Heart failure: a home-based intervention on discharge reduced out-of-hospital death and length of subsequent hospitalisations

Clinical bottom line (level 1b)

  1. Patients recently discharged with congestive heart failure who received home-based intervention compared with routine follow-up were less likely to die out of hospital (NNT = 7 at 18 months) , and spend less time in hospital over the next 18 months (on average 11 days fewer).
Stewart et al: Archives of Internal Medicine 1999; 159: 257-261
Expires October 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: acute tertiary hospital, Australia

97 patients (aged 36 to 93; mean 75, 52% female) 1 week after discharge following an episode of congestive heart failure (59% with acute pulmonary edema, 28% with fast AF, 21% with acute ischaemia) and
  • impaired systolic function (left ventricular ejection fraction = 55% on echocardiography or radionuclide ventriculography)
  • persistent functional impairment (NYHA class II or higher)
  • a history of 1 or more hospital admissions for acute heart failure


Excluded if
  • acute myocardial infarction or unstable angina which might have caused reduced systolic function leading to admission
  • terminal malignancy requiring palliative care
  • home address outside hospital catchment area


    • Control Group: (n = 48, 48 analysed): usual levels of postdischarge care: appointments with primary care physician or cardiologist within 2 weeks of discharge. 27% received regular home support (domiciliary care or community nurse visits)
    Experimental Group: (n = 49, 49 analysed): single home visit by a nurse and a pharmacist to assess the need for further intervention and to ensure optimal compliance with medication
    99% of patients were on a diuretic, 81% on an ACE inhibitor and 67% on digoxin.
    100% followed for 18 months

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    out-of-hospital death 18 months 9
    (18.8%)    		 2
    (4.08%)    		 78%
    (4% to 95%)    		 14.7%
    (2.31% to 27.0%)    		 7
    (4 to 43)
    unplanned readmissions or an out-of-hospital death 18 months 39
    (81.3%)    		 33
    (67.4%)    		 17%
    (-5% to 35%)    		 13.9%
    (-3.25% to 31.1%)    		 7
    (NNT = 3 to infinity;
    NNH = 31 to infinity)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    days in hospital 21.1
    (24.1)     		10.5
    (14.4)     		11
    (2.6 to 19)

    Comments

    1. The study is too small to demonstrate a reduction in unplanned admissions.
    2. These patients come from a larger randomised trial comparing home-based intervention in a broader collection of conditions. Unclear whether this analysis is data-dependent or a priori.
    3. Half of patients were not fully compliant with their medication (based on pill count) and 90% had inadequate knowledge about dosage, intended effect, possible adverse effects or special instructions.

    Citation

    1. Stewart S, Vandenbrock AJ, Pearson S, et al: prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Archives of Internal Medicine 1999; 159: 257-261
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer:

    Clinical Question.
    Patient heart failure
    Intervention or Exposure nurse/pharmacist home intervention
    Outcome mortality, readmission duration