Conflicting results for HF patient education programs

One-third of heart failure (HF) patients dies within a year after diagnosis. However, several meta-analyses have suggested a positive effect of HF disease management programs on outcomes. Two studies that involved such programs were presented during the American Academy of Cardiology's 56th annual scientific session. The studies produced conflicting results.

The first did not find that additional patient education and counseling reduced hospitalizations and other outcomes in HF patients. "These results are revealing in terms of allocating health care resources," said session panelist, Carl V. Leier, MD, professor of medicine, division of cardiovascular medicine, Ohio State University, Columbus.

The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) included 1,023 hospitalized HF patients with a mean age of 71 years and a mean LVEF of 34%. At hospital discharge, 51% were New York Heart Association (NYHA) Class II and the remaining patients were Class III or IV.

They were randomized to a control group, a basic support group, or to intensive support and followed for 18 months. Those in the control group received routine management from their cardiologist and general practitioner. The basic support group participated in patient education, a visit to an HF nurse every 3 months, and had telephone access to an HF nurse. Patients in the intensive support group had monthly visits with an HF nurse, two sessions of multidisciplinary advice, two nurse home visits, and 24-hour access to an HF team.

The results were presented by Tiny Jaarsma, MD, University Medical Center, Groningen, The Netherlands. After 18 months, 40% of patients reached one of the primary endpoints, which included time-to-hospitalization for HF or death, and the number of "unfavorable" days (hospitalization or death). There was no significant difference between the control group and basic or intensive support groups in time-to-hospitalization, Dr. Jaarsma said.

Although both support groups showed a 15% decrease in all-cause mortality and number of unfavorable days compared with controls, the difference was not significant. "There was a difference in the intensive intervention group in that they were readmitted to the hospital more often and faster after initial discharge," Dr. Jaarsma said. "However, patients in the support groups averaged 10-day hospitalizations compared with 14 days for control patients.

"While intensive patient support might decrease mortality, it does so at the cost of more and shorter hospitalizations," she said.

A smaller study conducted by Edimar A. Bocchi, MD, University of Sao Paulo Medical School, Brazil, found that a repetitive and intense patient education program reduced hospitalization time and time in the emergency room, as well as improved quality of life.

A total of 350 patients were randomized to repetitive patient support (n=233) or to a control group (n=117) receiving standard care. The patient support group attended five one-hour, multidisciplinary education sessions during the 6-month study, received biweekly monitoring telephone calls from a HF nurse, and had access to the HF team by telephone. "At the end, most of these patients knew more about heart failure than most doctors in training," Dr. Bocchi said.

While the patient support did not significantly change rates of HF failure or sudden death, patient-reported quality of life was significantly better compared with controls. Length of hospitalizations was significantly reduced from 19.9 days in the control group to 11.2 days. Emergency room visits were also significantly reduced from 3.76 visits to 2.19 visits. "We found education to be just as important as drug therapy, or perhaps more important to quality of life," Dr. Bocchi said.