Angiotensin converting enzyme (ACE) inhibitors reduce morbidity and mortality in chronic heart failure (CHF), however, the prognosis for patients with this disorder remains poor. In the treatment arm of the studies of left ventricular dysfunction (SOLVD) 35% of patients in the enalapril group died within the 3.5 years of follow up, 46% were admitted to hospital with worsening CHF, and 69% were admitted to hospital for any reason.1 Digoxin may reduce the need for admission2 but hospitalisation remains a frequent, distressing, costly, and recurring consequence of CHF.3

A number of investigators have attempted to identify potential precipitating and contributing factors to hospital admissions in patients with CHF.4-11 The report by Michalsen et al is an important contribution to this serious and costly health issue.12 Several common themes have emerged: limited understanding of the CHF state and its treatment is almost universal among patients; poor adherence to diet and pharmacological treatment is a frequent problem; other avoidable factors commonly contribute to CHF decompensation—for example, respiratory infections (preventable by immunisation), poor control of hypertension; and inadequate discharge planning and follow up.

Recently, the concept that specialised and intensive follow up of these often elderly and vulnerable patients, aimed at correcting the aforementioned deficiencies in care, might improve outcome and reduce hospitalisation has been tested in two important studies. The first landmark study in this area was by Rich et al.13 These authors conducted a prospective, randomised trial of the effect of a nurse directed, multidisciplinary intervention on the rates of hospital readmission, quality of life, and costs of care within 90 days of discharge among elderly, high risk patients who were hospitalised for CHF. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social service consultation and planning for an …