Table 2.
Study characteristics of intervention studies
| Study n=randomised Recruitment/setting |
Baseline characteristics of participants: CM vs usual care | Intervention | Control | Main results Intervention vs control |
|---|---|---|---|---|
| Hospital-initiated CM—RCTs | ||||
| Rich et al,14 USA n=98 randomised Patients ≥70 years admitted to medical wards of Jewish Hospital at Washington University Medical Centre were screened for congestive HF. |
Age: 80 (6.3), 77.3 (6.1) years p=0.04 Female (%): 60.3, 47.1% Ethnicity: white 46, 57.1% Disease status: Mean NYHA status 2.7 (1.1), 3.0 (1.0) |
Non-pharmacological comprehensive multidisciplinary treatment strategy NPCM (n=63) Components of intervention at home: Monitoring signs and symptoms Medication review (nurse) Education/self-management support Assessment of home environment Patient-directed access to study personnel |
UC (n=35) Components of intervention: visits by home nurse |
Number of readmissions (%) 21 (CI 21.7% to 44.9%) (33.3%), 16 (29.2% to 62.2%) (45.7%) Total hospital days: 272, 200 Mean number of days: 4.3 (SD1.1), 5.7 (SD2.0) |
| Rich et al,15 USA n=285 randomised As above for Rich et al14 |
Age: 80.1 (5.9), 78.4 (6.1) years p=0.02 Female (%): 68, 59% Ethnicity: non-white race 52, 59% Disease status: Mean NYHA class 2.4 (1.0), 2.4 (1.1) |
Nurse-directed multidisciplinary intervention (n=142) As above for Rich et al14 |
UC (n=140) As above for Rich et al14 |
Number of readmissions 24, 54 p=0.04 Total hospital days 556, 865 Mean number of days 3.9 (10), 6.2 (11.4) p=0.04 |
| Stewart et al,17 Australia n=97 randomised Patients were recruited while admitted to a large tertiary hospital |
Age: 76 (11), 74 (10) years Female (%): 55, 48% Ethnicity: non-English speaking 20.4, 18.75% Disease status: NYHA II 49, 50% III 47, 42% III 4, 4% |
Home-based intervention (n=49) Components of intervention at home: Monitoring signs and symptoms Education (pharmacist)/self-management support Medication review (pharmacist) Referral to GP Family involvement Equipment |
UC (n=48) Components of intervention: DM |
Number of readmissions 36, 63 (p=0.03) Number of patients experiencing a readmission 24, 31 (p=0.12) LOS in days 261, 452 (p=0.05) |
| Stewart et al,18
19 Australia n=200 randomised Patients admitted to a tertiary referral hospital |
Age: 75.2 (7.1), 76.1 (9.3) Female (%): 35, 41% Ethnicity: primary language not English 32, 32 Disease status: NYHA II 42, 48 III 46, 43 IV 12, 9 |
Multidisciplinary home base intervention (n=100) Components of intervention at home: Monitoring signs and symptoms Referral to other health and social care Appointment organisation Assessment of home environment Family involvement Education/self-management support Medication review (nurse/GP/cardiologist) |
UC (n=100) Components of intervention: Contact with other health and social professionals Appointment with GP or cardiac clinic or both |
6 months Number of readmissions 68, 188 (event rates give p=0.02) Rate of readmissions 0.14 (0.1, 018), 0.34 (0.19, 0.49) p=0·031 LOS in days 460, 1174 0.9 (0.6, 1.2), 2.9 (1.9, 3.9) p=0.004 18 months Number of readmissions 64, 125, p=0.02 Mean number of hospital days 10.5 (14.4), 21.1 (24.1) days per patient, p=0.004 |
| Blue et al,20 UK n=165 randomised Patients admitted as an emergency to the acute medical ward of the hospital |
Age: (SD) 74.4 (8.6), 75.6 (7.9) years Female (%): 36, 49% Ethnicity: not reported Disease status: NYHA II 19 (23), 16 (20) III 28 (34), 33 (42) IV 36 (43), 30 (38) Comorbidity or multimorbidity: Angina 40 (49), 38 (45) Past MI 41 (51), 46 (55) Diabetes 15 (19), 15 (18) Chronic lung disease 18 (22), 23 (27) Hypertension 42 (52), 36 (43) AF 42 (52), 29 (35) Valve disease 12 (15), 15 (18) |
Specialist nurse intervention (n=82) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Referral to other health and social care Appointment organisation Medication review (nurse, cardiologist ) |
UC (n=75) Components of intervention: GP care |
Number(%) of readmissions 12 (14), 26 (32) HR 0.38 (0.19, 0.76) p=0.0044 LOS in days 3.43 (12.2), 7.46 (16.6) CI 0.6 (0.41 to 0.88), p=0.0051 |
| Riegel et al,21 USA n=281 physicians randomised Patients admitted at 2 Southern California hospitals |
Age: 72.52 (13.05), 74.63 (12) Female (%): 46.2, 53.9 Ethnicity: (primary language) English 91 (70), 168 (73.7) Spanish 35 (26.9), 58 (25.4) Disease status: NYHA II 2.3, 3.6 III 35.9, 38.4 IV 61.7, 58.0 |
Telephonic CM (n=130) Components of intervention at home: Monitoring signs and symptoms Self-management support Referral to other HPs (including GP) and social care Family involvement |
UC (n=228) Components of intervention: not known |
Readmission rates 3 months 14.6, 22.8 p=0.06 (calculation 19 people vs 52 experiencing 1 or more admission) 6 months 17.7, 27.6 p=0.06 (calculation 23 people vs 63 people experiencing 1 or more admision) LOS in days 3 months 0.85 (2.3), 1.6 (3.9) p=0.56 6 months 1.1 (3.1), 2.1 (4.6) p=0.05 |
| Laramee et al,22 USA n=287 randomised Patients admitted to hospital for CHF were screened. |
Age: 70.6 (11.4), 70.8 (12.2) years Female (%): 42, 50% Ethnicity: not reported Disease status (SD): NYHA I 10 (7), 35 (26) II 76 (55), 47 (36) III 50 (36), 46 (35) IV 3 (2), 4 (3) Note p<0.001 |
CM (n=131 data available ) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Family involvement Equipment Patient-directed access to CM |
UC (n=125 data available) Components of intervention: not known |
Number of readmissions 3 months period 18 (14) vs21 (17) NS LOS in days in hospital for those patients with ≥1 readmission 6.9 (6.5), 9.5 (9.8) NS |
| DeBusk et al,23 USA n=462 randomised Patients who were admitted with a provisional diagnosis of HF from Kaiser Permanente medical centres in California |
Age: <60 years 15, 14%, 6–70 years 22, 24%, 70–80 years 40, 37%, >80 years 21, 26% Female (%): 52, 45% Ethnicity: American Indian 0, 1% Asian 4, 8% Black 2, 2% White 5, 6% Hispanic 3, 3% Disease status: NHYA I–II 50, 50% III–IV 50, 50% |
CM (n=228) Components of intervention at home: Monitoring signs and symptoms Education/self-management support CM meetings/feedback to other health providers |
UC (n=234) Components of interventions: not known |
Total number of readmissions in 1 year 76, 86 no stats available |
| Naylor et al,24
25 USA n=239 patients randomised Patients aged 65 years+ admitted to 6 study hospitals from home with a diagnosis of HF were screened for participation. |
Age: 76.4 (6.9), 75.6 (6.5) Female (%): 60, 56% Ethnicity: African-American 34, 38%, white 66, 62% Disease status: Functional status (Moinpur C 1992) Personal 17.1 (5.8), 16.9 (5.8) Social 8.4 (2.6), 8.6 (2.6) Total 25.5 (8), 25.4 (7.8) |
Transitional care intervention with APNs (n=118) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Family involvement CM meetings/feedback to other health providers Patient-directed access to CM |
UC (n=121) Components of intervention: Care from standard home care services Patient-directed access to home care services |
Number of readmissions 40 vears 72 NS $175 840, $498 110 Total hospital days (all cause) 588, 970 Per patient, mean±SD 5.0±7.3 8.0±2.3 NS Per hospitalised patient, mean±SD 11.1±7.2 14.5±13.4 NS |
| Riegel et al,26 San Diego, USA n=135 randomised Self-identified Hispanics were identified at 2 community hospitals close to US-Mexico border. |
Age: 71.6910.8), 72.7 (11.2) Female (%): 58, 49.2% Ethnicity: Hispanic patients Speak/read only Spanish 60.9, 65.1% Disease Status: NYHA II 17.4, 20% III 44.9, 47.7% IV 37.7, 32.3% |
Telephonic CM (n=69) Components of intervention at home: Monitoring signs and symptoms self-management support Referral to other HPs (including GP) and social care Family involvement |
Usual care (n=65) Components of intervention: DM information |
Readmission rates (%) (number of people) all NS 1 months 8.7, 13.8% (Calculation 6.003, 8.97) 3-month 21.7, 26.2% (Calculation 14.49, 17.03) 6 months 31.9, 33.8% (Calculation 22.011, 21.97) LOS in days (mean) all NS 1 months 0.59 (2.3), 1.41 (5.5) 3 months 2.19 (5.4), 2.4 (6.2) 6 months 3.65 (7.8), 3.4 (7.1) |
| Thompson et al,27 UK Randomisation was at GP practice level Patients recruited from 2 North of England general hospitals following an admission |
Age: 73 (14), 72 (12) Female (%):38, 27% Ethnicity: no details Disease status: NYHA III and IV 76, 73% |
Clinic and home-based intervention (n=58) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Family involvement In outpatient clinic Monitoring signs and symptoms Education/self-management support Family involvement Referral to other health and social care |
UC (n=48) Components of intervention at home: unknown |
Number of patients experiencing one or more readmissions 13, 21 Total number of readmissions 15, 45 Total number of hospital days 108, 459 p<0.01 for all at 6 months |
| Jaarsma et al,28
29 The Netherlands n=1049 randomised All patients had been admitted to hospital with symptoms of HF. |
Age: 71 (11), 70 (12), 72 (11) Female (%):34, 39, 40% Ethnicity: no detail Disease status: NYHA II 51, 48, 54% III 47, 48, 42% IV3, 4, 4% |
BNS (n=340) Components of intervention: Outpatients Education/self-management support Patient directed access to HF nurse INS (n=344) Components of intervention at home: Patient-directed access to HF nurse Referral to other health and social care Education/self-management support Equipment |
UC group (n=339) Components of intervention: DM |
Number of readmissions 121,134,120 NS LOS in days (medians) 8.0 (4, 14), 9.5 (5, 17), 12 (5, 19.5) p<0.01 between BNS group and control but NS between INS group and control |
| Brotons et al,31 Spain n=283 randomised Patients were recruited by well-trained nurses at 2 university hospitals. |
Age: 76.6 (7.5), 76 (8.9) years. Female (%): 54.2, 56.1% Ethnicity: not reported Disease status: NHYA I 42.4, 55.4% II 52.1, 37.4% III 4.9, 5.8% IV 0.7, 1.4% |
Home-based intervention (n=144) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Medication review (nurse, physician, cardiologist) Referral to physician or cardiologist as necessary |
UC (n=139) Components of intervention: not known |
Number of readmissions 52, 62 NS Mean number of readmissions 1.01, 1.3 NS |
| Stewart et al,32 WHICH trial, Australia n=280 randomised Patients admitted to participating hospitals were screened for study eligibility. |
Home vs clinic Age: 70 (15), 73 (13) years Female (%):27, 28% Ethnicity: no details Disease status: NYHA II or III 83, 88% Months since CHF diagnosis 34.6 (55.3), 44.8 (71.0) |
Home-based intervention (n=143) Components of intervention at home: Monitoring signs and symptoms Family involvement CM meetings/feedback to other health providers Referral to other health or social care Assessment of home environment Medication review (nurse, pharmacist, physician, cardiologist) |
Clinic-based intervention (n=137) Components of intervention: In clinic DM Assessment of home environment Family involvement? Referral to other health or social care CM meetings/feedback to other health providers |
Rates of readmissions/100 days/patient 0.52±0.76, 0.53±1.02 NS Mean days of hospitalisation 4.96±8.57, 3.62±6.36 NS At 12–18 months |
| Hospital-Initiated CM—NRCTs | ||||
| Riegel et al,35 USA n=240 were randomised Patients were recruited from 5 hospitals following a hospitalisation for HF. |
Age: 74.44 years. (10.65), 70.77 (11.77) Female (%): 55, 55% Ethnicity: no details Disease status: NYHA I 19.2, 24.2% II 26.7, 18.3% III 43.3, 44.2% IV 10.8, 13.3% |
Multidisciplinary DM (n=120) Components of intervention at home: Monitoring signs and symptoms Support group Referral to specialist RN visits |
UC (n=120) Components of intervention at home: DM |
Readmission rates 3 months 0.22 (0.52), 0.13 (0.45) (NS) 6 months 0.32 (0.58), 0.23 (0.53) (NS) LOS in days 3 months 0.89 (3.34), 0.48 (1.64) (NS) 6 months 1.31 (3.77), 1.08 (3.46) (NS) |
| Russell et al,36 USA n=447 Patients were referred from a single large not-for-profit general medical and surgical hospital. |
Age: 79.4 (10.7), 79.9 (10.7) Female (%): 55.6, 57.6 (numbers) Ethnicity: White non-Hispanic 56.9, 58.4 African-American 17.0, 16.5 Hispanic 14.8, 14. Asian/other 11.2, 10.7 Disease status: patients with a primary or secondary diagnosis of CHF |
Transitional care service (n=223) Components of intervention at home: Self-management support Referral to other health and social care Assessment of home environment CM meetings/feedback to other health providers Advance care planning Physical therapy |
Usual home care services (n=224) Components of intervention at home: Nurse visits Physical therapy (44.6) Home health aide service (27.7) |
Readmissions Unadjusted OR 30 days 0.58 (0.38, 0.88) p<0.01 Adjusted OR 30 days 0.57 (0.38, 0.87) p<0.01 |
| Stauffer et al,37 USA n=140 Patients were screened for eligibility within 48 h of hospital admission |
Age: 78.9 (8.3), 81.4 (8.3) Female (%): 58.1, 54.8% Ethnicity: Hispanic ethnicity 7.1, 3.6% Disease status: APR-DRG severity of illness 1 5.4, 1.2% 2 44.6, 31% 3 37.5, 57.1% 4 12.5, 10.7% |
Nurse-led transitional care intervention (n=56) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Family involvement Referral (assessing availability of social care) Patient-directed access to study personnel |
Control group (n=84) Components of interventions: unknown |
Readmission rate at 30 days 12.6 (7.4, 17.8) difference −12.6, per cent change −48%; 16.4 (14, 18.7) difference −1.6% change 11% |
| Community-initiated CM—RCTs | ||||
| Peters-Klimm et al,39 Germany n=199 at randomisation Recruitment was via general practice by mail. |
Baseline characteristics of participants: CM, UC Age: 70.4 years (10.0), 68.9 (9.7) Female (%):29, 26% Ethnicity: no details Disease status: NYHA I 1 (1.0), 5 (5) II 63 (64.9), 67 (67) III 33 (34), 27 (27) IV 0, 1 (1.0) Mean years with CHD 6.2 (4.6) (n=79), 6.8 (6.3) (n=74) |
CM (n=97) Components of intervention at home: Monitoring signs and symptoms Education/self-management support Medication review (CM/GP) Referral to GP |
UC (n=100) Components of control intervention: DM Education |
Number of admissions (baseline 36 vs 35) 18 vs 9 at 12 months (NS) Number of patients experiencing one or more CHF admissions 11 vs 7 at 12 months (NS) |
| Wade et al,42 USA n=2200 were randomised Aetna Medicare Advantage members with medical and pharmacy benefits were identified through analysis of claims. |
Age: 75.8, 77.7 years. Female (%): no detail Ethnicity: black/African-American 24, 20.4% Disease status (SD): no detail |
CM (n=152) Components of intervention at home: Referral to other health and social care Equipment |
THCM (n=164) Components of intervention: DM Education Referral to other health and social care |
No data available for primary outcome but described as NS The participant population overall had 42% fewer inpatient days during the intervention period compared with the previous year. No data |
| Hancock et al,43 UK n=28 randomised Residents from 33 of 35 long-term residential and nursing homes |
Age: 85.1 (6.7), 81.8 (7.1) years Female (%):56%, 58% Ethnicity:100% white British Disease status: I:II:III:IV 10:1:4:1, 5:4:1:1 |
CM (n=16) Components of interventions at home: Monitoring signs and symptoms Education CM meetings/feedback to other health providers Medication review (CM/GP/cardiologist ) |
Routine GP-led care (n=12) Components of intervention: DM |
Number of admissions at 6 and 12 months 0, 0 at 6 months 0, 0 at 12 months |
| Community-initiated CM—NRCTs | ||||
| Bonarek-Hessamfar et al,44 France n=362 Compared patients included prospectively from 1 January 2004 to 31 December 2005 from GP list |
Age: median 78, 80 years. Female (%): no details Ethnicity: no details Disease status: NHYA Median of III, IV |
Coordinated care via multidisciplinary network (n=129) Components of intervention at home: Monitoring signs and symptoms Education (diet) Physical therapy CM meetings/feedback to other health provider |
UC ( n=233) Components of intervention: not known |
Number of patients experiencing at least one admission 26, 58 Total number of admissions 35, 96 Median LOS 9.2, 11.7 days In the 2-year period |
| Lowery et al,45 USA n=1043 Intervention implemented in 4 Midwest VA medical centres from the same region and one affiliated outpatient clinic and 2 VA medical centres served as control. |
Age: 65.4 (0.51), 67.4 (0.45) years. Female (%):1, 1% Ethnicity: White 71.2, 79.9% Black 24, 16.1% Other 4.8, 4.0% Disease status: no details |
Nurse-practitioner-led DM model (n=457) Components of intervention at home: Location was lead tertiary centre, other medical centres (some primary care) or one affiliated outpatient clinic. Monitoring signs and symptoms Education/self-management support Referral to other health and social care Family involvement |
UC (n=510) Components of intervention: not known |
Mean number of readmissions 1 year 0.7 (0.32), 0.23 (0.65) p<0.001 (417, 428) 2-year 0.15 (0.58), 0.13 (0.42) NS (384, 382) Mean number of days in hospital 1 year 0.37 (2.25), 0.97 (3.15) p=0.0014 2-year 0.86 (3.98), 0.66 (2.74) NS |
AF, atrial fibrillation; APN, advanced practice nurse; APR-DRG, all-patient refined-diagnosis related group; BNS, basic nurse support; CHD, coronary heart disease; CHF, chronic heart failure; CM, case management or case manager; COPD, chronic obstructive pulmonary disease; DM, disease management; GP, general practitioner; HOCM/RCM, hypertrophic obstructive/restrictive cardiomyopathy; HP, health professional; INS, intensive nurse support; LOS, length of hospital stay; LV, left ventricular; MI, myocardial infarction; NPCM, non-pharmacological comprehensive multi-disciplinary treatment strategy; NRCT, non-randomised controlled trial; NS, not statistically significant; NYHA, New York Heart Association; PAD, peripheral arterial disease; SNF, skilled nursing facility; THCM, telehealth with CM; UC, usual care.