PMID- 23074521
OWN - NLM
STAT- PubMed-not-MEDLINE
DCOM- 20121018
LR  - 20211021
IS  - 1915-7398 (Print)
IS  - 1915-7398 (Electronic)
IS  - 1915-7398 (Linking)
VI  - 9
IP  - 17
DP  - 2009
TI  - Community-based care for the specialized management of heart failure: an 
      evidence-based analysis.
PG  - 1-42
AB  - In August 2008, the Medical Advisory Secretariat (MAS) presented a vignette to 
      the Ontario Health Technology Advisory Committee (OHTAC) on a proposed targeted 
      health care delivery model for chronic care. The proposed model was defined as 
      multidisciplinary, ambulatory, community-based care that bridged the gap between 
      primary and tertiary care, and was intended for individuals with a chronic 
      disease who were at risk of a hospital admission or emergency department visit. 
      The goals of this care model were thought to include: the prevention of emergency 
      department visits, a reduction in hospital admissions and re-admissions, 
      facilitation of earlier hospital discharge, a reduction or delay in long-term 
      care admissions, and an improvement in mortality and other disease-specific 
      patient outcomes.OHTAC approved the development of an evidence-based assessment 
      to determine the effectiveness of specialized community based care for the 
      management of heart failure, Type 2 diabetes and chronic wounds.PLEASE VISIT THE 
      MEDICAL ADVISORY SECRETARIAT WEB SITE AT: www.health.gov.on.ca/ohtas to review 
      the following reports associated with the Specialized Multidisciplinary 
      Community-Based care series.Specialized multidisciplinary community-based care 
      series: a summary of evidence-based analysesCommunity-based care for the 
      specialized management of heart failure: an evidence-based 
      analysisCommunity-based care for chronic wound management: an evidence-based 
      analysisPlease note that the evidence-based analysis of specialized 
      community-based care for the management of diabetes titled: "Community-based care 
      for the management of type 2 diabetes: an evidence-based analysis" has been 
      published as part of the Diabetes Strategy Evidence Platform at this URL: 
      http://www.health.gov.on.ca/english/providers/program/mas/tech/ohtas/tech_diabetes_20091020.htmlPLEASE 
      VISIT THE TORONTO HEALTH ECONOMICS AND TECHNOLOGY ASSESSMENT COLLABORATIVE WEB 
      SITE AT: http://theta.utoronto.ca/papers/MAS_CHF_Clinics_Report.pdf to review the 
      following economic project associated with this series:Community-based Care for 
      the specialized management of heart failure: a cost-effectiveness and budget 
      impact analysis. OBJECTIVE: The objective of this evidence-based analysis was to 
      determine the effectiveness of specialized multidisciplinary care in the 
      management of heart failure (HF). CLINICAL NEED: TARGET POPULATION AND CONDITION 
      HF is a progressive, chronic condition in which the heart becomes unable to 
      sufficiently pump blood throughout the body. There are several risk factors for 
      developing the condition including hypertension, diabetes, obesity, previous 
      myocardial infarction, and valvular heart disease.(1) Based on data from a 2005 
      study of the Canadian Community Health Survey (CCHS), the prevalence of 
      congestive heart failure in Canada is approximately 1% of the population over the 
      age of 12.(2) This figure rises sharply after the age of 45, with prevalence 
      reports ranging from 2.2% to 12%.(3) Extrapolating this to the Ontario 
      population, an estimated 98,000 residents in Ontario are believed to have HF. 
      Disease management programs are multidisciplinary approaches to care for chronic 
      disease that coordinate comprehensive care strategies along the disease continuum 
      and across healthcare delivery systems.(4) Evidence for the effectiveness of 
      disease management programs for HF has been provided by seven systematic reviews 
      completed between 2004 and 2007 (Table 1) with consistency of effect demonstrated 
      across four main outcomes measures: all cause mortality and hospitalization, and 
      heart-failure specific mortality and hospitalization. (4-10) However, while 
      disease management programs are multidisciplinary by definition, the published 
      evidence lacks consistency and clarity as to the exact nature of each program and 
      usual care comparators are generally ill defined. Consequently, the effectiveness 
      of multidisciplinary care for the management of persons with HF is still 
      uncertain. Therefore, MAS has completed a systematic review of specialized, 
      multidisciplinary, community-based care disease management programs compared to a 
      well-defined usual care group for persons with HF. RESEARCH QUESTIONS: What is 
      the effectiveness of specialized, multidisciplinary, community-based care (SMCCC) 
      compared with usual care for persons with HF? LITERATURE SEARCH STRATEGY: A 
      comprehensive literature search was completed of electronic databases including 
      MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane 
      Library and Cumulative Index to Nursing & Allied Health Literature. Bibliographic 
      references of selected studies were also searched. After a review of the title 
      and abstracts, relevant studies were obtained and the full reports evaluated. All 
      studies meeting explicit inclusion and exclusion criteria were retained. Where 
      appropriate, a meta-analysis was undertaken to determine the pooled estimate of 
      effect of specialized multidisciplinary community-based care for explicit 
      outcomes. The quality of the body of evidence, defined as one or more relevant 
      studies was determined using GRADE Working Group criteria. (11) INCLUSION 
      CRITERIA: Randomized controlled trialSystematic review with meta 
      analysisPopulation includes persons with New York Heart Association (NYHA) 
      classification 1-IV HFThe intervention includes a team consisting of a nurse and 
      physician one of which is a specialist in HF management.The control group 
      receives care by a single practitioner (e.g. primary care physician (PCP) or 
      cardiologist)The intervention begins after discharge from the hospitalThe study 
      reports 1-year outcomes EXCLUSION CRITERIA: The intervention is delivered 
      predominately through home-visitsStudies with mixed populations where discrete 
      data for HF is not reported OUTCOMES OF INTEREST: All cause mortalityAll cause 
      hospitalizationHF specific mortalityHF specific hospitalizationAll cause duration 
      of hospital stayHF specific duration of hospital stayEmergency room visitsQuality 
      of Life SUMMARY OF FINDINGS: One large and seven small randomized controlled 
      trials were obtained from the literature search. A meta-analysis was completed 
      for four of the seven outcomes including: All cause mortalityHF-specific 
      mortalityAll cause hospitalizationHF-specific hospitalization.Where the pooled 
      analysis was associated with significant heterogeneity, subgroup analyses were 
      completed using two primary categories: direct and indirect model of care; 
      andtype of control group (PCP or cardiologist).The direct model of care was a 
      clinic-based multidisciplinary HF program and the indirect model of care was a 
      physician supervised, nurse-led telephonic HF program. All studies, except one, 
      were completed in jurisdictions outside North America. (12-19) Similarly, all but 
      one study had a sample size of less than 250. The mean age in the studies ranged 
      from 65 to 77 years. Six of the studies(12;14-18) included populations with a 
      NYHA classification of II-III. In two studies, the control treatment was a 
      cardiologist (12;15) and two studies reported the inclusion of a dietitian, 
      physiotherapist and psychologist as members of the multidisciplinary team 
      (12;19). ALL CAUSE MORTALITY: Eight studies reported all cause mortality (number 
      of persons) at 1 year follow-up. (12-19) When the results of all eight studies 
      were pooled, there was a statistically significant RRR of 29% with moderate 
      heterogeneity (I(2) of 38%). The results of the subgroup analyses indicated a 
      significant RRR of 40% in all cause mortality when SMCCC is delivered through a 
      direct team model (clinic) and a 35% RRR when SMCCC was compared with a primary 
      care practitioner. HF-SPECIFIC MORTALITY: Three studies reported HF-specific 
      mortality (number of persons) at 1 year follow-up. (15;18;19) When the results of 
      these were pooled, there was an insignificant RRR of 42% with high statistical 
      heterogeneity (I(2) of 60%). The GRADE quality of evidence is moderate for the 
      pooled analysis of all studies. ALL CAUSE HOSPITALIZATION: Seven studies reported 
      all cause hospitalization at 1-year follow-up (13-15;17-19). When pooled, their 
      results showed a statistically insignificant 12% increase in hospitalizations in 
      the SMCCC group with high statistical heterogeneity (I(2) of 81%). A significant 
      RRR of 12% in all cause hospitalization in favour of the SMCCC care group was 
      achieved when SMCCC was delivered using an indirect model (telephonic) with an 
      associated (I(2) of 0%). The Grade quality of evidence was found to be low for 
      the pooled analysis of all studies and moderate for the subgroup analysis of the 
      indirect team care model. HF-SPECIFIC HOSPITALIZATION: Six studies reported 
      HF-specific hospitalization at 1-year follow-up. (13-15;17;19) When pooled, the 
      results of these studies showed an insignificant RRR of 14% with high statistical 
      heterogeneity (I(2) of 60%); however, the quality of evidence for the pooled 
      analysis of was low. DURATION OF HOSPITAL STAY: Seven studies reported duration 
      of hospital stay, four in terms of mean duration of stay in days (14;16;17;19) 
      and three in terms of total hospital bed days (12;13;18). Most studies reported 
      all cause duration of hospital stay while two also reported HF-specific duration 
      of hospital stay. These data were not amenable to meta-analyses as standard 
      deviations were not provided in the reports. However, in general (and in all but 
      one study) it appears that persons receiving SMCCC had shorter hospital stays, 
      whether measured as mean days in hospital or total hospital bed days. EMERGENCY 
      ROOM VISITS: Only one study reported emergency room visits. (14) This was 
      presented as a composite of readmissions and ER visits, where the authors 
      reported that 77% (59/76) of the SMCCC group and 84% (63/75) of the usual care 
      group were either readmitted or had an ER visit within the 1 year of follow-up 
      (P=0.029). (ABSTRACT TRUNCATED)
CN  - Medical Advisory Secretariat
LA  - eng
PT  - Journal Article
DEP - 20091101
PL  - Canada
TA  - Ont Health Technol Assess Ser
JT  - Ontario health technology assessment series
JID - 101521610
PMC - PMC3377506
EDAT- 2009/01/01 00:00
MHDA- 2009/01/01 00:01
PMCR- 2009/11/01
CRDT- 2012/10/18 06:00
PHST- 2012/10/18 06:00 [entrez]
PHST- 2009/01/01 00:00 [pubmed]
PHST- 2009/01/01 00:01 [medline]
PHST- 2009/11/01 00:00 [pmc-release]
PST - ppublish
SO  - Ont Health Technol Assess Ser. 2009;9(17):1-42. Epub 2009 Nov 1.