Impact of primary care involvement and setting on multidisciplinary heart failure management: a systematic review and meta-analysis

Abstract

Multidisciplinary disease management programmes (DMPs) are a cornerstone of modern guideline-recommended care for heart failure (HF). Few programmes are community initiated or involve primary care professionals, despite the importance of home-based care for HF. We compared the outcomes of different multidisciplinary HF DMPs in relation to their recruitment setting and involvement of primary care health professionals. We conducted a systematic review and meta-analysis of randomized controlled trials published in MEDLINE, Embase, and Cochrane between 2000 and 2020 using Cochrane Collaboration methodology. Our meta-analysis included 19 randomized controlled trials (7577 patients), classified according to recruitment setting and involvement of primary care professionals. Thirteen studies recruited in the hospital (n = 5243 patients) and six in the community (n = 2334 patients). Only six studies involved primary care professionals (n = 3427 patients), with two of these recruited in the community (n = 225 patients). Multidisciplinary HF DMPs that recruited in the community had no significant effect on all-cause and HF readmissions nor on mortality, irrespective of primary care involvement. Studies that recruited in the hospital demonstrated a significant reduction in mortality (relative risk 0.87, 95% confidence interval [CI] [0.76, 0.98]), HF readmissions (0.70, 95% CI [0.54, 0.89]), and all-cause readmissions (0.72, 95% CI [0.60, 0.87]). However, the difference in effect size between recruitment setting and involvement of primary care was not significant in a meta-regression analysis. Multidisciplinary HF DMPs that recruit in the community have no significant effect on mortality or hospital readmissions, unlike DMPs that recruit in the hospital, although the difference in effect size was not significant in a meta-regression analysis. Only six multidisciplinary studies involved primary care professionals. Given demographic evolutions and the importance of integrated home-based care for patients with HF, future multidisciplinary HF DMPs should consider integrating primary care professionals and evaluating the effectiveness of this model.

Keywords: care setting; community care; disease management; heart failure; multidisciplinary; primary care; transitional care.

Figure 1

Flowchart describing study selection and excluded studies. DMP, disease management programme; HF, heart failure; RCT, randomized controlled trial. The number between parentheses reflects the number of articles reporting on the respective trials.

Figure 2

Risk of bias appraisal. Green = low risk of bias. Orange = unclear risk of bias. Red = high risk of bias.

Figure 3

Effectiveness of multidisciplinary heart failure DMPs in reducing all‐cause hospital admission. Results of the meta‐analysis are depicted in the forest plot. CI, confidence interval; DMP, disease management programme; PCP, primary care professional. Total = total number of patients in the study arm.

Figure 4

Effectiveness of multidisciplinary heart failure (HF) DMPs in reducing HF hospital admission. Results of the meta‐analysis are depicted in the forest plot. CI, confidence interval; DMP, disease management programme; PCP, primary care professional. Total = total number of patients in the study arm.

Figure 5

Effectiveness of multidisciplinary heart failure DMPs in reducing all‐cause deaths. Results of the meta‐analysis are depicted in the forest plot. CI, confidence interval; DMP, disease management programme; PCP, primary care professional.

Figure 6

Bubble diagram of random effects meta‐regression analysis by recruitment setting (A) and primary care involvement (B). Treatment effects are displayed on the y‐axis as log‐risk ratios. The regression line is plotted in black. HF, heart failure; PCP, primary care professional.

Figure 7

L'Abbé plots comparing event rates for all‐cause readmission (A), heart failure readmission (B), and deaths (C). Studies recruiting in the community are coloured red, and studies recruiting in the hospital are coloured blue.