Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure

Background: Chronic heart failure (CHF) exerts a significant burden on the health care system in the UK. A recent study concluded that it contributes to almost 4% of total National Health Service expenditure with recurrent hospitalisation in typically older patients (pts) being a major cost component. Nurse-led programs of care to reduce recurrent hospitalisation in such pts have proven to be particularly cost-effective. To date they have predominantly focussed on either home or clinic-based follow-up. Aim: In a randomised controlled study, we examined the effectiveness of a nurse-led, CHF program, involving a composite of clinic plus home-based follow-up, in reducing recurrent hospital stay. Methods: A total of 113 typically older pts admitted to two hospitals in York and Scunthorpe were recruited to the study. The majority were aged > 65 years and 70% were male. All pts had a history of at least one admission with acute HF and evidence of systolic left ventricular dysfunction. Most pts also had concurrent disease states likely to complicate treatment for their CHF. A total of 62 and 51 pts, respectively, were randomised to clinic plus home-based intervention (C+HBI) lasting 6 months post-discharge or to usual, post-discharge care (UC). In this preliminary analysis we compared morbidity and mortality rates within 6 months of their index admission. Results: During 6 months follow-up, a total of 13 (21%) versus 21 (41%) of pts in the C+HBI and UC groups, respectively, had an emergency hospital admission (P = 0.024: OR 0.38, 95% CI 0.17 - 0.87). Pts in the HBI group had fewer emergency admissions (15 vs. 33 admissions) and days of reccurrent hospital stay (108 vs. 351 days). On an adjusted basis, therefore, C+HBI was associated with a lower rate of emergency admission (0.24 vs. 0.59 admissions/pt: P = 0.007) and recurrent hospital stay (1.7 vs. 6.9 days/pt: P = 0.003) relative to UC. During the same follow-up period, 9 (15%) versus 8 (16%) pts died (NS). Conclusions: We have previously speculated that the combination of home and clinic based follow-up would be most practical and, potentially, most effective effective in optimising the management of high pts with CHF. To date, there have been few studies specifically examining this approach. In this randomised study, involving pts from two independent hospitals in the North of England, we found that C+HBI was associated with significant reductions in recurrent readmissions and associated stay. As such, this represents another form of postdischarge management that can be implemented widely to reduce the overall burden of CHF