Gorthi Janardhana, Hunter Claire B, Mooss Ayran N, Alla Venkata M, Hilleman Daniel E
The Creighton University Cardiac Center, Creighton University School of Medicine, Omaha, NE, USA.
Cardiol Res. 2014 Oct;5(5):126-138. doi: 10.14740/cr362w. Epub 2014 Oct 6.
The recent enactment of the Patient Protection and Affordable Care Act which established the federal Hospital Readmissions Reduction Program (HRRP) has accelerated efforts to develop heart failure (HF) disease management programs (DMPs) that reduce readmissions in patients hospitalized for HF. This systematic review identified randomized controlled trials of HF DMPs which included home care, outpatient clinic interventions, structured telephone support, and non-invasive and invasive telemonitoring. These different types of DMPs have been associated with conflicting results. No specific type of DMP has produced consistent benefit in reducing HF hospitalizations. Although probably effective at reducing readmissions, home visits and outpatient clinic interventions have substantial limitations including cost and accessibility. Telemanagement has the potential to reach a large number of patients at a reasonable cost. Structured telephone support follow-up has been shown to significantly reduce HF readmissions, but does not significantly reduce all-cause mortality or all-cause hospitalization. A meta-analysis of 11 non-invasive telemonitoring studies demonstrated significant reductions in all-cause mortality and HF hospitalizations. Invasive telemonitoring is a potentially effective means of reducing HF hospitalizations, but only one study using pulmonary artery pressure monitoring was able to demonstrate a reduction in HF hospitalizations. Other studies using invasive hemodynamic monitoring have failed to demonstrate changes in rates of readmission or mortality. The efficacy of HF DMPs is associated with inconsistent results. Our review should not be interpreted to indicate that HF DMPs are universally ineffective. Rather, our data suggest that one approach applied to a broad spectrum of different patient types may produce an erratic impact on readmissions and clinical outcomes. HF DMPs should include the flexibility to meet the individualized needs of specific patients.
最近颁布的《患者保护与平价医疗法案》设立了联邦医院再入院减少计划（HRRP），这加速了开发心力衰竭（HF）疾病管理计划（DMP）的努力，这些计划旨在减少因HF住院患者的再入院率。本系统评价确定了HF DMP的随机对照试验，其中包括家庭护理、门诊干预、结构化电话支持以及非侵入性和侵入性远程监测。这些不同类型的DMP产生了相互矛盾的结果。没有特定类型的DMP在减少HF住院方面产生一致的益处。尽管家庭访视和门诊干预可能有效减少再入院率，但存在包括成本和可及性在内的重大局限性。远程管理有潜力以合理的成本覆盖大量患者。结构化电话支持随访已被证明可显著降低HF再入院率，但并未显著降低全因死亡率或全因住院率。对11项非侵入性远程监测研究的荟萃分析表明，全因死亡率和HF住院率显著降低。侵入性远程监测是减少HF住院的一种潜在有效手段，但只有一项使用肺动脉压力监测的研究能够证明HF住院率有所降低。其他使用侵入性血流动力学监测的研究未能证明再入院率或死亡率有变化。HF DMP的疗效结果不一致。我们的评价不应被解释为表明HF DMP普遍无效。相反，我们的数据表明，一种应用于广泛不同患者类型的方法可能对再入院率和临床结果产生不稳定的影响。HF DMP应具有灵活性，以满足特定患者的个性化需求。
