Disease Management for Heart Failure Complicated by Depression | Journal Scan

Study Questions:

What is the effectiveness of disease management on symptom burden, functional status, and health-related quality of life in heart failure (HF) patients?

Methods:

The PCDM (Patient-Centered Disease Management) study was a multisite randomized clinical trial comparing usual care in HF patients with PCDM intervention. The collaborative group administering PCDM intervention was comprised of a nurse coordinator, cardiologist, psychiatrist, and primary care physician. The PCDM intervention included three components including multidisciplinary collaborative care disease management of HF, screening for and treatment of depression, and telemonitoring with patient self-care support. The study cohort was comprised of 392 HF patients from four Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of <60 (heavy symptom burden and impaired functional status and quality of life), and who were enrolled between May 2009 and June 2011. Approximately 96% of these patients were male and 81.8% were white.

Results:

The study investigators found no significant differences in baseline characteristics between usual care (n = 197) HF patients versus those randomized to the PCDM intervention (n = 187) including baseline mean KCCQ overall summary scores, which were 36.9 versus 37.9 (p = 0.48). The KCCQ overall summary scores improved in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (p = 0.97). When the investigators evaluated effect over time using 3-month, 6-month, and 12-month data, PCDM intervention was not associated with greater improvement in the KCCQ overall summary scores (p = 0.74). Mortality (a secondary outcome) was significantly lower at 1 year in the intervention arm (8 of 187 [4.3%]) when compared to the usual care arm (19 of 197 [9.6%]) (p = 0.04). There was a greater improvement in the Patient Health Questionnaire 9 scores in HF patients who screened positive for depression after 1 year in the intervention arm than in the usual care arm (2.1 points lower, p = 0.01). However, there was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs. 29.9%, p = 0.87).

Conclusions:

The authors concluded that PCDM intervention did not improve overall health status when compared to usual care.

Perspective:

The prevalence of depression in HF is over 20% and it affects both caregivers and family members, making management of depression challenging. Depression is also associated with increased costs; up to $5 billion of the total $20 billion in costs associated with HF during 1998 was ascribed to depression. The findings of this study, unfortunately, suggest that a multidisciplinary approach is not effective in managing HF patients with complex comorbidities such as depression in Veterans Administration hospitals. Also unclear is whether these patients may have other unrecognized comorbidities such as post-traumatic stress disorder. This study, therefore, raises important questions on how best to design future disease management strategies for HF patients complicated by depression.

Clinical Topics: Heart Failure and Cardiomyopathies

Keywords: Cardiomyopathies, Caregivers, Cohort Studies, Comorbidity, Cost of Illness, Depression, Depressive Disorder, Treatment-Resistant, Disease Management, Health Status, Hospitalization, Patient Care, Physicians, Primary Care, Prevalence, Psychiatry, Quality of Life, Questionnaires, Research Personnel, Stress Disorders, Post-Traumatic, Veterans


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