Preventative Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
J Am Coll Cardiol. 2012 Oct 2;60(14):1239-48. doi: 10.1016/j.jacc.2012.06.025.
The goal of this study was to make a head-to-head comparison of 2 common forms of multidisciplinary chronic heart failure (CHF) management.
Although direct patient contact appears to be best in delivering CHF management overall, the precise form to optimize health outcomes is less clear.
This prospective, multicenter randomized controlled trial with blinded endpoint adjudication comprised 280 hospitalized CHF patients (73% male, age 71 ± 14 years, and 73% with left ventricular ejection fraction ≤45%) randomized to home-based intervention (HBI) or specialized CHF clinic-based intervention (CBI). The primary endpoint was all-cause, unplanned hospitalization or death during 12- to 18-month follow-up. Secondary endpoints included type/duration of hospitalization and healthcare costs.
The primary endpoint occurred in 102 of 143 (71%) HBI versus 104 of 137 (76%) CBI patients (adjusted hazard ratio [HR]: 0.97 [95% confidence interval (CI): 0.73 to 1.30], p = 0.861): 96 (67.1%) HBI versus 95 (69.3%) CBI patients had an unplanned hospitalization (p = 0.887), and 31 (21.7%) versus 38 (27.7%) died (p = 0.252). The median duration of each unplanned hospitalization was significantly less in the HBI group (4.0 [interquartile range (IQR): 2.0 to 7.0] days vs. 6.0 [IQR: 3.5 to 13] days; p = 0.004). Overall, 75% of all hospitalization was attributable to 64 (22.9%) patients, of whom 43 (67%) were CBI patients (adjusted odds ratio: 2.55 [95% CI: 1.37 to 4.73], p = 0.003). HBI was associated with significantly fewer days of all-cause hospitalization (-35%; p = 0.003) and from cardiovascular causes (-37%; p = 0.025) but not for CHF (-24%; p = 0.218). Consequently, healthcare costs ($AU3.93 vs. $AU5.53 million) were significantly less for the HBI group (median: $AU34 [IQR: 13 to 81] per day vs. $AU52 [17 to 140] per day; p = 0.030).
HBI was not superior to CBI in reducing all-cause death or hospitalization. However, HBI was associated with significantly lower healthcare costs, attributable to fewer days of hospitalization. (Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [WHICH?]; ACTRN12607000069459).
本研究旨在对头对头比较 2 种常见形式的多学科慢性心力衰竭（CHF）管理。
尽管直接与患者接触似乎是整体上提供 CHF 管理的最佳方式，但优化健康结果的确切形式并不明确。
这是一项前瞻性、多中心、随机对照试验，采用盲终点裁决，纳入 280 例住院 CHF 患者（73%为男性，年龄 71±14 岁，73%左心室射血分数≤45%），随机分为家庭为基础的干预（HBI）或专门的 CHF 诊所为基础的干预（CBI）。主要终点是在 12 至 18 个月的随访期间全因、无计划住院或死亡。次要终点包括住院类型/持续时间和医疗保健费用。
HBI 组有 143 例中的 102 例（71%）和 CBI 组有 137 例中的 104 例（调整后的危险比[HR]：0.97 [95%置信区间（CI）：0.73 至 1.30]，p=0.861）发生了主要终点事件：HBI 组中有 96 例（67.1%）和 CBI 组中有 95 例（69.3%）发生了无计划住院（p=0.887），31 例（21.7%）和 38 例（27.7%）死亡（p=0.252）。HBI 组的每个无计划住院的中位持续时间明显较短（4.0 [四分位距（IQR）：2.0 至 7.0]天与 6.0 [IQR：3.5 至 13]天；p=0.004）。总体而言，75%的所有住院是由 64 例（22.9%）患者引起的，其中 43 例（67%）是 CBI 患者（调整后的优势比：2.55 [95%CI：1.37 至 4.73]，p=0.003）。HBI 与全因住院天数显著减少（-35%；p=0.003）和心血管原因住院天数显著减少（-37%；p=0.025）有关，但与 CHF 无关（-24%；p=0.218）。因此，HBI 组的医疗保健费用（澳元 3.93 与澳元 5.53 百万）显著较低（中位数：澳元 34 [IQR：13 至 81]每天与澳元 52 [17 至 140]每天；p=0.030）。
HBI 并没有优于 CBI 在降低全因死亡或住院方面的效果。然而，HBI 与显著较低的医疗保健费用相关，这归因于住院天数的减少。（Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [WHICH?]; ACTRN12607000069459）。
