Effects of heart failure management programmes

Abstract

Abstract of the thesis “Effects of heart failure management programmes” The main purpose of the studies presented in this thesis, was to assess whether an intensive 1-year intervention at a heart failure clinic for patients with heart failure, NYHA classification III or IV, reduces the incidence of hospitalisation for worsening heart failure and/or all cause mortality and improves functional status and quality of life at acceptable costs and whether the observed effects may be (partly) attributable to beneficial changes in patient adherence to drug therapy. Important differences with many previous studies were that our heart failure clinic was directed by a combination of a clinician and a heart failure nurse and that the study was performed in a country with a relatively strong primary care health-care system. In a systematic review in the beginning of the thesis, the results of previous studies on heart failure management programmes are reviewed critically and their applicability to countries, such as the Netherlands, with well-structured primary care facilities is discussed. In the core chapters of the thesis the main results of the Deventer-Alkmaar Heart Failure study (DEAL-HF study) are presented first: the number of admissions for worsening heart failure and/or all-cause deaths in the intervention group was lower than in the control group (23 vs. 47; relative risk(RR) 0.49; 95% confidence interval 0.30 to 0.81; p= 0.001). There also was an improvement of the left ventricular ejection fraction (LVEF) in the intervention group (plus 2.6%) compared with a decrease in the usual care group (minus 3.1%; p=0.004). Patients in the intervention group were hospitalised for a total of 359 days, compared with 644 days for those in the usual care group. Beneficial effects were also observed on NYHA functional class, quality of life, self-care behaviour and health care costs. Then, several sub-studies within the DEAL-HF population are presented. First, we assessed the effect of the heart failure management programme on adherence of prescribers and patients to the medication regimes: beta-blocker dosaging and the number of patients using spironolactone increased. This may have been an important contributor to the observed improved clinical outcomes. Then we investigated the correlation between the change in a biochemical parameter, NT-proBNP, and the change in quality of life and functional class during the follow-up of the main study. Long-term changes in NT-proBNP were indeed accompanied by similar changes in quality of life, functional status and echo parameters. Finally we studied the costs of the heart failure management programme in relation to the observed effects. This more detailed analysis of the costs and effects of the heart failure management programme studied in the DEAL HF study confirms that such a programme exerts beneficial clinical benefit and saves costs.