHF) management.
  
  
  BACKGROUND
  Although direct patient contact appears to be best in delivering CHF management overall, the precise form to optimize health outcomes is less clear.
  
  
  METHODS
  This prospective, multicenter randomized controlled trial with blinded endpoint adjudication comprised 280 hospitalized CHF patients (73% male, age 71 ± 14 years, and 73% with left ventricular ejection fraction ≤45%) randomized to home-based intervention (HBI) or specialized CHF clinic-based intervention (CBI). The primary endpoint was all-cause, unplanned hospitalization or death during 12- to 18-month follow-up. Secondary endpoints included type/duration of hospitalization and healthcare costs.
  
  
  RESULTS
  The primary endpoint occurred in 102 of 143 (71%) HBI versus 104 of 137 (76%) CBI patients (adjusted hazard ratio [HR]: 0.97 [95% confidence interval (CI): 0.73 to 1.30], p = 0.861): 96 (67.1%) HBI versus 95 (69.3%) CBI patients had an unplanned hospitalization (p = 0.887), and 31 (21.7%) versus 38 (27.7%) died (p = 0.252). The median duration of each unplanned hospitalization was significantly less in the HBI group (4.0 [interquartile range (IQR): 2.0 to 7.0] days vs. 6.0 [IQR: 3.5 to 13] days; p = 0.004). Overall, 75% of all hospitalization was attributable to 64 (22.9%) patients, of whom 43 (67%) were CBI patients (adjusted odds ratio: 2.55 [95% CI: 1.37 to 4.73], p = 0.003). HBI was associated with significantly fewer days of all-cause hospitalization (-35%; p = 0.003) and from cardiovascular causes (-37%; p = 0.025) but not for CHF (-24%; p = 0.218). Consequently, healthcare costs ($AU3.93 vs. $AU5.53 million) were significantly less for the HBI group (median: $AU34 [IQR: 13 to 81] per day vs. $AU52 [17 to 140] per day; p = 0.030).
  
  
  CONCLUSIONS
  HBI was not superior to CBI in reducing all-cause death or hospitalization. However, HBI was associated with significantly lower healthcare costs, attributable to fewer days of hospitalization. (Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [WHICH?]; ACTRN12607000069459).
authors.affiliation: Preventative Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia. simon.stewart@bakeridi.edu.au
authors.forename: Simon
authors.initials: S
authors.lastname: Stewart
authors.forename: Melinda J
authors.initials: MJ
authors.lastname: Carrington
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Marwick
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Davidson
authors.forename: Peter
authors.initials: P
authors.lastname: Macdonald
authors.forename: John D
authors.initials: JD
authors.lastname: Horowitz
authors.forename: Henry
authors.initials: H
authors.lastname: Krum
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Newton
authors.forename: Christopher
authors.initials: C
authors.lastname: Reid
authors.forename: Yih Kai
authors.initials: YK
authors.lastname: Chan
authors.forename: Paul A
authors.initials: PA
authors.lastname: Scuffham
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data*; D001315:Australia; D002317:Cardiovascular Agents / Q000627:therapeutic use; D002908:Chronic Disease; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000191:economics / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006699:Home Care Services / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data; D011446:Prospective Studies; D011788:Quality of Life; D013318:Stroke Volume / Q000502:physiology; D011795:Surveys and Questionnaires; D018487:Ventricular Dysfunction, Left
chemical_list: D002317:Cardiovascular Agents