A systematic review of randomized trials of disease management programs inheart failure

PURPOSE: Disease management programs are often advocated for the care of pa tients with chronic disease. This systematic review was conducted to determ ine whether these programs improve outcomes for patients with heart failure . METHODS: Randomized clinical trials of disease management programs in patie nts with heart failure were identified by searching Medline 1966 to 1999, E mbase 1980 to 1998, Cinahl 1982 to 1999, Sigle 1980 to 1998, the Cochrane C ontrolled Trial Registry, the Cochrane Effective Practice and Organization of Care Study Registry, and the bibliographies of published studies. We als o contacted experts in the field. Studies were selected and data extracted independently by two investigators, and summary risk ratios (RR) and 95% co nfidence intervals (CI) were calculated using both the random and fixed eff ects models. RESULTS: A total of 11 trials (involving 2,067 patients with heart failure) were identified. Disease management programs were cost saving in 7 of the 8 trials that reported cost data and also appeared to have beneficial effec ts on prescribing practices. Hospitalizations (RR = 0.87, 95% CI: 0.79 to 0 .96 but not all-cause mortality (RR = 0.94, 95% CI: 0.75 to 1.19) were redu ced by the programs. However, there were considerable differences in the ef fects of various interventions on hospitalization rates; specialized follow -up by a multidisciplinary team led to a substantial reduction in the risk of hospitalization (RR = 0.77, 95% CI 0.68 to 0.86, n = 1366), whereas tria ls employing telephone contact with improved coordination of primary care s ervices failed to find any benefit (RR = 1.15, 95% CI 0.96 to 1.37, n = 646 ). CONCLUSION: Disease management programs for the care of patients with heart failure that involve specialized follow-up by a multidisciplinary team red uce hospitalizations and appear to be cost saving. Data on mortality are in conclusive. Further studies are needed to establish the incremental benefit s of the different elements of these programs. (C) 2001 by Excerpta Medica, Inc.