Heart Failure Clinic, Division of Cardiology/Coronary Care Unit, San Camillo Hospital, Trieste, Italy.
J Cardiovasc Med (Hagerstown). 2010 Oct;11(10):739-47. doi: 10.2459/JCM.0b013e328339d981.
Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile.
Heart failure outpatient clinic.
Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1-6) was used as an index of global functional impairment.
Mild to moderate frailty (frailty score = 2-3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4-6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were -1003.31 euro for frailty score 1 (95% confidence interval -3717.00-1709.00), 1104.72 euro for frailty score 2 (-280.6-2491.00), 2635.42 euro for frailty score 3 (352.60-4917.00, P = 0.025) and 419.53 euro for frailty score 4-6 (-1909.00-2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations.
This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care.
疾病管理计划（DMP）可改善心力衰竭患者的预后。由于老年心力衰竭患者是一个异质性群体，因此本研究旨在通过其脆弱性特征来确定哪些患者最能从 DMP 中受益。
心力衰竭门诊。
连续纳入（n=173）年龄大于 70 岁的患者，并将其随机分为多学科 DMP 组（n=86）或常规护理组（n=87）。采用改良的虚弱评分（范围 1-6）作为全身功能障碍的指标。
在 DMP 患者中，与常规护理相比，轻度至中度虚弱（虚弱评分=2-3）与结局（死亡和/或心力衰竭入院、心力衰竭入院和全因入院）的显著改善相关。即使在更虚弱的患者（虚弱评分=4-6）中，心力衰竭入院也显著减少。相比之下，非虚弱患者（虚弱评分=1）并未从中获得显著益处。在成本效益分析中，根据其虚弱评分分层，每位患者的平均节省额分别为：虚弱评分 1 为-1003.31 欧元（95%置信区间-3717.00-1709.00），虚弱评分 2 为-1104.72 欧元（-280.6-2491.00），虚弱评分 3 为-2635.42 欧元（352.60-4917.00，P=0.025），虚弱评分 4-6 为-419.53 欧元（-1909.00-2749.00）。因此，DMP 在中度虚弱患者中具有显著的成本效益，但在非虚弱或严重虚弱患者中则不然。因此，DMP 在中度虚弱患者中具有优势（即比常规护理更具成本效益且更有效）。在敏感性分析中，即使干预措施的成本和住院费用发生变化，DMP 仍保持优势。
这表明，强化的、基于医院的 DMP 似乎对轻度至中度虚弱的老年患者更有效。因此，对脆弱性进行多维评估似乎是选择适当护理模式的有用工具。
