Prolonged Effects of a Home-Based Intervention in Patients With Chronic Illness

Abstract

Background: Data on the long-term benefits of nonspecific disease management programs are limited. We performed a long-term follow-up of a previously published randomized trial. Methods: We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, homebased intervention (HBI) (n = 260) or to usual postdischarge care (n= 268). Results: During follow-up, HBI had no impact on allcause mortality (relative risk, 1.04; 95% confidence interval, 0.80-1.35) or event-free survival from death or unplanned hospitalization (relative risk, 1.03; 95% confidence interval, 0.86-1.24). Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization, with 677 readmissions vs 824 for the usual care group (mean ± SD rate, 0.72 ± 0.96 vs 0.84 ± 1.20 readmissions/patient per year; P=.08). When accounting for increased hospital activity in HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years, post hoc analyses showed that HBI reduced readmissions by 14% within 2 years in patients without this condition (mean±SD rate, 0.54±0.72 vs 0.63±0.88 readmission/ patient per year; P=.04) and by 21% in all surviving patients within 3 to 8 years (mean±SD rate, 0.64±1.26 vs 0.81±1.61 readmissions/patient per year; P=.03). Overall, recurrent hospital costs were significantly lower (14%) in the HBI group

Extending the Horizon in Chronic Heart Failure

“…6,7 Moreover, we recently documented the long-term benefits of this form of intervention in a large group of patients with a range of chronic disease states. 23 Within the limitations of our inability to track in any detail the patterns of healthcare patients received beyond the first few years and via hospital care, what are the likely mechanisms of beneficial effect? For example, it would be improbable to suggest that patients exposed to HBI experienced an "epiphany" at their first home visit and decided to make drastic changes to their lifestyle and health behavior.…”

A Multicenter, Randomized Trial of a Nurse-Led, Home-Based Intervention for Optimal Secondary Cardiac Prevention Suggests Some Benefits for Men but Not for Women

“…16 We have previously demonstrated that when excluding patients with chronic pulmonary disease in a cohort of chronically ill patients being managed within the public health system of Australia (characterized by far less hospital activity and in particular elective hospitalizations), a more transient form of HBI was associated with an approximate one-third reduction in recurrent all-cause hospital stay. 29 The impact of HBI was particularly striking with respect to CVD events with significantly fewer admissions for CHF (de novo), acute coronary syndrome, and stroke. 29 However, there have been contemporary randomized trials of management programs focusing on both low-risk 30 and high-risk CHF patients 31 that have failed to demonstrate health benefits relative to UC.…”

“…29 The impact of HBI was particularly striking with respect to CVD events with significantly fewer admissions for CHF (de novo), acute coronary syndrome, and stroke. 29 However, there have been contemporary randomized trials of management programs focusing on both low-risk 30 and high-risk CHF patients 31 that have failed to demonstrate health benefits relative to UC. The results of the Coaching Patients on Achieving Cardiovascular Health Study 31 are particularly relevant given that a similar program of postdischarge management was compared with the care of cardiologists for patients with CHF.…”

“…As such, one might question both the primary end point (all cause) and possible impact of HBI on noncardiac and elective admissions (particularly with previous evidence showing that HBI tends to increase elective admissions). 29 Moreover, in the early stages of designing this study, we flagged the potential to invoke the phenomenon of clinical cascade whereby more detailed care and attention lowers admission thresholds and increases hospital activity. Given high levels of participation and trends in elective admissions, we cannot discount this possibility.…”

Nurse-led medication reviews and the quality of drug treatment of elderly hospitalized patients

“…Studies have shown that nurse-led medication reviews with subsequent intervention can reduce re-admissions to hospital of patients with heart failure [27,28], and a homebased intervention assessed by a pharmacist and a nurse showed a 25% reduction in unplanned re-admissions to hospital [29,30]. A recently published study has shown that after training in clinical pharmacology, nurses are able to identify DRPs not detected during the usual care in hospitalized patients [31].…”