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Randomised trial of telephone intervention in chronic heart failure: DIAL trial

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38516.398067.E0 (Published 18 August 2005) Cite this as: BMJ 2005;331:425

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Close the clinics and cancel home visits in heart failure management? What do the results of the DIAL Trial really tell us?

Dear Editor

The recently published DIAL trial [1] is a welcome addition to the increasing
number of studies demonstrating the benefits of applying dedicated chronic
heart failure (HF) management programs. [2] In the first multi-centre randomised
trial including more than 1500 patients followed for more than a year, the
GESICA Investigators demonstrated that a simple and effective telephone intervention
applied by highly trained nurses resulted in a significant reduction in HF
admissions. A key question, of course, is how can we interpret the results
of the DIAL trial relative to other popular forms of HF management? Should
we accept the author’s assertions that

"…Although multidisciplinary and complex strategies could provide greater
advantage, the results of our simple intervention were still similar to those
of other reported combined strategies. In fact our intervention would be justified
as it is equally effective at a reasonably lower cost
" 1

There are a number of reasons why a careful analysis of the literature
particularly based on a recent systematic review and meta-analysis of more
than 29 randomised studies of HF management, [2] would draw different conclusions
from that outlined above. Although the DIAL trial undoubtedly recruited a
younger (mean age 65 compared to 72 years) and probably more stable HF patients
that included a greater preponderance of men (71% versus an average of 55%),
it is worth comparing the results of this study with that of the 29 studies
included in the aforementioned meta-analysis. As such, the table below clearly
shows that the absolute impact of the telephonic intervention tested
in the DIAL trial, while being largely consistent with other studies of telephonic
support in HF, is clearly inferior to "multidisciplinary and complex strategies"
on health outcomes: particularly when considering their combined impact on
all-cause mortality (RR 0.75, 95% CI 0.59 to 0.96) and all-cause hospitalisation
(RR 0.81, 95% CI 0.71 to 0.92).2

Clearly, telephonic interventions do have a positive impact on HF-related
admissions. However, as demonstrated by the data presented in Table 1, its
overall impact on all-cause events is less impressive than more complex
programs of care: undoubtedly because the syndrome of HF is associated with
a range of co morbidities that also require management and substantially contribute
to morbidity/mortality.

In terms of cost-effectiveness of these programs, it has been clearly demonstrated
that the majority of HF-related costs are attributable to recurrent hospital
stay. [3] The last column of Table 1 shows that both clinic and community-based,
multidisciplinary programs of care have a more substantive impact on recurrent
hospital stay (range 39 to 61%) than telephone-based programs overall; these
data were not presented for the DIAL trial. It is on this basis that multidisciplinary
programs of care should be applied whenever possible to both reduce costs
and improve individual health outcomes.[3]

Is there a role, therefore, for telephonic management in heart failure?
Overall, a careful analysis of the DIAL trial shows that its results are largely
consistent (if not more positive) with previous studies of its type. Based
on this impressive study, there is obvious merit in managing patients with
HF who have access to a telephone but limited access to specialist HF care
(i.e. those living in rural and remote regions). However, there is no reason
to suggest (at this stage) that clinics should be closed and home visits
cancelled in favour of phone calls to HF patients in order to prolong survival
and reduce recurrent hospital admissions in a cost-effective manner.

References

1. GESICA Investigators. Randomised trial of telephone intervention in
chronic heart: DIAL Trial. BMJ, Doi:10.1136/bmj.38516.398067.EO.
(Published 1 August 2005) 2005.

2. McAlister FA, Stewart S, Ferrua J, McMurray JJV. Multidisciplinary strategies
for the management of heart failure patients a high risk admission: a systematic
review of randomised trials. J Am Coll Cardiol. 2004; 44(4).

3. Stewart S. Financial aspects of heart failure programs of care. Eur
J Heart Fail.
Mar 16 2005; 7(3):423-428.

 

Table 1 Comparison of absolute and relative effect of different forms of
HF management: comparison to DIAL trial results *



Type of Intervention


Intervention vs. Usual Care


Mean F/U

(months)


All-Cause Mortality:

Effect & RR (95% CI)


All Cause Readmission:

Effect & RR (95% CI)


HF Readmission:

Effect & RR (95% CI)


Rate of recurrent hospital stay
*

             

Multidisciplinary care via HF Clinic (7 studies)

576 vs. 607

9 months

15% vs. 21% (- 6%)

RR 0.66 (0.42 to 1.05)

38% vs. 48% (- 10%)

RR .0.76 (0.58 to 1.01)

27% vs. 35% (- 8%)
0.76 (0.58 to 0.99)

43 to 49%

Multidisciplinary care via community (7 studies)

477 vs. 469

7 months

21% vs. 26% (- 5%)

RR 0.81 (0.65 to 1.01)

43% vs. 54 %( - 11%)

RR .0.81 (0.71 to 0.92)

29% vs. 41% (- 12%)
0.72 (0.59 to 0.87)

39 to 61%

Multidisciplinary care via telephone
(7 studies)

553 vs. 640

7 months

10% vs. 11% (- 1%)

RR 0.91 (0.67 to 1.29)

42% vs. 42% (nil effect)

RR .0.98 (0.80 to 1.20)

20% vs. 27% (- 7%)
0.75 (0.57 to 0.99)

24 to 30%

DIAL Trial

760 vs. 758

16 months

15% vs. 16% (- 1%)

RR 0.95 (0.73 to 1.23)

34% vs. 39% (- 5%)

RR .0.85 0.72 to 0.99)

17% vs. 22% (- 6%)
0.75 (0.57 to 0.99)


???

Adapted from McAlister [2] and Stewart [3]. F/U = months. RR = Relative
Risk. CI = Confidence Interval

Competing interests:
None declared

Competing interests: No competing interests

23 August 2005
Robyn Clark
PhD Scholar supported by the National Institute of Clinical Studies & National Heart Foundation
Prof Simon Stewart
University of South Australia 5000