Aims

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT),

Methods and results

The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6 months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37–0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6 months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29–0.55; P < 0.001 with death considered as a competing risk). After 1 year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23–0.61, P < 0.001).

Conclusions

A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

中文翻译：

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临床实践中心力衰竭患者多维出院后疾病管理计划的可行性和有效性：HerzMobil Tirol 计划

目标

目前尚不清楚临床试验环境之外的过渡性护理管理是否能为住院后的急性心力衰竭 (AHF) 患者带来益处。我们使用远程医疗监控系统评估了多维出院后疾病管理计划的可行性和有效性，该系统整合到心力衰竭护士、住院医师以及二级和三级转诊中心（HerzMobil Tirol，HMT）的综合网络中，

方法和结果

非随机研究包括 2016 年至 2019 年出院后接受HMT（ n  = 251）或同时接受常规护理（UC，n = 257）管理的 508 名 AHF 患者。对年龄和性别进行回顾性匹配。主要终点是 6 个月内 HF 再入院时间和全因死亡率。多变量 Cox 比例风险模型用于评估有效性。主要终点发生在 HMT 的 48 名患者（19.1%）和 UC 的 89 名患者（34.6%）中。与 UC 相比，HMT 管理与主要终点降低 46% 相关（调整后 HR 0.54；95% CI 0.37-0.77；P < 0.001)。亚组分析显示一致的有效性。每 100 患者年 6 个月内复发性 HF 住院和死亡的复合材料在 HMT 中为 64.2，在 UC 中为 108.2（调整后的 HR 0.41；95% CI 0.29-0.55；P  < 0.001，死亡被视为竞争风险）。1 年后，25 名 (10%) 患者死于 HMT，而 UC 则为 66 名 (25.7%) (HR 0.38; 95% CI 0.23–0.61, P  < 0.001)。

结论

一个多维的出院后疾病管理计划，包括一个远程医疗监控系统，该系统与专业心力衰竭护士和住院医师的综合网络相结合，在临床实践中是可行和有效的。