Systematic review of multidisciplinary interventions in heart failure

Abstract

Objective: To determine the impact of multidisciplinary interventions on hospital admission and mortality in heart failure.

Design: Systematic review. Thirteen databases were searched and reference lists from included trials and related reviews were checked. Trial authors were contacted if further information was required.

Setting: Randomised controlled trials conducted in both hospital and community settings.

Patients: Trials were included if all, or a defined subgroup of patients, had a diagnosis of heart failure.

Interventions: Multidisciplinary interventions were defined as those in which heart failure management was the responsibility of a multidisciplinary team including medical input plus one or more of the following: specialist nurse, pharmacist, dietician, or social worker. Interventions were separated into four mutually exclusive groups: provision of home visits; home physiological monitoring or televideo link; telephone follow up but no home visits; and hospital or clinic interventions alone. Pharmaceutical and exercise based interventions were excluded.

Main outcome measures: All cause hospital admission, all cause mortality, and heart failure hospital admission.

Results: 74 trials were identified, of which 30 contained relevant data for inclusion in meta-analyses. Multidisciplinary interventions reduced all cause admission (relative risk (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95, p = 0.002), although significant heterogeneity was found (p = 0.002). All cause mortality was also reduced (RR 0.79, 95% CI 0.69 to 0.92, p = 0.002) as was heart failure admission (RR 0.70, 95% CI 0.61 to 0.81, p < 0.001). These results varied little with sensitivity analyses.

Conclusion: Multidisciplinary interventions for heart failure reduce both hospital admission and all cause mortality. The most effective interventions were delivered at least partly in the home.

Figure 1

Flowchart describing study selection and excluded studies. RCT, randomised controlled trial.

Figure 2

Forest plot for all cause admission results. CI, confidence interval; RR, relative risk. Note: data on all cause admission were not available for the three trials in subgroup B (videophone/remote monitoring).

Figure 3

Forest plot of all cause mortality results. The control group from the study of Cleland/Coletta appears twice, as this was a three arm trial (telemonitoring, telephone support, and usual care). As a result, estimates for each subgroup are correctly calculated but the total estimate is slightly inaccurate. This should read 0.79 (95% CI 0.69 to 0.92) and the overall test for heterogeneity should have a χ² of 40.07, p  =  0.04.