Heart failure disease management model does not outshine usual care

Multisite patient-centered disease management may not be able to compete with the level of care patients already receive at Veterans Affairs medical centers. At one year, cardiomyopathy scores for heart failure patients in an intervention arm were no better than those getting usual care.

In research published online March 30 in JAMA: Internal Medicine, 392 Veterans Affairs (VA) heart failure patients were enrolled and randomized between usual care and an intervention arm. Patients in the Patient-Centered Disease Management (PCDM) intervention were assigned to a collaborative care team, including a nurse, primary care physician, cardiologist and a psychiatrist. They were screened and treated for depression and received daily telemonitoring and self-care support.

Patients in the usual care arm continued to see their regular healthcare professionals. Some in the usual care arm were already enrolled in telemonitoring through the VA, which continued.

David B. Bekelman, MD, MPH, of the VA Eastern Colorado Health Care System in Denver, and colleagues from VA medical centers across the U.S. found that both groups had significant improvement but no real difference, about 13.5 points in each group, in scores for cardiomyopathy at one year. When reviewed at three, six and 12 months, improvement in the intervention group was not greater than that of patients receiving usual care.

However, among secondary outcomes, mortality in the intervention arm was almost half of what it was in the usual care arm. Patients in the intervention arm also reported better scores on depression scales than usual care (2.1 points lower) at one year. No significant difference was noted in hospitalization rates at one year between the two arms, either.

“This study raises questions about the effectiveness and cost-effectiveness of disease management interventions in the current health care environment,” wrote Bekelman et al. They noted that analyses have shown reduced rates of hospitalization and mortality through disease management interventions, but only in small single-center trials.

In larger, more complex and heterogenous studies, Bekelman et al wrote, “It can be difficult to distinguish the effect of intervention components from the effect of the skilled and motivated staff who conduct the intervention.” This was a particular concern as components of the intervention, like telemonitoring, may or may not be as effective as previously considered, according to some studies.

Further studies, they wrote, were needed.