BMJ  2007;334:910-911 (5 May), doi:10.1136/bmj.39197.577442.80

Editorials

Telephone interventions for disease management in heart failure

Such support for patients at home cuts admissions to hospital for heart failure

Several randomised trials have established that disease management programmes offering, for example, home visits, heart failure clinics, and telephone interventions result in better adherence to treatment and reduced admissions to hospital for heart failure than standard care for people with heart failure.^{1 2 3 4} Current evidence is unclear, however, on the impact of such programmes on mortality, all cause admissions, quality of life, and cost reduction. The most effective components of the interventions and the benefits to different subgroups are also unknown. Moreover, such evidence comes from small trials with short follow-up, performed at single centres, that applied complex strategies to selected high risk populations. These characteristics might affect both the internal and external validity of the trials' findings. In this week's BMJ, Clark and colleagues present a meta-analysis that includes 14 trials of telephone interventions in heart failure; it shows an overall 21% reduction in admissions for heart failure (but not in total admissions) and a 20% reduction in total mortality.⁵ The authors also report a benefit of these interventions on quality of life and cost reduction. The two types of intervention—structured telephone support and telemonitoring—were similarly effective.

In this new systematic review by Clark and colleagues only one trial included more than 1000 patients and only two trials had more than 12 months' follow-up.^{6 7} But previous meta-analyses of heart failure programmes included fewer, smaller trials and did not show a beneficial effect of telephone interventions.^{8 9}

Clark and colleagues reported a reduction in mortality, but this effect was seen in only one structured telephone study (TEN-HMS).⁷ Conversely, in the largest trial done so far, the DIAL trial, in which we were both investigators, mortality was not reduced, although admissions for heart failure were significantly reduced (relative risk reduction 29%, P=0.005).⁶ The DIAL trial randomised ambulatory stable patients with previously optimised drug treatment (95% used angiotensin converting enzyme inhibitors or angiotensin receptor blockers and 70% used blockers) to education and monitoring by nurses by telephone, and all patients were followed up by cardiologists. The reduced mortality seen in the TEN-HMS trial might have been explained by a more effective intervention or by a higher effect because it included sicker patients.

Evaluations of complex interventions with multiple and simultaneous strategies should aim to answer questions about how the interventions work and which of their components are essential. Available evidence suggests that disease management interventions in heart failure should incorporate education on self care and adherence to diet and medicines; monitoring and surveillance to detect early signs of decompensation; people trained in heart failure to provide the interventions; and facilitated access to specialised care for any clinical deterioration.

The impact of these interventions might be attributed at least in part to the ability to detect early signs of pulmonary and systemic congestion and to allow early consultation with medical specialists before severe decompensation occurs. Other mechanisms might include the effect of education and behavioural advice, as we found in the DIAL trial—patients with improved knowledge of medical treatment and early compliance with diet, daily weighing, and drug treatment (from baseline to the first 45 days) benefited most from the intervention.¹⁰

Telephone interventions usually need fewer resources than more complex interventions and transcend geographical and transport barriers, allowing wide scale implementation in clinical practice. More complex interventions might be needed in certain situations, such as advanced heart failure or in frail elderly patients. These might still be provided by telephone—for example, through transfer of patient data and other technologies—but such systems are more resource intensive and perhaps less feasible.

Overall, the evidence supports telephone interventions in the management of heart failure. But, as there have been no head-to-head comparisons of different disease management strategies, any intervention that includes education, monitoring, facilitated access, and trained personnel may be effective, no matter how it is delivered. And, despite all these promising data about telephone based programmes in heart failure, we must bear in mind that these interventions cannot substitute for medical assistance for these patients; they simply provide support to the clinician-patient relationship and offer a better way to provide medical care in heart failure.

¹ Departamento de Cardiología, Instituto FLENI, Montañeses 2325 (1428) Buenos Aires, Argentina, ² Fundación GESICA, AV. Rivadavia 2358 PB 4 (1034), Buenos Aires

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Yu DS, Thompson DR, Lee DT. Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. Eur Heart J 2006;27:596-612.[Abstract/Free Full Text]
2. Blue L, Lang E, McMurray JJ, Davie AP, McDonagh TA, Murdoch DR, et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ 2001;323:715-18.[Abstract/Free Full Text]
3. Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med 2002;162:705-12.[Abstract/Free Full Text]
4. Krumholz HM, Amatruda J, Smith GL, Mattera JA, Roumanis SA, Radford MJ, et al. Randomised trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002;39:83-9.[Abstract/Free Full Text]
5. Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S. Telemonitoring or structured telephone support programs for patients with chronic heart failure: systematic review and meta-analysis. BMJ 2007 doi: 10.1136/bmj.39156.536968.55[Abstract/Free Full Text]
6. GESICA Investigators. Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ 2005;331:425-30.[Abstract/Free Full Text]
7. Cleland JGF, Louis AA, Rigby AS, Janssens U, Balk AH. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death. The trans-European network-home-care management system (TEN-HMS study). J Am Coll Cardiol 2005;45:1654-64.[Abstract/Free Full Text]
8. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. A systematic review of randomized trials. J Am Coll Cardiol 2004;44:810-9.[Abstract/Free Full Text]
9. Göhler A, Januzzi JL, Worrell SS, Osterziel KJ, Gazelle GS, Dietz R, et al. A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. J Card Fail 2006;12:554-67.[CrossRef][ISI][Medline]
10. Grancelli H, Ferrante D, Varini S, Nul D, Zambrano C, Soifer S, et al. Improvement of treatment compliance explains benefit in telephone intervention on heart failure patients. DIAL trial [abstract]. Circulation 2003;108:(suppl IV):IV-484.

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