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Standard Versus Intensified Management of HF to Reduce Health Care Costs
Study Questions:
Will more intensive post-discharge management of higher-risk patients with heart failure (HF) reduce total health care costs, increase survival, or improve quality of life in these patients over a 12-month period when compared with the current standard management of home visits or phone calls based on patient geography?
Methods:
This multicenter, randomized trial compared the effects of two outpatient interventions on health care costs and patient outcomes over a period of 12 months after discharge for acute decompensated HF. The trial randomized 787 patients with confirmed HF who were discharged from 4 hospitals to either standard management (home visits or telephone calls based on patient geography) or targeted intensive intervention (patients were risk-stratified into high, medium and low risk using the GARDIAN-HF tool [Green, Amber and Red Delineation of Risk And Need in HF]). In the intensive intervention arm, low-risk or green patients received the same level of care as the standard management arm, but higher-risk amber and red patients received more intensive home care and structured telephone support.
Results:
There was no significant difference in total health care costs, the study’s primary endpoint, between the intensive intervention arm (median cost of A$1579 per patient per month) and the standard management arm (median cost of A$1450 per patient per month) (p = 0.336). Total health care costs were a measure of three components, only one of which showed a statistically significant difference favoring standard management over intensive intervention:
- Hospital-based care (median $1109 for intensive intervention vs. $997 for standard management; p = 0.445)
- Community care (median $265 for intensive intervention vs. $266 for standard management; p = 0.893)
- HF-specific management, which included the additional cost of the intensive HF management in the intensive intervention arm and was significantly higher in the intensive intervention arm (median $152 per patient per month for intensive intervention vs. $121 per patient per month for standard management; p < 0.001).
There was no significant difference in mortality between the intensive intervention group and the standard management group (17.7 vs. 18.4%, respectively; p = 0.848). There was also no difference between unplanned hospitalizations (63 vs. 57%, respectively), and both groups had similar days alive and out-of-hospital measures (84.9 vs. 86.1%, respectively, p = 0.493).
Finally, there was no significant difference in the health-related quality-of-life measures used in the study, with the exception of a greater improvement in a subscale related to self-efficacy in the intensive intervention arm.
Conclusions:
Targeted, more intensive management of higher-risk patients during a 12-month study period showed no significant difference in overall health care costs, survival and hospitalization, or health-related quality of life. The authors note that these outcomes were unexpected given the significant amount of time and resources that went into profiling patient risk and delivering more intensive management to those at highest risk.
Perspective:
Although there are significant differences between the Australian health care system and the US health care system, most particularly payment structure, this study highlights similar concerns about effective allocation of resources when treating patients with complicated HF after hospitalization for decompensation.
Spending resources to identify those patients at high risk for morbidity, mortality, and readmission seems intuitive, but in this study, it made no difference in cost or quality of life despite the significant amount of time and effort that went into the risk stratification and care delivery. In fact, the authors point out that the GARDIAN-HF tool did predict higher mortality and hospitalization rates in the higher-risk categories, underlining its effectiveness. It may be that once we identify these high-risk patients, merely intensifying standard interventions such as home nursing is not the right approach. Perhaps using resources to identify those at highest risk and then applying different interventions, such as referral for advanced therapeutics versus palliative or hospice care, would be more beneficial in terms of both cost and quality of life in these patients.
Keywords: Australia, Health Care Costs, Heart Failure, Home Care Services, Home Nursing, Hospice Care, Hospitalization, Outpatients, Patient Discharge, Quality of Life, Resource Allocation, Telephone
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