A Randomized Controlled Trial of Heart Failure Disease Management vs Usual Care in Skilled Nursing Facilities.

Abstract

OBJECTIVE\nPatients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.\n\n\nDESIGN\nCluster-randomized controlled trial.\n\n\nPARTICIPANTS\nThe trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).\n\n\nMETHODS\nThe HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60\xa0days. Secondary outcomes included the composite endpoint at 30\xa0days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60\xa0days. Rehospitalization and mortality rates were calculated as an exploratory outcome.\n\n\nRESULTS\nMean age of the patients was 79 ± 10\xa0years, 58% were women, and the mean ejection fraction was 51%±16%. At 30 and 60\xa0days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30\xa0days and 60\xa0days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P\xa0= .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P\xa0= .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P\xa0= .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.\n\n\nCONCLUSIONS AND IMPLICATIONS\nThe composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.