A systematic review of randomized trials of disease management programs in heart failure

PURPOSE: Disease management programs are often advocated for the care of patients with chronic disease. This systematic review was conducted to determine whether these programs improve outcomes for patients with heart failure. METHODS: Randomized clinical trials of disease management programs in patients with heart failure were identified by searching Medline 1966 to 1999, Embase 1980 to 1998, Cinahl 1982 to 1999, Sigle 1980 to 1998, the Cochrane Controlled Trial Registry, the Cochrane Effective Practice and Organization of Care Study Registry, and the bibliographies of published studies. We also contacted experts in the field. Studies were selected and data extracted independently by two investigators, and summary risk ratios (RR) and 95% confidence intervals (CI) were calculated using both the random and fixed effects 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 effects 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 reduced by the programs. However, there were considerable differences in the effects 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 trials employing telephone contact with improved coordination of primary care services 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 reduce hospitalizations and appear to be cost saving. Data on mortality are inconclusive. Further studies are needed to establish the incremental benefits of the different elements of these programs.