Published Online
on August 16, 2004

A more recent version of this article appeared on September 14, 2004

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Submitted on November 18, 2002
Revised on June 10, 2004
Accepted on June 17, 2004

Randomized, Controlled Evaluation of Short- and Long-Term Benefits of Heart Failure Disease Management Within a Diverse Provider Network. The SPAN-CHF Trial

Carey Kimmelstiel MD, Daniel Levine MD, Kathleen Perry RN, Ayan R. Patel MD, Ara Sadaniantz MD, Noreen Gorham RN, Margaret Cunnie RN, Lynne Duggan RN, Linda Cotter MS, RN, Patricia Shea-Albright RNP, Athena Poppas MD, Kenneth LaBresh MD, Daniel Forman MD, David Brill MD, William Rand PhD, Douglas Gregory PhD, James E. Udelson MD, Beverly Lorell MD, Varda Konstam PhD^*, Kathleen Furlong RN, and Marvin A. Konstam MD

From the Division of Cardiology, Tufts-New England Medical Center, and Tufts University School of Medicine (C.K., K.P., A.R.P., L.C., W.R., D.G., J.E.U., M.A.K.); Brown University Medical School (D.L., A.S., N.G., P.C., L.D., P.S.-A., A.P., K.L., D.F., D.B.); and Beth Israel Deaconess Medical Center and Harvard Medical School (B.L.), Boston, Mass.

^* To whom correspondence should be addressed. E-mail: mkonstam{at}tufts-nemc.org.

Background--Several trials support the usefulness of disease management (DM) for improving clinical outcomes in heart failure (HF). Most of these studies are limited by small sample size; absence of concurrent, randomized controls; limited follow-up; restriction to urban academic centers; and low baseline use of effective medications.

Methods and Results--We performed a prospective, randomized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy. During a 90-day follow-up, patients randomized to DM experienced fewer hospitalizations for HF [primary end point, 0.55±0.15 per patient-year alive versus 1.14±0.22 per patient-year alive in control subjects; relative risk (RR), 0.48, P=0.027]. Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF (4.3±0.4 versus 7.8±0.6 days hospitalized per patient-year; RR, 0.54; P<0.001), cardiovascular hospitalizations (0.81±0.19 versus 1.43±0.24 per patient-year alive; RR, 0.57; P=0.043), and days in hospital per patient-year alive for cardiovascular cause (RR, 0.64; P<0.001). Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days. On long-term (mean, 283 days) follow-up, there was substantial attrition of the 3-month gain in outcomes, with sustained significant reduction only in days in hospital for cardiac cause.

Conclusions--In a population with high background use of standard HF therapy, a DM intervention, uniformly delivered across varied clinical sites, produced significant short-term improvement in HF-related clinical outcomes. Longer-term benefit likely requires more active chronic intervention, even among patients who appear clinically stable.

Key words: disease management • heart failure • cardiovascular diseases

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