Capomolla Soccorso, Febo Oreste, Ceresa Monica, Caporotondi Angelo, Guazzotti Giampaolo, La Rovere Maria, Ferrari Marina, Lenta Francesca, Baldin Sonia, Vaccarini Chiara, Gnemmi Marco, Pinna GianDomenico, Maestri Roberto, Abelli Paola, Verdirosi Sandro, Cobelli Franco
Fondazione Salvatore Maugeri, IRCCS, Dipartimento di Cardiologia, Istituto Scientifico di Montescano, Montescano, Pavia, Italy.
J Am Coll Cardiol. 2002 Oct 2;40(7):1259-66. doi: 10.1016/s0735-1097(02)02140-x.
This study compared the effectiveness and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care in chronic heart failure (CHF) outpatients.
Previous studies showed that about 50% of readmissions for CHF can be prevented by a multidisciplinary approach. However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management related to evidence-based medicine have not been considered.
A total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared.
After 12 +/- 3 months of follow-up, the individual rate access in DH was 5.5 +/- 3.8 days. The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13 vs. 78, p < 0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed a cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 (CI $13,904 to $34,048).
A heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients. This management strategy is cost-effective and has an equitable value from a societal point of view.
本研究比较了日间医院（DH）提供的心力衰竭（HF）管理项目与慢性心力衰竭（CHF）门诊患者常规护理的有效性及成本/效用比。
先前的研究表明，多学科方法可预防约50%的CHF再入院情况。然而，与循证医学相关的HF门诊管理流程的性能、有效性及成本/效用比尚未得到考量。
共有234名由HF科室出院的前瞻性患者被随机分为两种管理策略：122名患者接受常规社区护理，112名患者接受由DH提供的HF管理项目。评估管理情况（再入院率、治疗干预）、功能参数（纽约心脏协会[NYHA]心功能分级、左心室直径、射血分数、二尖瓣舒张早期血流减速时间、峰值摄氧量及二尖瓣反流）以及严重结局（心源性死亡和紧急心脏移植）。比较两种策略的成本/效用比。
经过12±3个月的随访，DH组患者的个人就诊天数为5.5±3.8天。DH组患者再次入院的频率低于常规护理组患者（13次 vs. 78次，p<0.00001）。分配至常规护理管理的患者NYHA心功能分级变化各异（13%改善，16%恶化，p=无显著性差异）；相比之下，DH组NYHA心功能分级有显著变化（23%改善，11%恶化，p<0.009）。在一年的随访中，234名患者中有25名（10.6%）发生严重心脏事件；社区组122名患者中有21名（17.2%）发生心源性死亡，DH组112名患者中有3名（2.7%）发生心源性死亡（p<0.0007）。1名DH组患者接受了紧急移植。通过Cox回归分析对两种管理模式进行比较，结果显示DH管理可显著预防严重事件的出现（相对风险[RR] 0.17；置信区间[CI] 0.06至0.66）。两种管理策略的成本/效用比相似（常规护理2409美元 vs. DH 2244美元）。增量分析显示，每获得一个质量调整生命年可节省成本1068美元。CHF的DH管理整合的成本/效用比为19462美元（CI 13904美元至34048美元）。
由DH提供的心力衰竭门诊管理项目可降低CHF患者的死亡率和发病率。从社会角度来看，这种管理策略具有成本效益且价值公平。
