Prolonged impact of home versus clinic-based management of chronic heart failure: extended follow-up of a pragmatic, multicentre randomized trial cohort.
OBJECTIVE
We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).


METHODS
We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.


RESULTS
280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n=143) or clinic-based (n=137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p=0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p=0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p=0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p<0.01 for rate and duration of hospital stay).


CONCLUSIONS
Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.


BACKGROUND
Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803).
Preventative Cardiology and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Electronic address: simon.stewart@bakeridi.edu.au.
Simon
S
Stewart
Preventative Cardiology and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
Melinda J
MJ
Carrington
The Queen Elizabeth Hospital and University of Adelaide, Adelaide, Australia.
John D
JD
Horowitz
Menzies Research Institute Tasmania, Hobart, Australia.
Thomas H
TH
Marwick
The Centre for Cardiovascular and Chronic Care, University of Technology Sydney, St Vincent's and Mater Health, Sydney, Australia.
Phillip J
PJ
Newton
Faculty of Health, University of Technology Sydney and St Vincent's Hospital, Sydney, Australia.
Patricia M
PM
Davidson
St Vincent's Hospital and Victor Chang Cardiac Research Institute, Sydney, Australia.
Peter
P
Macdonald
Cardiovascular Research Centre, Faculty of Health Science, Australian Catholic University, Melbourne, Australia.
David R
DR
Thompson
Preventative Cardiology and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
Yih-Kai
YK
Chan
Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health & Preventive Medicine, Monash University, Australia.
Henry
H
Krum
Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health & Preventive Medicine, Monash University, Australia.
Christopher
C
Reid
Centre for Applied Health Economics, School of Medicine, Griffith Health Institute, Griffith University, Brisbane, Australia.
Paul A
PA
Scuffham
D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D015331:Cohort Studies; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D006699:Home Care Services / Q000639:trends*; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D010351:Patient Discharge / Q000639:trends; D016037:Single-Blind Method; D013997:Time Factors
Chronic heart failure; Disease management programs; Readmission; Survival