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• Kamlesh Khunti
  Published on: 16 April 2008
• When is a heart failure programme successful?
  Tiny Jaarsma
  Published on: 15 February 2008

• Published on: 16 April 2008

  • Kamlesh Khunti, Professor of Primary Care Diabetes & Vascular Medicine
  • Other Contributors:
    • Dr Margaret Stone, Dr Sanjoy Paul, Mr David A Turner, Dr Iain Squire

  Dear Editor,

  We would like to thank Jaarsma on highlighting an important topic regarding choosing appropriate outcomes in heart failure research. The COACH trial recently found that neither moderate or intensive disease management programmes by a nurse specialising in management of patients with heart failure reduced death or hospitalisation compared to standard treatment. (1) In contrast, our trial evaluated...

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  Dear Editor,

  We would like to thank Jaarsma on highlighting an important topic regarding choosing appropriate outcomes in heart failure research. The COACH trial recently found that neither moderate or intensive disease management programmes by a nurse specialising in management of patients with heart failure reduced death or hospitalisation compared to standard treatment. (1) In contrast, our trial evaluated the effectiveness of improvements in prescribing of evidence based therapies for heart failure and the appropriate assessment in terms of echocardiography and quality of life. There are major differences between the two trials. The COACH trial enrolled patients with heart failure after hospitalisation (1). Most previously published studies of disease management programmes for patients with heart failure have recruited patients in a similar way (2). Our trial was one of the first large intervention trials to have recruited patients with both confirmed and presumed heart failure from the community. We chose our outcomes of process, intermediate outcomes of care and optimisation of diagnosis and medication management because despite the strong evidence base, patients are still inadequately diagnosed and managed in primary care (3) We also used an outcome of health related quality of life as these are important outcomes for patients and they have been recognised as important clinical indicators which predict use of health services and mortality in people with chronic heart failure. (4) Jaarsma mentions that the challenge is to find the most optimal heart failure management programme in both primary and secondary care. However, we believe that different models of care and assessment of outcomes will be required for management of patients who have been discharged after hospitalisation compared to those who are managed by primary care physicians. Jaarsma also highlights that the COACH trial used time to hospitalisation then questions whether this is a good endpoint. This was illustrated in our cost-effectiveness study when the disease management programme seemed to lead to increased use of outpatient and inpatient services. We therefore agree that time to hospitalisation may not be a good endpoint if appropriate care can lead to referrals for hospitalisation (5).

  References

  (1) Jaarsma T, van der Wal MH, Lesman-Leegte I, Luttik ML, Hogenhuis J, Veeger NJ et al.
  Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH).
  Arch Intern Med 2008; 168(3):316-324.

  (2) McAlister FA, Lawson FME, Teo KK, et al.
  Randomised trials of secondary prevention programmes in coronary heart disease: Systematic review.
  BMJ 2001; 323(7319):957-962.

  (3) Strum H, Haaijer-Ruskamp F, Veeger N, Balje-Volkers C, Swedberg K, van Gilst W.
  The relevance of comorbidities for heart failure treatment in primary care: A European survey.
  Eur J Heart Fail 2006;8:31-37.

  (4) Chin MH, Goldman L.
  Gender differences in 1-year survival and quality of life among patients admitted with congestive heart failure.
  Med Care 1998; 36(7):1033-1046.

  (5) Turner DA, Paul S, Stone M, Juarez-Garcia A, Squire I, Khunti K.
  The cost-effectiveness a disease management programme for secondary prevention of coronary heart disease and heart failure in primary care.
  Heart (in press)

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  Conflict of Interest:
  None declared.

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• Published on: 15 February 2008

  When is a heart failure programme successful?

  • Tiny Jaarsma, Associate Professor

  Dear Editor,

  With great interest we read the article of Khunti and colleagues reporting on a cluster randomized controlled trial evaluating a nurse-led disease management programme for secondary prevention of coronary heart disease and heart failure in primary care (1). The authors should be commended for their large trial with 1316 patients from 20 primary care practices.
  The authors describ...

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  Dear Editor,

  With great interest we read the article of Khunti and colleagues reporting on a cluster randomized controlled trial evaluating a nurse-led disease management programme for secondary prevention of coronary heart disease and heart failure in primary care (1). The authors should be commended for their large trial with 1316 patients from 20 primary care practices.
  The authors describe favourable results of the intervention for CHD patients, however, for patients with confirmed diagnoses of left ventricular dysfunction the intervention in this trial was less effective than they had expected with no effects with regard to optimized treatment or quality of life. This study confirms the difficulty of finding an optimal model which is still pragmatically feasible to be implemented for a primary care setting and at the same time is effective.
  The authors evaluated the effectiveness of their heart failure programme as improvement of prescribing an ACE –inhibitor, the confirmation of the diagnosis by echocardiogram and quality of life. Although the MAHLER study recently showed the importance of guideline adherence in heart failure (2), one might wonder if the chosen outcomes in the study of Khunti et al. were the most optimal indices to evaluate optimal heart failure disease management.
  We recently published the COACH trial in which we found that moderate or intensive education and counselling did not decrease the time to hospitalisation when compared to a control group without education and counselling (3). We even found a small, non significant increase in hospitalisations. We discussed that due to a lower threshold of patients to the heart failure nurses the increase of hospitalisations could be explained and questioned if in evaluating heart failure disease management programmes hospitalisation is a good enpoint, since timely hospitalisation is likely to relieve symptoms and result in better diagnosis and management. (4)
  To date the challenge is to find the most optimal heart failure management program in both primary and secondary care and at the same time find a realistic way to evaluate cost-effectiveness of these programmes.

  References

  1. Khunti K, Stone M, Paul S, et al.
  Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial.
  Heart 2007 93:1398- 405.

  2. Komajda M, Lapuerta P, Hermans N, et al.
  Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey.
  Eur Heart J 2005 26:1653-9.

  3. Jaarsma T, Wal MHL van der, Lesman-Leegte I, et al.
  Effects of moderate and intensive disease management program on outcome in patients with heart failure. The Coordinating Study evaluating Outcomes of Advising and Counselling in Heart Failure (COACH).
  Arch Intern Med. 2008; 168:316- 324.

  4. Cleland JG, Coletta AP, Clark AL.
  Clinical trials update from the American College of Cardiology 2007: ALPHA, EVEREST, FUSION II, VALIDD, PARR-2, REMODEL, SPICE, COURAGE, COACH, REMADHE, pro-BNP for the evaluation of dyspnoea and THIS-diet.
  Eur J Heart Fail 2007; 9: 740-5.

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  Conflict of Interest:
  None declared.

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