Patient Outcomes for Multi-faceted Intervention for Veterans with Heart Failure Comparable to Usual Care
BACKGROUND:
Disease management interventions for patients with heart failure (HF) often rely solely on nurse case management. Thus, investigators in this study developed the Patient-Centered Disease Management (PCDM) intervention that combines multidisciplinary collaborative care by a nurse coordinator, cardiologist, psychiatrist and primary care provider, home tele-monitoring, and depression management. Investigators then identified Veterans from four VAMCs who had a diagnosis of heart failure and a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall score of less than 60 (scale range is 0 to 100, lower score is worse), which indicates a heavy symptom burden and impaired functional status and quality of life. These Veterans were enrolled in the PCDM randomized trial between May 2009 and June 2011. The primary aim of the study was to determine whether or not Veterans enrolled in the intervention (n=187) experienced better health status (i.e., symptom burden, functional status, and quality of life) compared with Veterans enrolled in usual care (n=197). Secondary measures included hospitalization, depressive symptoms, and mortality. Veterans in the usual care group continued to receive care from their regular healthcare professionals and regular telehealth nurses (if enrolled in tele-monitoring), but had no involvement with the PCDM intervention's collaborative care team.
FINDINGS:
- The PCDM intervention did not improve HF health status for Veterans compared with usual care. While there was significant improvement in the KCCQ overall summary scores in both groups after one year (mean increase of 13.5 points in each group), there was no significant difference between Veterans in the intervention group compared to Veterans in the usual care group.
- Among secondary outcomes, there were significantly fewer deaths at one year among Veterans in the intervention group (8 of 187, or 4%) than in the usual care group (19 of 197, or 10%). Among Veterans who screened positive for depression, there also was greater improvement in depression scores after one year for Veterans in the intervention group compared to Veterans in the usual care group (2.1 points lower).
- There was no significant difference in 1-year hospitalization rates between groups (29% vs. 30%).
IMPLICATIONS:
- This study adds to the existing literature by leaving open questions about the effectiveness and cost-effectiveness of disease management and tele-monitoring interventions for patients with HF.
LIMITATIONS:
- Study participants were not blinded to the intervention.
- It was not possible to assess fidelity of the collaborative care intervention. Any discrepancies may inform why the intervention did not improve patient health status compared with usual care.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 06-068), and Dr. Bekelman was supported by an HSR&D Career Development Award (CDA 08-022). Drs. Bekelman, Plomondon, Carey, Nelson, and Rumsfeld are part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care, Seattle and Denver.
Bekelman D, Plomondon M, Carey E, Sullivan M, Nelson K, Hattler B, McBryde C, Lehmann K, Gianola K, Heidenreich P, and Rumsfeld J. Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial. JAMA Internal Medicine. March 30, 2015;e-pub ahead of print.
