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Type: Journal article
Title: Impact of home versus clinic-based management of chronic heart failure: the WHICH? (Which heart failure intervention is most cost-effective & consumer friendly in reducing hospital care) multicenter, randomized trial
Author: Stewart, S.
Carrington, M.
Marwick, T.
Davidson, P.
Macdonald, P.
Horowitz, J.
Krum, H.
Newton, P.
Reid, C.
Chan, Y.
Scuffham, P.
Citation: Journal of the American College of Cardiology, 2012; 60(14):1239-1248
Publisher: Elsevier Science Inc
Issue Date: 2012
ISSN: 0735-1097
Statement of
Simon Stewart, Melinda J. Carrington, Thomas H. Marwick, Patricia M. Davidson, Peter Macdonald, John D. Horowitz, Henry Krum, Phillip J. Newton, Christopher Reid, Yih Kai Chan and Paul A. Scuffham
Abstract: <h4>Objectives</h4>The goal of this study was to make a head-to-head comparison of 2 common forms of multidisciplinary chronic heart failure (CHF) management.<h4>Background</h4>Although direct patient contact appears to be best in delivering CHF management overall, the precise form to optimize health outcomes is less clear.<h4>Methods</h4>This prospective, multicenter randomized controlled trial with blinded endpoint adjudication comprised 280 hospitalized CHF patients (73% male, age 71 ± 14 years, and 73% with left ventricular ejection fraction ≤45%) randomized to home-based intervention (HBI) or specialized CHF clinic-based intervention (CBI). The primary endpoint was all-cause, unplanned hospitalization or death during 12- to 18-month follow-up. Secondary endpoints included type/duration of hospitalization and healthcare costs.<h4>Results</h4>The primary endpoint occurred in 102 of 143 (71%) HBI versus 104 of 137 (76%) CBI patients (adjusted hazard ratio [HR]: 0.97 [95% confidence interval (CI): 0.73 to 1.30], p = 0.861): 96 (67.1%) HBI versus 95 (69.3%) CBI patients had an unplanned hospitalization (p = 0.887), and 31 (21.7%) versus 38 (27.7%) died (p = 0.252). The median duration of each unplanned hospitalization was significantly less in the HBI group (4.0 [interquartile range (IQR): 2.0 to 7.0] days vs. 6.0 [IQR: 3.5 to 13] days; p = 0.004). Overall, 75% of all hospitalization was attributable to 64 (22.9%) patients, of whom 43 (67%) were CBI patients (adjusted odds ratio: 2.55 [95% CI: 1.37 to 4.73], p = 0.003). HBI was associated with significantly fewer days of all-cause hospitalization (-35%; p = 0.003) and from cardiovascular causes (-37%; p = 0.025) but not for CHF (-24%; p = 0.218). Consequently, healthcare costs ($AU3.93 vs. $AU5.53 million) were significantly less for the HBI group (median: $AU34 [IQR: 13 to 81] per day vs. $AU52 [17 to 140] per day; p = 0.030).<h4>Conclusions</h4>HBI was not superior to CBI in reducing all-cause death or hospitalization. However, HBI was associated with significantly lower healthcare costs, attributable to fewer days of hospitalization. (Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [WHICH?]; ACTRN12607000069459).
Keywords: Humans
Ventricular Dysfunction, Left
Chronic Disease
Cardiovascular Agents
Stroke Volume
Ambulatory Care
Length of Stay
Patient Readmission
Cohort Studies
Follow-Up Studies
Prospective Studies
Quality of Life
Aged, 80 and over
Middle Aged
Home Care Services
Cost-Benefit Analysis
Heart Failure
Surveys and Questionnaires
Rights: © 2012 by the American College of Cardiology Foundation
DOI: 10.1016/j.jacc.2012.06.025
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