Home is where the heart is when it comes to transitional care in heart failure, but is it the only way to improve health outcomes?

This article refers to ‘Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis’ by H.G.C. Van Spall et al., published in this issue on pages 1427–1443. Along with an evolving armoury of pharmacological agents and devices, predominantly nurse-led heart failure (HF) management programmes represent important cogs in the wheel of effective management of patients hospitalized with the syndrome.1 Indeed, if we were to take the analogy further, we could argue that these programmes represent the ‘lubricant’ that ensures that each cog of effective HF management (including the health professionals who deliver care) work smoothly together and for the best interests of the patient. It's now been 20 years since the formative randomized trials of HF management (of varying types) were conducted and more than a decade since a definitive systematic review and meta-analysis of the available evidence confirmed that the application of multidisciplinary programmes was associated with both reduced risk for rehospitalization and prolonged survival in hospitalized individuals.2 Remarkably, however, the application of post-discharge HF management programmes remains inconsistent and their inherent value has been questioned. This scenario defies expert recommendations for their routine application and a plethora of systematic reviews and meta-analyses that are consistently positive overall,3 whilst noting the consistent inconsistency of evidence to support the application of remote management techniques.3, 4 In reality, the translation of evidence in favour of HF management programmes has been complicated by a number of persistent issues that have both shaped and impeded their application. Firstly, the nomenclature used to describe the overall nature and components of HF management programmes is both broad and inconsistent. Secondly, in reflection of the wide range of options for application of the same framework of integrated care, the interventions used to build the case for HF management programmes are inherently heterogeneous, including in their modes of delivery (e.g. remote vs. face-to-face care), personnel (single-person vs. multidisciplinary team) and the intensity and frequency of programme-to-patient contact over the short to longer term. Thirdly, the individual components of non-pharmacological management (from exercise to self-care strategies) are often open to interpretation and it is difficult to determine which combination works best in individual cases. Fourthly, there is a continued push to simplify an inherently complex intervention into a formula or strategy that is easier to understand and apply, which explains the continued focus on the development of remote management techniques and monitoring devices. Finally, the HF patient population is inherently diverse and its needs, according to each patient's age and socioeconomic profile, clinical complexity and the health care system in which he or she is managed, will vary. This is never more evident than with respect to the increasing number of older individuals with HF and multimorbidity.5 Given this context, it is important that we continue to interrogate the available evidence to identify which components of HF management are most effective in which group of individuals. Such information is vital, both to support currently funded services and to strengthen recommendations for new health services in regions in which HF management has yet to be applied. In this issue, Van Spall and colleagues6 report on their systematic review and network meta-analysis of 53 randomized controlled trials involving 12 356 HF patients that applied ‘transitional care’, loosely defined as services that coordinate the transition of individuals from a health facility to (typically) home or between health service providers. In the context of HF, this largely focuses on the highly vulnerable period (particularly within 30 days) following an acute hospital admission.7 In order to tease out the evidence for and against different forms of transitional care, the authors arbitrarily divided study interventions into seven categories.6 Overall, they found that, in comparison with usual care, those programmes that applied nurse home visits and disease management clinics were most effective in decreasing all-cause mortality (risk reduction: 20–22%).6 With respect to reducing all-cause readmission, the most effective components were (in rank-order) nurse home visits, nurse case management and disease management clinics (risk reduction: 20–35%).6 Not surprisingly, in health economic terms, nurse home visits were predominant in achieving cost-savings. Critically, remote management (structured telephone support and telemonitoring) programmes, those delivered by pharmacists and those focused on education alone were found to be ineffective.6 As with all studies of this type, careful reading is required to interpret the study findings in a balanced manner. Firstly, there are a number of positives that deserve to be highlighted. This type of meta-analysis has the advantage of comparing the relative effectiveness of different forms of treatment not directly addressed by individual trials. Moreover, an important aspect of the robust set of analyses was the choice of all-cause mortality and readmission rather than HF-related events specifically; the latter is both problematic to adjudicate within trials and increasingly irrelevant in a patient population in which HF rarely occurs in isolation.5 In reflection of an ever-growing number of HF management trials (see below), a large and geographically disperse set of studies were used to generate these data.6 However, the study is critically weakened by a factor that also represents its major strength in that it provides the potential to delineate the relative impacts of different forms of HF management: the interpretation of primary study reports to determine the type of programme applied. In the absence of a clear taxonomy and in reflection of a perennial problem in the literature, a number of closely related interventions that would otherwise be classed as the same have been placed in different categories.6 This critical point represents an important caveat in the interpretation of study findings and conclusions. It is also a reminder of the limitations of retrospective analyses. How do these findings, with all their caveats, support what we already know? Unfortunately, research efforts to better understand the dynamics of HF management have largely failed to keep pace with the need for more sophisticated trials of different forms of HF management. This undoubtedly reflects a lack of both intent and funding support for head-to-head trials that require substantive funding to recruit large numbers of participants in order to examine (with sufficient study power) smaller but still potentially important differences in outcome, the path of least resistance being to reconfirm the benefits of HF management in different contexts relative to standard care. One of the few exceptions to this status quo, along with the COACH trial,8 is the WHICH? trial of home vs. clinic-based management of HF.9, 10 This was a prospective, multicentre trial that randomized 280 hospitalized HF patients (73% male; mean age 71 ± 14 years; 73% with a left ventricular ejection fraction of ≤45%) to the same model of nurse-led, multidisciplinary management delivered through either an outreach, home-based intervention (HBI) or an outpatient specialized chronic HF clinic-based intervention (CBI). During the initial study follow-up of 12–18 months, the primary endpoint of event-free survival of all-cause hospitalization or death was not met (71% vs. 76% in favour of the HBI group; adjusted hazard ratio 0.97, 95% confidence interval 0.73–1.30; P = 0.861).9 There was, however, a large and significant reduction in the secondary endpoint of hospital stay in favour of the HBI.9 During longer-term follow-up, patients assigned to HBI had significantly prolonged survival and reduced hospital stay compared to those in the CBI group,11 and a full health–economic analysis confirmed the benefits of HBI over CBI.10 Although these trial findings are consistent with those reported by Van Spall and colleagues,6 they also require careful consideration. In a recent analysis of the overall impact of the same model of HBI across the full spectrum of chronic heart disease, in which the positive effects of HBI in reducing recurrent hospital stay and prolonging survival were confirmed, it was clear that HBI has potentially differential effects (including potential negative effects on survival) on an individual basis, particularly in very complex clinical cases in which active management might have been better replaced with a more conservative approach.12 Overall, therefore, it does appear that, based on this network meta-analysis of the available literature6 and a purposeful, head-to-head trial of two different ways of applying HF management,9-11 those programmes applying nurse home visits provide the greatest cost-benefits with respect to reducing recurrent hospitalization and prolonging survival in HF. There are a myriad reasons why outreach home visits are likely to be more effective than other models of ‘transitional’ care, especially when they are based on a multidisciplinary team approach.13 However, these advantages will not apply to every individual, and a less-is-more approach is likely to be more beneficial in many patients in that it may avoid provoking worse outcomes.12 The findings of Van Spall and colleagues6 are, therefore, a timely reminder of the need for less simplistic HF management trials (at least in high-income countries where the evidence base is now so strong) to prove the overall efficacy of this broad approach. In their place, we are in desperate need of more sophisticated head-to-head trials of different models of care that will both confirm important differentials in overall efficacy and perhaps guide the development of more nuanced management tailored to suit individual needs. Although nurse home visits will undoubtedly be predominant in HF management, they will not necessarily be practical, necessary or therapeutic in every case. Conflict of interest: none declared.