Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure
Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure
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DOI：
10.1161/01.cir.0000148957.62328.89
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发表时间：
2004-12-07
期刊：
影响因子：
37.8
通讯作者：
Freeman, GL
中科院分区：
文献类型：
--
作者：
Galbreath, AD;Krasuski, RA;Freeman, GL
背景 - 由于充血性心力衰竭（CHF）的患病率高且费用昂贵，人们已做出重大努力来开发疾病管理（DM）项目，以改善临床和经济方面的结果。此类项目在大量不同类型的CHF患者中的有效性仍不明确。
方法与结果 - 我们将1069名患者（年龄70.9±10.3岁）随机分组，这些患者患有收缩性（射血分数35±9%）或经超声心动图确诊的舒张性心力衰竭（HF），以在18个月期间评估电话疾病管理。在基线以及每6个月收集数据。通过卡普兰 - 迈耶（Kaplan - Meier）法和考克斯（Cox）回归方法进行生存分析。在广泛查阅病历后确定医疗保健利用情况，试图涵盖所有住院和门诊就诊、药物治疗以及诊断检查。我们从近53000次与健康相关的诊疗中获取了92%患者的数据。每位患者的总成本是通过将观察到的诊疗的估计成本相加来确定的，不包括疾病管理的成本。卡普兰 - 迈耶分析显示，疾病管理患者的死亡率降低（P = 0.037），疾病管理患者比对照组平均多存活76天。亚组分析显示，疾病管理对收缩性心力衰竭患者有有益的结果（风险比0.62；P = 0.040），在纽约心脏协会（NYHA）心功能Ⅲ级和Ⅳ级患者中更为显著。尽管疾病管理更有可能使NYHA心功能分级得到改善（P < 0.001），但在每次就诊都有数据的217名患者的6分钟步行试验数据显示疾病管理没有显著益处（P = 0.08）。疾病管理并没有减少包括药物治疗、门诊或急诊就诊、操作或住院在内的总体以及与CHF相关的医疗保健利用。按组对成本进行重复测量方差分析显示没有显著差异，即使在NYHA心功能分级较高的组中也是如此。
结论 - 参与疾病管理带来了显著的生存益处，尤其在有症状的收缩性心力衰竭患者中最为明显。尽管疾病管理与NYHA心功能分级的改善有关，但6分钟步行试验结果没有改善。疾病管理没有减少医疗保健利用，也没有节省成本。心力衰竭中的疾病管理可提高预期寿命，但没有改善功能能力的客观指标，也没有降低成本。
Background - Because of the prevalence and expense of congestive heart failure (CHF), significant efforts have been made to develop disease management (DM) programs that will improve clinical and financial outcomes. The effectiveness of such programs in a large, heterogeneous population of CHF patients remains unknown.Methods and Results - We randomized 1069 patients (aged 70.9 +/- 10.3 years) with systolic (ejection fraction 35 +/- 9%) or echocardiographically confirmed diastolic heart failure (HF) to assess telephonic DM over an 18-month period. Data were collected at baseline and at 6-month intervals. Survival analysis was performed by Kaplan-Meier and Cox regression methods. Healthcare utilization was defined after extensive record review, with an attempt to account for all inpatient and outpatient visits, medications, and diagnostic tests. We obtained data on 92% of the patients, from nearly 53 000 health-related encounters. Total cost per patient was defined by adding estimated costs for the observed encounters, excluding the cost of the DM. Kaplan-Meier analysis showed that DM patients had a reduced mortality rate (P = 0.037), with DM patients surviving an average of 76 days longer than controls. Subgroup analysis showed that DM had beneficial outcomes in patients with systolic HF (hazard ratio 0.62; P = 0.040), which was more pronounced in NYHA classes III and IV. Although improvements in NYHA class were more likely with DM (P < 0.001), 6-minute walk data from 217 patients in whom data were available at each visit showed no significant benefit from DM (P = 0.08). Total and CHF-related healthcare utilization, including medications, office or emergency department visits, procedures, or hospitalizations, was not decreased by DM. Repeated-measures ANOVA for cost by group showed no significant differences, even in the higher NYHA class groups.Conclusions - Participation in DM resulted in a significant survival benefit, most notably in symptomatic systolic HF patients. Although DM was associated with improved NYHA class, 6-minute walk test results did not improve. Healthcare utilization was not reduced by DM, and it conferred no cost savings. DM in HF results in improved life expectancy but does not improve objective measures of functional capacity and does not reduce cost.