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Friday 24 May 2019
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Home-based HF program

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A home-based intervention for managing chronic heart failure (CHF) patients had mortality and unplanned hospitalisation rates similar to a clinic-based intervention but cost the healthcare system one-third less, according to a randomised trial. The cost savings were mostly due to fewer days in the hospital.
The results appeared in the October 2 issue of the Journal of the American College of Cardiology.
Simon Stewart, PhD, of the Baker IDI Heart and Diabetes Institute in Melbourne, Australia, and colleagues compared two ways to manage CHF patients post-discharge: a home-based intervention (HBI) and a clinic-based intervention (CBI). The multidisciplinary management programs differed in only one respect. CBI patients were randomised to receive a home visit from a CHF-trained nurse within seven to 14 days of discharge while CBI patients were managed through a specialist CHF clinic as outpatients.
The study was conducted through WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care), a prospective, multi-centre randomised controlled trial. Researchers enrolled 280 patients at three tertiary referral hospitals in Australia discharged to home with a diagnosis of CHF that was confirmed by a cardiologist. The HBI group included 143 patients, 140 of whom were visited at home. The CBI group had 137 patients, 124 of whom visited the clinic.
"With the exception of access to the CHF clinic (CBI group) and home visits (HBI), patients in both groups had access to the same healthcare professionals (including cardiologists and family physicians)," Stewart and colleagues wrote. "This environment enabled us to standardise the level and qualities of care provided, and observe critical differences in patient journeys according to the mode of CHF-MP [CHF-management program] applied."
The primary endpoint was all-cause unplanned hospitalisation or death during 12- and 18-month follow-up. Researchers also tracked event-free survival, which they measured as days alive out of hospital, pharmacologic therapy at baseline and 12-month follow-up, health-related quality of life data and health utilisation data. Costs were in 2009-2010 Australian dollars, which were roughly the same as 2009-2010 US dollars.
The two groups were well matched with the exception that the HBI group was, on average, three years younger and tended to have less comorbidity. 
Unplanned hospitalisation or death occurred in 71% of the HBI group compared with 76% of the CBI group. Twelve-month all-cause mortality rates were 18% in the HBI group and 22% in the CBI group, and 67% of the HBI patients had one or more unplanned readmission compared with 69% of the HBI group.
But the two groups differed on hospital duration. The average length of stay for an unplanned hospitalisation in the HBI group was lower, with a median of four days versus a median of six days in the CBI group. Researchers attributed the difference in days of hospitalisation to 64 patients who were hospitalised for 25 days or more during the study follow-up. Among those patients, 67% were in the CBI group.
Hospital costs ate up a large portion of total costs for both groups, at 89% for the HBI group and 93% for the CBI group. The management programs themselves carried similar costs. Due to the fewer days of hospitalisation, total healthcare costs in the HBI program were less, at $3.93 million (both US and Australian dollars) versus $5.53 million for CBI program.
"Reflecting shorter episodes of hospitalisation (the most costly component of CHF management), HBI patients accumulated significantly fewer days of total all-cause (35%  days fewer) and cardiovascular-related hospitalisation (37% days fewer), with a consistent (borderline) trend with respect to less unplanned hospitalisation (30% days fewer)," they wrote. "HBI was also associated with a nonsignificant reduction in CHF stay. Combined, this resulted in significantly more prolonged days out of hospital alive in favour of HBI."
Evaluating differences between the programs, the authors suggested that HBI patients appeared to be more engaged. They noted that the HBI approach potentially allowed caregivers to accurately assess the patient's clinical and psychological state and ability to take care of him or herself. With that knowledge, physicians could devise a tailored management program.
They listed among the study's limitation possible differences in the quality of care and baseline differences between the two patient groups. They added that long-term cost could be affected by greater morbidity among survivors.
Within the study's timeframe, they noted that total healthcare costs were almost one-third less in the HBI group. "The fact that we observed the greatest differences with respect to all-cause and cardiovascular-related hospitalisation in this typically older cohort of CHF patients suggests that the benefits of a more generic hospital transition program involving home visits outweigh a more CHF-specific focus," they concluded.

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