Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial

Abstract

Background: Although multidisciplinary congestive heart failure clinics in the United States appear to be effective in reducing the number of hospital readmissions, it is unclear whether the same benefit is seen in countries such as Canada, where access to both general and specialized medical care is free and unrestricted. We sought to determine the impact of care at a multidisciplinary specialized outpatient congestive heart failure clinic compared with standard care.

Methods: We randomly assigned 230 eligible patients who had experienced an acute episode of congestive heart failure to standard care (n = 115) or follow-up at a multidisciplinary specialized heart failure outpatient clinic (n = 115). The intervention consisted of a structured outpatient clinic environment with complete access to cardiologists and allied health professionals. The primary outcomes were all-cause hospital admission rates and total number of days in hospital at 6 months. The secondary outcomes were total number of emergency department visits, quality of life and total mortality.

Results: At 6 months, fewer patients in the intervention group had required readmission to hospital than patients in the control group (45 [39%] v. 66 [57%], crude hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.38-0.92. Patients in the intervention group stayed in hospital for 514 days compared with 815 days required by patients in the control group (adjusted HR 0.56, 95% CI 0.35-0.89). The number of patients seen in the emergency department and the total number of emergency department visits were similar in the intervention and control groups. At 6 months, quality of life, which was self-assessed using the Minnesota Living with Heart Failure questionnaire, was unchanged in the control group but improved in the intervention group (p < 0.001). No difference in mortality was observed, with 19 deaths in the control group and 12 in the intervention group (HR 0.61, 95% CI 0.24-1.54).

Interpretation: Compared with usual care, care at a multidisciplinary specialized congestive heart failure outpatient clinic reduced the number of hospital readmissions and hospital days and improved quality of life. When our results are integrated with those from other, similar trials, multidisciplinary disease management strategies for congestive heart failure are associated with clinically worthwhile improvements in survival.

Fig. 1: Patient recruitment and follow-up.

Fig. 2: Survival probability for repeat hospital admissions for the control group and the intervention group (p = 0.0035, log-rank test).