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Impact of Nurse-Led, Multidisciplinary, Home-Based Interventions in Chronic Heart Disease
Study Questions:
In patients with any form of heart disease, is home-based intervention superior to standard care in preventing recurrent hospitalizations and premature mortality on an all-cause basis?
Methods:
The study was a prospectively-planned, combined, secondary analysis of three randomized trials comparing patients with cardiac disease (n = 1226) in Australia who received either nurse-led, multidisciplinary home-based intervention or standard management after hospitalization. The patients had heart disease without heart failure (HF), atrial fibrillation (AF) without HF, and HF. They were assigned to receive either standard care or a home visit with a cardiac nurse between 7 and 14 days after discharge (with access to a physician to address treatment gaps). The primary outcome of days alive and days out of hospital was examined on an intention-to-treat basis.
Results:
The most common primary discharge diagnoses were AF (20%), acute coronary syndrome (19%), and acute HF (17%). Women comprised of 34% of the population and averaged 4 years older than the men (average age = 71; standard deviation ± 11). The patients who received home-based intervention accumulated significantly fewer cardiovascular admissions and had 600 fewer hospital-stay days per 100 patients across all 3 categories (p = 0.017). In the home-based-intervention group, the number to treat to prevent one mortality was 21 patients, with the greatest benefits in patients with multiple comorbidities (p = 0.041) and those aged 60-82 years old (p = 0.005).
Conclusions:
Patients with cardiac disease, including those without HF, who are older and with multiple comorbidities benefited from home-based intervention that included face-to-face interaction with a cardiac nurse and multidisciplinary support. Even though the study did not calculate a cost saving, the reduction in hospital days and mortality is impressive. In a healthcare system that has a large number of government-insured patients, there is potential to improve care to all patients with cardiovascular disease through a nurse-led, home-based intervention.
Perspective:
A nurse-led program, with immediate access to other members of the team to address treatment gaps, can improve care in older patients with multiple comorbidities across the spectrum of heart disease. In addition, assessing health disparities, addressing the barriers to follow-up visits, and coordinating care are integral components of the nurse visit. The patient receives comprehensive treatment and the ability to be cared for safely in his or her home.
Keywords: Acute Coronary Syndrome, Atrial Fibrillation, Australia, Comorbidity, Heart Failure, Hospitalization, House Calls, Intention to Treat Analysis, Mortality, Premature, Patient Discharge, Geriatrics, Angiography, Angina, Stable
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