Cameron Bennett, FRACP, MBiomedE

Congestive heart failure (CHF) is a common disease with high mortality and morbidity.1, 2 Better physiological understanding has led to significant advances in therapy in recent years, with synthesis of this evidence into widely available treatment guidelines.3, 4 However, patients who have had an acute hospitalization with heart failure continue to have a high rate of symptomatic relapse, with up to 25% readmitted within 3 months.2 One of the major challenges in heart failure therapy is to avert these relapses to prevent hospital readmission.

Angiotensin‐converting enzyme (ACE) inhibitors, beta‐blockers, and spironolactone have promised a reduction in hospitalization rates as well as mortality; however, suboptimal prescribing5 and adherence to therapy6, 7 may limit their anticipated benefits. This has led to interest in improved systems of care to reduce hospital utilization. Such approaches have included improved systems for optimizing medications,68 comprehensive discharge planning and postdischarge support,914 and self‐management and case management strategies1517 to enhance patient participation in care.

Combinations of these strategies are known as disease management programs (DMPs), and trials of such combination strategies to improve patient outcomes have been promising.1823 Recognized features4 include skilled multidisciplinary team care; individualized guideline‐based treatment plans that may include dietary and exercise programs as well as optimal pharmacological therapy; patient education and self‐management strategies; improved integration between hospital and community care providers; vigilant follow‐up including prompt review after hospitalization; ready access to expert assessment in the event of deterioration; and regular monitoring with expert titration of therapy, through clinics, home visits, or telemonitoring. Several randomized controlled trials have suggested that DMPs may reduce heart failure‐related9, 1517 and all‐cause9, 10 readmissions. Meta‐analyses12, 1823 have demonstrated reduction in risk of all‐cause readmission of 12% to 25% as well as a reduction in mortality of 14% to 25%.

Trials of DMPs have generally involved careful participant selection, and differences in methods and outcome reporting have led some reviewers to be circumspect in their interpretation of the impact of these programs on readmission rates.23 A large, real‐world quality improvement program conducted as part of the Royal Australasian College of Physicians Clinical Support Systems Project provided an opportunity to measure whether a multifaceted program targeting a representative group of patients with CHF and their healthcare providers could reduce readmission rates. As previously published, this program delivered measurable improvements in processes of care including evidence‐based prescribing, adherence, multidisciplinary involvement, and discharge communication, associated with a reduction in 12‐month mortality.24

Objective

The Brisbane Cardiac Consortium sought to improve processes of care for patients with CHF by using evidence‐based strategies targeting patients and their healthcare providers to optimize uptake of management guidelines, improve discharge processes between hospital and primary care, and increase patient participation in care. We hypothesized that the program would reduce hospital readmissions in the intervention patients in the first 12 months following discharge.

Methods

Results

There were 220 patients identified with a clinical diagnosis of CHF during the baseline period, and 235 during the intervention period. Figure 1 shows ascertainment, in‐hospital mortality, and eligibility rates for the 2 cohorts. Eighty‐nine (45%) of baseline patients and 76 (35%) of intervention patients received intensive posthospital follow‐up as described above. Information on readmission was available for 197 baseline patients and 219 intervention patients discharged alive; this is the sample used for all analyses in this report. Table 1 shows the demographic and clinical characteristics of these patients. Table 2 summarizes the previously reported improvements in processes of care.

Figure 1

Duing the 12‐month follow‐up, 107 (49%) of intervention patients were readmitted to the hospital compared to 71 (36%) of control patients, representing a 1.7‐fold increase in the adjusted probability of readmission in the intervention group (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 1.14‐2.56; P = 0.009). As shown in Table 3, this was partly balanced by a trend toward reduced post‐hospital mortality, such that no significant difference was seen in readmission‐free survival.

Time‐to‐event analysis (Figures 2 and 3) demonstrated similar findings, with a significant reduction in time to first readmission in the intervention group (adjusted hazard ratio [HR] = 1.43; 95% CI = 1.04‐1.97; P = 0.046) but no difference in time to death or first readmission (adjusted HR = 1.14; 95% CI = 0.86‐1.46; P = 0.36).

Figure 2

Figure 3

There was a trend to increased readmissions attributed to heart failure: 47 (21.5%) of intervention patients compared to 33 (16.7%) in the baseline group (OR = 1.30; 95% CI = 0.87‐1.93; P = 0.20). No significant difference was demonstrated in the frequency of readmissions (average 0.75 admission per participant per year in baseline, compared to 0.93 intervention; P = 0.32) nor the mean number of days in hospital in 12 months subsequent to the index admission (5.9 in the baseline group compared to 6.5 in the intervention group; P = 0.1).

Subgroup analysis by intervention intensity showed similar results, with 42 of 76 (55.3%) intensive group participants in the intervention group and 36 of 89 (40.4%) in the baseline group requiring hospital readmission within 12 months. The HR for death or readmission was estimated to be 1.27 (95% CI = 0.85‐1.9).

Discussion

In this study, heart failure patients who received a multidisciplinary intervention (including inpatient education, self‐management support, improved timely medical follow‐up, and better integration between hospital and primary care) showed a trend to improved 1‐year post‐hospital survival, but this appeared to be at the cost of increased readmissions among survivors. This occurred despite our previously reported improved optimization of pharmacological therapy both in‐hospital and posthospital with this program.18

There are a number of potential explanations for this finding, which have important implications for adoption of disease management programs. First, the intervention may not have been of sufficient intensity. Programs primarily aimed at educating providers and patients in evidence‐based guidelines, without structured postdischarge support, have not always improved clinical outcomes.26 In our study, general practitioners were supported to provide improved postdischarge care to their CHF patients, but direct postdischarge patient support was only provided to consenting patients and was limited in scope. There is still some debate about which elements of successful DMPs are most important for efficacy. Most authorities support the central importance of medication optimization, intensive education, and self‐care support. Taylor et al.23 found stronger evidence for programs using individual case management or outreach rather than clinic‐based interventions. Yu et al.27 concluded that outpatient drug titration and ready access to specialist review were factors contributing to success. In our program, even the more intensive intervention did not include regular clinical review by specialist nurses, a system for rapid review in the event of deterioration or supervised drug titration protocols. Furthermore, strategies which prompted more frequent primary care review and improved patient, carer, and general practitioner recognition of disease deterioration may have provided more opportunities to initiate readmission, especially in the absence of an alternative care pathway such as rapid‐access clinics or outreach services.28

Second, this study may reflect the reality of generalizing randomized controlled trial data to an unselected population. Many trials enrolled patients with high anticipated event rates but excluded patients with complex comorbidities, poor life expectancy, and cognitive impairment. Such studies enrolled a high‐risk population (10%‐48% of screened patients randomized) who had a relatively high readmission rate (50%‐60% at 6‐12 months) compared to our unselected population. These studies may overstate the benefits of applying heart failure DMPs in an unselected population. Galbreath et al.29 enrolled a self‐selected community sample of heart failure patients into a disease management program incorporating education, self‐management, telephone support, and advice to primary care providers and home health providers. Like our model, they demonstrated a survival benefit in the intervention group but no reduction in hospital or other healthcare utilization.

Third, only about one‐half of the readmissions were due to heart failure, again reflecting the complexity of this real‐world patient group. Interventions that focus on a single disease in patients with complex comorbidities might be expected to have only limited impact on their subsequent healthcare needs.

Fourth, findings may reflect differences in patient characteristics between the 2 cohorts. While statistical adjustment for measured differences did not have any significant impact on results, unmeasured patient characteristics may have introduced bias. The beforeafter nature of the study also raises the possibility that temporal trends in care practices influenced patient outcomes, such as changing patterns of drug and device therapies. There is conflicting evidence in the literature regarding trends in CHF readmission rates,3032 but it is possible that health system factors external to the study contributed to a higher readmission rate in the later cohort.

Finally, there was a trend toward reduction in mortality within the intervention cohort. These additional survivors might be expected to have more advanced heart failure or other comorbid disease, and therefore may have been more susceptible to deterioration and the need for inpatient care.

Conclusions

We acknowledge the weaknesses inherent in this nonrandomized study design, including convenience sampling, measured and unmeasured confounders and temporal trends in processes and systems of care. Nonetheless, this real world study suggests a note of caution in the widespread enthusiasm for chronic disease management programs. A complex bundle of interventions that resulted in measurable improvements in adherence to evidence‐based guidelines, discharge processes, integration between care providers, and patient education appeared to prolong life expectancy but increase hospital utilization. Mortality reduction in an incurable chronic disease such as heart failure will increase the burden of disease (and therefore treatment costs) unless treatments concurrently reduce disability and the frequency of symptomatic relapse.33 Whether this balance is achieved will depend on patient selection and the intensity and/or components of the intervention. These factors have not been fully defined in the literature to date.

Our study suggests that a widely applied, discharge‐focused intervention which primarily augmented the CHF management knowledge of care providers and patients, and enhanced attendance within the existing care model of primary care and internal medicine/cardiology outpatient services, improved the quality of care and may have reduced mortality at the cost of higher hospital utilization. It raises questions about whether a disease management service can achieve the uncertain promise of reduced readmissions in a cost‐effective manner outside of a high‐risk experimental population.

Congestive heart failure (CHF) is a common disease with high mortality and morbidity.1, 2 Better physiological understanding has led to significant advances in therapy in recent years, with synthesis of this evidence into widely available treatment guidelines.3, 4 However, patients who have had an acute hospitalization with heart failure continue to have a high rate of symptomatic relapse, with up to 25% readmitted within 3 months.2 One of the major challenges in heart failure therapy is to avert these relapses to prevent hospital readmission.

Angiotensin‐converting enzyme (ACE) inhibitors, beta‐blockers, and spironolactone have promised a reduction in hospitalization rates as well as mortality; however, suboptimal prescribing5 and adherence to therapy6, 7 may limit their anticipated benefits. This has led to interest in improved systems of care to reduce hospital utilization. Such approaches have included improved systems for optimizing medications,68 comprehensive discharge planning and postdischarge support,914 and self‐management and case management strategies1517 to enhance patient participation in care.

Combinations of these strategies are known as disease management programs (DMPs), and trials of such combination strategies to improve patient outcomes have been promising.1823 Recognized features4 include skilled multidisciplinary team care; individualized guideline‐based treatment plans that may include dietary and exercise programs as well as optimal pharmacological therapy; patient education and self‐management strategies; improved integration between hospital and community care providers; vigilant follow‐up including prompt review after hospitalization; ready access to expert assessment in the event of deterioration; and regular monitoring with expert titration of therapy, through clinics, home visits, or telemonitoring. Several randomized controlled trials have suggested that DMPs may reduce heart failure‐related9, 1517 and all‐cause9, 10 readmissions. Meta‐analyses12, 1823 have demonstrated reduction in risk of all‐cause readmission of 12% to 25% as well as a reduction in mortality of 14% to 25%.

Trials of DMPs have generally involved careful participant selection, and differences in methods and outcome reporting have led some reviewers to be circumspect in their interpretation of the impact of these programs on readmission rates.23 A large, real‐world quality improvement program conducted as part of the Royal Australasian College of Physicians Clinical Support Systems Project provided an opportunity to measure whether a multifaceted program targeting a representative group of patients with CHF and their healthcare providers could reduce readmission rates. As previously published, this program delivered measurable improvements in processes of care including evidence‐based prescribing, adherence, multidisciplinary involvement, and discharge communication, associated with a reduction in 12‐month mortality.24

Objective

The Brisbane Cardiac Consortium sought to improve processes of care for patients with CHF by using evidence‐based strategies targeting patients and their healthcare providers to optimize uptake of management guidelines, improve discharge processes between hospital and primary care, and increase patient participation in care. We hypothesized that the program would reduce hospital readmissions in the intervention patients in the first 12 months following discharge.

Methods

Results

There were 220 patients identified with a clinical diagnosis of CHF during the baseline period, and 235 during the intervention period. Figure 1 shows ascertainment, in‐hospital mortality, and eligibility rates for the 2 cohorts. Eighty‐nine (45%) of baseline patients and 76 (35%) of intervention patients received intensive posthospital follow‐up as described above. Information on readmission was available for 197 baseline patients and 219 intervention patients discharged alive; this is the sample used for all analyses in this report. Table 1 shows the demographic and clinical characteristics of these patients. Table 2 summarizes the previously reported improvements in processes of care.

Figure 1

Duing the 12‐month follow‐up, 107 (49%) of intervention patients were readmitted to the hospital compared to 71 (36%) of control patients, representing a 1.7‐fold increase in the adjusted probability of readmission in the intervention group (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 1.14‐2.56; P = 0.009). As shown in Table 3, this was partly balanced by a trend toward reduced post‐hospital mortality, such that no significant difference was seen in readmission‐free survival.

Time‐to‐event analysis (Figures 2 and 3) demonstrated similar findings, with a significant reduction in time to first readmission in the intervention group (adjusted hazard ratio [HR] = 1.43; 95% CI = 1.04‐1.97; P = 0.046) but no difference in time to death or first readmission (adjusted HR = 1.14; 95% CI = 0.86‐1.46; P = 0.36).

Figure 2

Figure 3

There was a trend to increased readmissions attributed to heart failure: 47 (21.5%) of intervention patients compared to 33 (16.7%) in the baseline group (OR = 1.30; 95% CI = 0.87‐1.93; P = 0.20). No significant difference was demonstrated in the frequency of readmissions (average 0.75 admission per participant per year in baseline, compared to 0.93 intervention; P = 0.32) nor the mean number of days in hospital in 12 months subsequent to the index admission (5.9 in the baseline group compared to 6.5 in the intervention group; P = 0.1).

Subgroup analysis by intervention intensity showed similar results, with 42 of 76 (55.3%) intensive group participants in the intervention group and 36 of 89 (40.4%) in the baseline group requiring hospital readmission within 12 months. The HR for death or readmission was estimated to be 1.27 (95% CI = 0.85‐1.9).

Discussion

In this study, heart failure patients who received a multidisciplinary intervention (including inpatient education, self‐management support, improved timely medical follow‐up, and better integration between hospital and primary care) showed a trend to improved 1‐year post‐hospital survival, but this appeared to be at the cost of increased readmissions among survivors. This occurred despite our previously reported improved optimization of pharmacological therapy both in‐hospital and posthospital with this program.18

There are a number of potential explanations for this finding, which have important implications for adoption of disease management programs. First, the intervention may not have been of sufficient intensity. Programs primarily aimed at educating providers and patients in evidence‐based guidelines, without structured postdischarge support, have not always improved clinical outcomes.26 In our study, general practitioners were supported to provide improved postdischarge care to their CHF patients, but direct postdischarge patient support was only provided to consenting patients and was limited in scope. There is still some debate about which elements of successful DMPs are most important for efficacy. Most authorities support the central importance of medication optimization, intensive education, and self‐care support. Taylor et al.23 found stronger evidence for programs using individual case management or outreach rather than clinic‐based interventions. Yu et al.27 concluded that outpatient drug titration and ready access to specialist review were factors contributing to success. In our program, even the more intensive intervention did not include regular clinical review by specialist nurses, a system for rapid review in the event of deterioration or supervised drug titration protocols. Furthermore, strategies which prompted more frequent primary care review and improved patient, carer, and general practitioner recognition of disease deterioration may have provided more opportunities to initiate readmission, especially in the absence of an alternative care pathway such as rapid‐access clinics or outreach services.28

Second, this study may reflect the reality of generalizing randomized controlled trial data to an unselected population. Many trials enrolled patients with high anticipated event rates but excluded patients with complex comorbidities, poor life expectancy, and cognitive impairment. Such studies enrolled a high‐risk population (10%‐48% of screened patients randomized) who had a relatively high readmission rate (50%‐60% at 6‐12 months) compared to our unselected population. These studies may overstate the benefits of applying heart failure DMPs in an unselected population. Galbreath et al.29 enrolled a self‐selected community sample of heart failure patients into a disease management program incorporating education, self‐management, telephone support, and advice to primary care providers and home health providers. Like our model, they demonstrated a survival benefit in the intervention group but no reduction in hospital or other healthcare utilization.

Third, only about one‐half of the readmissions were due to heart failure, again reflecting the complexity of this real‐world patient group. Interventions that focus on a single disease in patients with complex comorbidities might be expected to have only limited impact on their subsequent healthcare needs.

Fourth, findings may reflect differences in patient characteristics between the 2 cohorts. While statistical adjustment for measured differences did not have any significant impact on results, unmeasured patient characteristics may have introduced bias. The beforeafter nature of the study also raises the possibility that temporal trends in care practices influenced patient outcomes, such as changing patterns of drug and device therapies. There is conflicting evidence in the literature regarding trends in CHF readmission rates,3032 but it is possible that health system factors external to the study contributed to a higher readmission rate in the later cohort.

Finally, there was a trend toward reduction in mortality within the intervention cohort. These additional survivors might be expected to have more advanced heart failure or other comorbid disease, and therefore may have been more susceptible to deterioration and the need for inpatient care.

Conclusions

We acknowledge the weaknesses inherent in this nonrandomized study design, including convenience sampling, measured and unmeasured confounders and temporal trends in processes and systems of care. Nonetheless, this real world study suggests a note of caution in the widespread enthusiasm for chronic disease management programs. A complex bundle of interventions that resulted in measurable improvements in adherence to evidence‐based guidelines, discharge processes, integration between care providers, and patient education appeared to prolong life expectancy but increase hospital utilization. Mortality reduction in an incurable chronic disease such as heart failure will increase the burden of disease (and therefore treatment costs) unless treatments concurrently reduce disability and the frequency of symptomatic relapse.33 Whether this balance is achieved will depend on patient selection and the intensity and/or components of the intervention. These factors have not been fully defined in the literature to date.

Our study suggests that a widely applied, discharge‐focused intervention which primarily augmented the CHF management knowledge of care providers and patients, and enhanced attendance within the existing care model of primary care and internal medicine/cardiology outpatient services, improved the quality of care and may have reduced mortality at the cost of higher hospital utilization. It raises questions about whether a disease management service can achieve the uncertain promise of reduced readmissions in a cost‐effective manner outside of a high‐risk experimental population.

Congestive heart failure (CHF) is a common disease with high mortality and morbidity.1, 2 Better physiological understanding has led to significant advances in therapy in recent years, with synthesis of this evidence into widely available treatment guidelines.3, 4 However, patients who have had an acute hospitalization with heart failure continue to have a high rate of symptomatic relapse, with up to 25% readmitted within 3 months.2 One of the major challenges in heart failure therapy is to avert these relapses to prevent hospital readmission.

Angiotensin‐converting enzyme (ACE) inhibitors, beta‐blockers, and spironolactone have promised a reduction in hospitalization rates as well as mortality; however, suboptimal prescribing5 and adherence to therapy6, 7 may limit their anticipated benefits. This has led to interest in improved systems of care to reduce hospital utilization. Such approaches have included improved systems for optimizing medications,68 comprehensive discharge planning and postdischarge support,914 and self‐management and case management strategies1517 to enhance patient participation in care.

Combinations of these strategies are known as disease management programs (DMPs), and trials of such combination strategies to improve patient outcomes have been promising.1823 Recognized features4 include skilled multidisciplinary team care; individualized guideline‐based treatment plans that may include dietary and exercise programs as well as optimal pharmacological therapy; patient education and self‐management strategies; improved integration between hospital and community care providers; vigilant follow‐up including prompt review after hospitalization; ready access to expert assessment in the event of deterioration; and regular monitoring with expert titration of therapy, through clinics, home visits, or telemonitoring. Several randomized controlled trials have suggested that DMPs may reduce heart failure‐related9, 1517 and all‐cause9, 10 readmissions. Meta‐analyses12, 1823 have demonstrated reduction in risk of all‐cause readmission of 12% to 25% as well as a reduction in mortality of 14% to 25%.

Trials of DMPs have generally involved careful participant selection, and differences in methods and outcome reporting have led some reviewers to be circumspect in their interpretation of the impact of these programs on readmission rates.23 A large, real‐world quality improvement program conducted as part of the Royal Australasian College of Physicians Clinical Support Systems Project provided an opportunity to measure whether a multifaceted program targeting a representative group of patients with CHF and their healthcare providers could reduce readmission rates. As previously published, this program delivered measurable improvements in processes of care including evidence‐based prescribing, adherence, multidisciplinary involvement, and discharge communication, associated with a reduction in 12‐month mortality.24

Objective

The Brisbane Cardiac Consortium sought to improve processes of care for patients with CHF by using evidence‐based strategies targeting patients and their healthcare providers to optimize uptake of management guidelines, improve discharge processes between hospital and primary care, and increase patient participation in care. We hypothesized that the program would reduce hospital readmissions in the intervention patients in the first 12 months following discharge.

Methods

Results

There were 220 patients identified with a clinical diagnosis of CHF during the baseline period, and 235 during the intervention period. Figure 1 shows ascertainment, in‐hospital mortality, and eligibility rates for the 2 cohorts. Eighty‐nine (45%) of baseline patients and 76 (35%) of intervention patients received intensive posthospital follow‐up as described above. Information on readmission was available for 197 baseline patients and 219 intervention patients discharged alive; this is the sample used for all analyses in this report. Table 1 shows the demographic and clinical characteristics of these patients. Table 2 summarizes the previously reported improvements in processes of care.

Figure 1

Duing the 12‐month follow‐up, 107 (49%) of intervention patients were readmitted to the hospital compared to 71 (36%) of control patients, representing a 1.7‐fold increase in the adjusted probability of readmission in the intervention group (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 1.14‐2.56; P = 0.009). As shown in Table 3, this was partly balanced by a trend toward reduced post‐hospital mortality, such that no significant difference was seen in readmission‐free survival.

Time‐to‐event analysis (Figures 2 and 3) demonstrated similar findings, with a significant reduction in time to first readmission in the intervention group (adjusted hazard ratio [HR] = 1.43; 95% CI = 1.04‐1.97; P = 0.046) but no difference in time to death or first readmission (adjusted HR = 1.14; 95% CI = 0.86‐1.46; P = 0.36).

Figure 2

Figure 3

There was a trend to increased readmissions attributed to heart failure: 47 (21.5%) of intervention patients compared to 33 (16.7%) in the baseline group (OR = 1.30; 95% CI = 0.87‐1.93; P = 0.20). No significant difference was demonstrated in the frequency of readmissions (average 0.75 admission per participant per year in baseline, compared to 0.93 intervention; P = 0.32) nor the mean number of days in hospital in 12 months subsequent to the index admission (5.9 in the baseline group compared to 6.5 in the intervention group; P = 0.1).

Subgroup analysis by intervention intensity showed similar results, with 42 of 76 (55.3%) intensive group participants in the intervention group and 36 of 89 (40.4%) in the baseline group requiring hospital readmission within 12 months. The HR for death or readmission was estimated to be 1.27 (95% CI = 0.85‐1.9).

Discussion

In this study, heart failure patients who received a multidisciplinary intervention (including inpatient education, self‐management support, improved timely medical follow‐up, and better integration between hospital and primary care) showed a trend to improved 1‐year post‐hospital survival, but this appeared to be at the cost of increased readmissions among survivors. This occurred despite our previously reported improved optimization of pharmacological therapy both in‐hospital and posthospital with this program.18

There are a number of potential explanations for this finding, which have important implications for adoption of disease management programs. First, the intervention may not have been of sufficient intensity. Programs primarily aimed at educating providers and patients in evidence‐based guidelines, without structured postdischarge support, have not always improved clinical outcomes.26 In our study, general practitioners were supported to provide improved postdischarge care to their CHF patients, but direct postdischarge patient support was only provided to consenting patients and was limited in scope. There is still some debate about which elements of successful DMPs are most important for efficacy. Most authorities support the central importance of medication optimization, intensive education, and self‐care support. Taylor et al.23 found stronger evidence for programs using individual case management or outreach rather than clinic‐based interventions. Yu et al.27 concluded that outpatient drug titration and ready access to specialist review were factors contributing to success. In our program, even the more intensive intervention did not include regular clinical review by specialist nurses, a system for rapid review in the event of deterioration or supervised drug titration protocols. Furthermore, strategies which prompted more frequent primary care review and improved patient, carer, and general practitioner recognition of disease deterioration may have provided more opportunities to initiate readmission, especially in the absence of an alternative care pathway such as rapid‐access clinics or outreach services.28

Second, this study may reflect the reality of generalizing randomized controlled trial data to an unselected population. Many trials enrolled patients with high anticipated event rates but excluded patients with complex comorbidities, poor life expectancy, and cognitive impairment. Such studies enrolled a high‐risk population (10%‐48% of screened patients randomized) who had a relatively high readmission rate (50%‐60% at 6‐12 months) compared to our unselected population. These studies may overstate the benefits of applying heart failure DMPs in an unselected population. Galbreath et al.29 enrolled a self‐selected community sample of heart failure patients into a disease management program incorporating education, self‐management, telephone support, and advice to primary care providers and home health providers. Like our model, they demonstrated a survival benefit in the intervention group but no reduction in hospital or other healthcare utilization.

Third, only about one‐half of the readmissions were due to heart failure, again reflecting the complexity of this real‐world patient group. Interventions that focus on a single disease in patients with complex comorbidities might be expected to have only limited impact on their subsequent healthcare needs.

Fourth, findings may reflect differences in patient characteristics between the 2 cohorts. While statistical adjustment for measured differences did not have any significant impact on results, unmeasured patient characteristics may have introduced bias. The beforeafter nature of the study also raises the possibility that temporal trends in care practices influenced patient outcomes, such as changing patterns of drug and device therapies. There is conflicting evidence in the literature regarding trends in CHF readmission rates,3032 but it is possible that health system factors external to the study contributed to a higher readmission rate in the later cohort.

Finally, there was a trend toward reduction in mortality within the intervention cohort. These additional survivors might be expected to have more advanced heart failure or other comorbid disease, and therefore may have been more susceptible to deterioration and the need for inpatient care.

Conclusions

We acknowledge the weaknesses inherent in this nonrandomized study design, including convenience sampling, measured and unmeasured confounders and temporal trends in processes and systems of care. Nonetheless, this real world study suggests a note of caution in the widespread enthusiasm for chronic disease management programs. A complex bundle of interventions that resulted in measurable improvements in adherence to evidence‐based guidelines, discharge processes, integration between care providers, and patient education appeared to prolong life expectancy but increase hospital utilization. Mortality reduction in an incurable chronic disease such as heart failure will increase the burden of disease (and therefore treatment costs) unless treatments concurrently reduce disability and the frequency of symptomatic relapse.33 Whether this balance is achieved will depend on patient selection and the intensity and/or components of the intervention. These factors have not been fully defined in the literature to date.

Our study suggests that a widely applied, discharge‐focused intervention which primarily augmented the CHF management knowledge of care providers and patients, and enhanced attendance within the existing care model of primary care and internal medicine/cardiology outpatient services, improved the quality of care and may have reduced mortality at the cost of higher hospital utilization. It raises questions about whether a disease management service can achieve the uncertain promise of reduced readmissions in a cost‐effective manner outside of a high‐risk experimental population.