Table 1.
Overview of Primary Studies
| Author, Year of Publication | Population† | Intervention | Components | Follow-Up (Months) | Quality (Study Design) |
|---|---|---|---|---|---|
| Akosah et al. (2002) | N: 38/63; Age: 68/76*; Male: 71/43*; NYHA: NR; Country: USA | Short-term, multidisciplinary, aggressive-intervention in HF clinic following hospital discharge primarily focused on patient education and medication titration | DSD, SMS | 12 | 40 (other) |
| Ansari et al. (2003) | N: 54/51; Age: 69/70; Male: 94/98; NYHA: NR; Country: USA | Nurse practitioners initiate and titrate beta-blockers supervised by two cardiologists at a single academically affiliated Veterans Affairs medical center | DSD, DS | 12 | 80 (RCT) |
| Atienza et al. (2004) | N: 164/174; Age: 69/67; Male: Total: 60; NYHA: 2.5/2.5; Country: Spain | Comprehensive hospital discharge planning, a visit by the primary care physician after discharge to monitor and reinforce the educational knowledge, telemonitoring, and close follow-up at a HF clinic | DSD, SMS, CIS | 12 | 80 (RCT) |
| Austin et al. (2005) | N: 100/100; Age: 71.9/71.8; Male: 67/64; NYHA: 2.4/2.5; Country: UK | Cardiac rehabilitation program including patient education, exercise training and lifestyle modifications, and eight-weekly clinic attendance with cardiologist and nurse | DSD, SMS, DS | 5.5 | 70 (RCT) |
| Azevedo et al. (2002) | N: 157/182; Age: 69/65; Male: 52.2; NYHA: NR; Country: Portugal | Outpatient management at HF clinic by a multidisciplinary team after hospital discharge based on current RCTs and tailored to individual's patient characteristics | DSD, DS | 12 | 40 (CCT) |
| Benatar et al. (2003) | N: 108/108; Age: 62/63; Male: 36/38; NYHA: Total: 3.1; Country: USA | Nurse telemanagement model provided during a period of 3 months after hospital discharge, incorporating an advanced practice nurse supervised by a cardiologist and home monitoring devices to measure and transfer physiological signs | DSD, SMS, CIS | 12 | 65 (RCT) |
| Blue et al. (2001) | N: 84/81; Age: 76/74; Male: 64/51; NYHA: 3.2/3.18; Country: Scotland | Nurse specialist making a number of planned home visits of decreasing frequency, supplemented by telephone contact as needed, to educate, monitor, teach self-monitoring and management, liaise with other health care and social workers, and provide psychological support | DSD, SMS, DS, CIS | 12 | 75 (RCT) |
| Bouvy et al. (2003) | N: 74/78; Age: 69/70; Male: 72/60; NYHA: 2.54/2.31; Country: the Netherlands | Monthly consultations provided by trained pharmacist, including an initial interview regarding patients' drug use and subsequent follow-up for 6 months with computerized medication history, to improve diuretic compliance | DSD, SMS, DS, CIS | 6 | 75 (RCT) |
| Branch (1999) | N: 23/23; Age: Total: 66; Male: Total: 52; NYHA: NR; Country: USA | CHF clinic that aims to maximize outpatient management by employing a multidisciplinary team of care providers and intensive patient and family education, communication, and involvement | DSD, SMS, DS | 3 | 20 (BA) |
| Bull, Hansen, and Gross (2000) | N: 40/71; Age: Total: 74; Male: not stated; NYHA: NR; Country: USA | A professional–patient partnership model of discharge planning, including provider education, patient needs assessment, and information for patient and carers given by the nurses and social workers at the hospital | SMS, CIS | 2 | 50 (CCT) |
| Capomolla et al. (2002) | N: 112/122; Age: 56/56; Male: 84/84; NYHA: I–II (%): 66/65; Country: Italy | Day hospital follow-up care within a HF unit, which implemented an individualized HF management program by a multidisciplinary team, including education | DSD, SMS, DS, CIS | 12 | 70 (RCT) |
| Cline et al. (1998) | N: 80/110; Age: Total: 76; Male: Total: 53; NYHA: 2.6/2.6; Country: Sweden | Education on HF and self-management, with follow-up at an easy access nurse-directed outpatient clinic for 1 year after discharge. The nurses received a lecture and could consults the cardiologist | DSD, SMS, DS | 12 | 60 (RCT) |
| Costantini et al. (2001) | N: 283/173; Age: 72/69; Male: 43/41; NYHA: NR; Country: USA | A cardiologist and nurse care manager at an academic medical center reviewed patient's data and made guideline-based recommendations regarding ACE inhibitor; ECG and implementation of daily weights used for the care manager sheet. The nurse provided patient education, assessed discharge needs, and evaluated patient's ability to comply with prescribed plan | DSD, SMS, DS, CIS | NR | 50 (CCT) |
| DeBusk et al. (2004) | N: 228/234; Age: Total: 72; Male: 48/54; NYHA: NR; Country: USA | Nurse case management provided education, structured telephone surveillance, and treatment for heart failure given by five HMO's hospitals. Coordination of patients' care with primary care physicians according to the study protocol | DSD, SMS, DS, CIS | 12 | 80 (RCT) |
| Doughty et al. (2002) | N: 100/97; Age: 73/74; Male: 64/57; NYHA: 3.8/3.8; Country: New Zealand | Integrated primary/secondary care involving a clinical review at a hospital-based HF clinic early after discharge, education sessions, a personal diary to record medication and body weight, information booklets, and regular (12 months) clinical follow-up alternating between GP and HF clinic | DSD, SMS, DS, CIS | 12 | 80 (RCT) |
| Ducharme et al. (2005) | N: 115/115; Age: 68/70; Male: 73/71; NYHA: 3.3/3.2; Country: Canada | A structured multidisciplinary outpatient clinic environment with complete access to cardiologists and allied health professionals, patient education, and telephone follow-up | DSD, SMS, CIS | 6 | 80 (RCT) |
| Dunagan et al. (2005) | N: 76/75; Age: 71/69; Male: 41/47; NYHA: 2.9/2.9; Country: USA | Scheduled telephone calls by specially trained nurses working at the hospital promoting self-management and guideline-based therapy as prescribed by primary physicians, additional to an educational booklet that is part of usual primary care | SMS, DS, CIS | 12 | 80 (RCT) |
| Ekman et al. (1998) | N: 79/79; Age: Total: 80; Male: 58/63; NYHA: 3.2/3.2; Country: Sweden | A nurse-monitored, outpatient care program aiming at symptom management, including education, cooperation of nurses and center doctors, telephone follow-up stated in practical guidelines | DSD, SMS, DS, CIS | 6 | 70 (RCT) |
| Fonarow et al. (1997) | N: 214/214; Age: Total: 52; Male: Total: 81; NYHA: NR; Country: USA | Comprehensive HF management program, including guideline-based medication management, nurse provided individual and group education and cardiologist follow-up care and telephone follow-up after discharge | SMS, DS, CIS | 6 | 50 (BA) |
| Gattis et al. (1999) | N: 90/91; Age: 72/63*; Male: 69/67; NYHA: NR; Country: USA | Clinical pharmacist evaluation, which included medication evaluation, therapeutic recommendations to the attending physician, patient education, and follow-up monitoring | DSD, SMS, DS, CIS | 6 | 70 (RCT) |
| GESICA (2005) | N: 760/758; Age: 65/65; Male: 73/69; NYHA: NR; Country: Argentina | Frequent telephone follow-up from a single surveillance center provided by nurses trained in HF to monitor and reinforce self-management performed by using a predetermined questionnaire | DSD, SMS, DS, CIS | 16 | 85 (RCT) |
| Harrison et al. (2002) | N: 92/100; Age: 76/76; Male: 53/56; NYHA: 2.9/2.8; Country: Canada | The transitional care used a comprehensive evidence-based protocol for counseling and education for HF self-management plus additional and planned linkages to support individuals in taking charge of aspects of their care given by hospital and community nurses | DSD, SMS, DS, CIS | 2.8 | 70 (RCT) |
| Heidenreich, Ruggerio, and Massie (1999) | N: 68/86; Age: 74/75; Male: 58/58; NYHA: NR; Country: USA | Multidisciplinary program of patient education, daily self-monitoring, and physician notification of abnormal weight gain, vital signs, and symptoms given by small practices (largely primary care) of a multispeciality group | SMS, CIS | 12 | 65 (CCT) |
| Holst et al. (2001) | N: 36/36; Age: Total: 54; Male: Total: 81; NYHA: NR; Country: Australia | Comprehensive management program of cardiology assessment, intensive education, and referral to a tailored exercise program | DSD, SMS | 6 | 50 (BA) |
| Hughes et al. (2000) | N: 981/985; Age: 70/70; Male: 97/96; NYHA: NR; Country: USA | Home-based primary care, including a primary care manager, 24-hour contact for patients, and home-based primary care team participation in discharge planning | DSD, CIS | 12 | 60 (RCT) |
| Kasper et al. (2002) | N: 102/98; Age: 60/64; Male: 65/56; NYHA: 2.2/2.5; Country: USA | Multidisciplinary team including nurse coordinator (monitored by telephone calls), CHF nurse (adjusting medication in CHF clinic), CHF cardiologist (decision support for nurses), and primary physician (received updates and managed all not CHF-related problems); intervention given during 6 months | DSD, SMS, DS, CIS | 6 | 65 (RCT) |
| Krumholz et al. (2002) | N: 44/44; Age: 76/72; Male: 48/66; NYHA: NR; Country: USA | Face-to-face education session followed by a telemonitoring phase by the nurse for a total intervention period of 1 year. This telephone contacts reinforced care domains but did not modify current regimens or recommendations; the patient learned to understand when and how to seek and access the care | DSD, SMS | 12 | 70 (RCT) |
| Laramee et al. (2003) | N: 141/146; Age: 71/71; Male: 48/50; NYHA: 2.3/2.2; Country: USA | Four major components: early discharge planning, patient and family CHF education, 12 weeks of telephone follow-up, and promotion of optimal CHF medications given by a CHF case manager of the hospital | DSD, SMS, DS, CIS | 3 | 60 (RCT) |
| McDonald et al. (2002) | N: 51/47; Age: 71/71; Male: 63/68; NYHA: 3/3; Country: Ireland | Specialist nurse-led education and specialist dietician consults during admission, also given to patient's carer. In addition, patients were discharged with a letter to the referring physician about the study and that management of HF-related issues should be referred to the clinic or the nurse. Telephone follow-up to ascertain clinical status and discuss problems | DSD, SMS, CIS | 3 | 55 (RCT) |
| Naylor et al. (2004) | N: 118/121; Age: 76/76; Male: 40/44; NYHA: NR; Country: USA | A 3-month comprehensive transitional care intervention directed by advanced practice nurse (APN), including discharge planning and home follow-up. APN received a training program guided by a multidisciplinary team of HF experts, implemented an evidence-based protocol, focused on collaboration between caregivers | DSD, SMS, DS, CIS | 12 | 60 (RCT) |
| Oddone et al. (1999) and Weinberger, Oddone, and Henderson (1996) | N: 249/255; Age: 63/63; Male: Total: 99 (not disease specific reported); NYHA: 2.5/2.6; Country: USA | A team consisting of a nurse and a primary care physician taking care of discharge planning, arrangement of visits with primary care clinic after discharge, telephone follow-up, review of treatment plans during primary clinic visits consisting of an inpatient and outpatient component | DSD, SMS, CIS | 6 | 55 (RCT) |
| Pugh et al. (2001) | N: 27/31; Age: 71/77; Male: 44/42; NYHA: 2.6/2.6; Country: USA | Patient education, monitoring and providing care by a nurse case manager of the clinic across the care continuum | SMS, CIS | 6 | 60 (RCT) |
| Rainville (1999) | N: 17/17; Age: 73/67; Male: 47/53; NYHA: 2.9/3.2; Country: USA | A pharmacist and clinical nurse specialist identified patient issues that posed potential risk for rehospitalization, determined corrective action, and gave patient education | DSD, SMS, CIS | 12 | 45 (RCT) |
| Rauh et al. (1999) | N: 347/407; Age: 74/76; Male: 76/74; NYHA: NR; Country: USA | A multidisciplinary team approach included an intensive education program, aggressive pharmacologic treatment for patients with advanced CHF, and telephone follow-up following the developed treatment protocols | DSD, SMS, DS, CIS | 3 | 45 (BA) |
| Rich et al. (1995) | N: 142/140; Age: 80/78; Male: 32/41; NYHA: 2.4/2.4; Country: USA | A nurse-led multidisciplinary intervention consisting of comprehensive education (patient and family), prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and after discharge intensive follow-up | DSD, SMS, CIS | 1.5 | 60 (RCT) |
| Riegel et al. (2002) | N: 130/228; Age: 73/75; Male: 54/46; NYHA: NR; Country: USA | Standardized telephonic case-management intervention after hospital discharge using decision-support software based on guidelines, and automatically produced reports sent to the physicians | DSD, SMS, DS, CIS | 6 | 75 (RCT) |
| Roglieri et al. (1997) | N: 149/149; Age: NR; Male: Missing; NYHA: NR; Country: USA | A comprehensive disease management program for CHF, based on national guidelines, including patient education, telemonitoring of patients, and physician education | SMS, DS, CIS | 12 | 25 (BA) |
| Shah et al. (1998) | N: 27/27; Age: Total: 62; Male: 100/100; NYHA: Total: 2.6; Country: USA | Education, self-measurement instruments and 24-hour telephone access to a nurse to report changes in combination with telephone contact to monitor. Nurses report the physician monthly | DSD, SMS, CIS | 8.5 | 55 (BA) |
| Stewart, Pearson, and Horowitz (1998) | N: 49/48; Age: 76/74; Male: 45/52; NYHA: 2.5/2.4; Country: Australia | Multidisciplinary home-based intervention of a single home visit (by a nurse and pharmacist) to optimize medication management, identify early deterioration, and intensify medical follow-up and caregiver vigilance as appropriate. Additional education and incremental monitoring by their physician if needed | DSD, SMS, CIS | 6 | 70 (RCT) |
| Stewart, Marley, and Horowitz (1999) | N: 100/100; Age: 75/76; Male: 65/59; NYHA: 2.7/2.6; Country: Australia | Multidisciplinary home-based intervention comprised a single home visit (by a cardiac nurse) to optimize medication management, identify early clinical deterioration, and enhance self-monitoring | DSD, SMS, DS, CIS | 6 | 75 (RCT) |
| Stewart and Horowitz (2002) | N: 149/148; Age: 75/75; Male: 56/56; NYHA: 2.6/2.7; Country: Australia | Multidisciplinary home-based intervention by a cardiac nurse and pharmacist to optimize medication management, identify early clinical deterioration, and enhance self-monitoring. Nurses provided a critical link to the appropriate health care if problems arose | DSD, SMS, CIS | 50.4 | 70 (RCT) |
| Stromberg et al. (2003) | N: 52/54; Age: 77/78; Male: 63/59; NYHA: 3.0/2.9; Country: Australia | Follow-up at a nurse-led heart failure clinic; given individualized education and psychosocial support, and protocol led medication changes | DSD, SMS | 12 | 90 (RCT) |
| Tsuyuki et al. (2004) | N: 140/136; Age: 72/71; Male: 58/58; NYHA: 2.3/2.2; Country: Canada | Two stage intervention: (1) a pharmacist nurse assessed each patient and made recommendations to the physician to adjust ACEs; (2) patient education about self-management, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge | SMS, CIS | 6 | 45 (RCT) |
| Vavouranakis et al. (2003) | N: 28/33; Age: Total: 65; Male: Total: 88; NYHA: Total:3.4; Country: USA | A home-based intervention including education and follow-up by nurses supervised by a cardiologist | DSD, SMS, CIS | 12 | 65 (BA) |
| West et al. (#b501) | N: 45/50; Age: Total: 66; Male: Total: 71; NYHA: Total:2.3; Country: USA | A physician-supervised, nurse-mediated, home-based system to promote optimal dose of drugs by consensus guidelines; promote of low sodium intake and surveillance of symptoms and worsening | DSD, SMS, DS, CIS | 6 | 55 (BA) |
| Whellan et al. (2005) | N: 117/117; Age: Total: 62; Male: Total:62; NYHA: Total:2.7; Country: USA | CHF disease management program at a tertiary care center, including patient education and regular (telephone) follow-up | DSD, SMS, DS, CIS | 12 | 60 (BA) |
*
p-value < .05.
†
N (I/C); mean age (I/C); % male (I/C); NYHA class (I/C) and country.
BA, before-after study; CCT, nonrandomized controlled clinical trial; CIS, clinical information system; DSD, delivery system design; DS, decision support; RCT, randomized controlled trial; SMS, self-management support.