Result card

  • EFF5: Does Structured telephone support (STS) impact on the re-hospitalization rate (disease-specific and all-cause) of adults with chronic heart failure, compared to standard care without Structured telephone support (STS)?
English

Does Structured telephone support (STS) impact on the re-hospitalization rate (disease-specific and all-cause) of adults with chronic heart failure, compared to standard care without Structured telephone support (STS)?

Authors: Mirjana Huic, Pernilla Östlund, Romana Tandara Hacek, Jelena Barbaric, Marius Ciutan, Cristina Mototolea, Silvia Gabriela Scintee

Internal reviewers: J. Puñal, J. Gonzalez-Enriquez, H. Stürzlinger, A. Lo Scalzo, S. Maltoni

Acknowledgments: We would like to thank Ms Ana Utrobičić, MLIS, the Head of the Central Medical Library at the University of Split School of Medicine, Split, Croatia for development of systematic literature search strategy and performed search on standard medical and HTA databases.

The same methodology was used as described in section for the whole domain.

All five high quality systematic reviews were used to answer the question ”Does Structured telephone support (STS) impact on the re-hospitalization rate (disease-specific and all-cause) of adults with chronic heart failure, compared to standard care without Structured telephone support (STS)?” {Feltner et al, 2014; Kotb et al, 2015; Pandor et al, 2013; Inglis et al, 2011; Clark et al, 2007}, as well as two recently published RCTs {Angermann 2012, Krum 2013}; studies’ details can be found in Appendices 3 and 4.

Data found on all-cause and HF-specific re-hospitalization rate in STS group comparing with usual care were conflicting. The majority (included 5 published SRs) reported significantly lower HF-specific re-hospitalization rate in STS group {Feltner 2014, Kotb 2015, Pandor 2013, Inglis 2011, Clark 2007}. When sensitivity analysis was done including only RCT with follow-up period longer than 6 months this difference was not statistically significant anymore {Inglis 2011}.

On the contrary, two recently published RCTs  {Angermann 2012, Krum 2013} with 6 and 12 months follow-up period, respectively, reported a non-significant difference in HF-specific re-hospitalization between STS and Usual care groups.

In the most recent SR and HTA published by Feltner et al, 2014 { } whilst structured telephone support (STS) interventions statistically significant reduced HF-specific readmission (high strength of evidence, SOE) but not all-cause readmissions (moderate SOE), in follow-up period of 3-6 months, with NNT of 14 (Table 1).

 

 

Table 1. All-cause and heart failure (HF)-specific re-hospitalisation data from 8 RCTs on STS compared with usual care, at 3-6 months follow-up period, Feltner et al, 2014 { }

 

Outcome

Outcome timing

Trials (Participants) number

RR (95% CI)

NNT

SOE*

All-cause readmission

 

30 d

1 (134)

0.80 (0.38–1.65)

Riegel et al, 2006

NA

Insufficient

All-cause readmission

 

3–6 mo

8 (2166)

0.92 (0.77–1.10)

Laramee et al, 2003:

1.10 (0.79–1.53)

 

Riegal et al, 2002:

0.86 (0.68–1.09)

 

Tsuyuki et al, 2004:

1.12 (0.84–1.50)

 

Dunagan et al, 2005:

0.56 (0.40–0.79)

 

López Cabezas et al, 2006:

0.58 (0.35–0.95)

 

Riegel et al, 2006:

1.02 (0.76–1.36)

 

Domingues et al, 2011:

1.14 (0.72–1.82)

Angermann et al, 2012:

1.10 (0.89–1.35)

NA

Moderate for

no benefit

HF-specific readmission

30 d

1 (134)

0.63 (0.24–1.87)

NA

Insufficient

HF-specific readmission

3–6 mo

7 (1790)

0.74 (0.61–0.90)

14

High for benefit

 

 

 

 

 

 

 

 

 

 

Abbreviations: NNT = number needed to treat; RR = risk ratio; SOE = strength of evidence assessed by Feltner et al 2014 { }

 

Kotb et al, 2015 { } in direct comparisons showed that statistically significant fewer patients receiving structured telephone support interventions were hospitalized for all causes (0.86 [0.77, 0.97)]  (data from 12 trials) and due to heart failure (0.76 [0.65, 0.89)] (data from 11 trials)  than patients who received usual care. In Network meta-analysis (NMA), compared to usual care, structured telephone support, significantly reduced the odds of hospitalizations due to heart failure (0.69; [0.56 to 0.85]). STS no longer found to significantly reduce all-cause hospitalization compared to usual care.

 

 

Pandor et al, 2013 { } showed that, compared with usual care, STS interventions had no major effect on all-cause hospitalisations. There were no major effects on HF-related hospitalisation for STS HM (HR 1.03, 95% CrI 0.66 to 1.54); STS HH (HR 0.77, 95% CrI 0.62 to 0.96) was associated with a statistically significant 23% reduction.

 

In SR published by Inglis et al, 2011 { }, based on data from 13 RCTs, Structured telephone support significantly reduced CHF-related hospitalisations (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) (Box 1) as well as risk of all-cause hospitalization (RR 0.92, 95% CI 0.85 to 0.99, P = 0.02). In Sensitivity analysis including only RCTs with a follow-up period >6 months (6 published studies), both risks were not statistically significant between two groups.

Box 1. All-cause and HF-specific re-hospitalization, structured telephone support in comparison with usual care, in SR published by  Inglis et al, 2011 { }

All-cause hospitalisation (11 published studies, n=4295)

 

Structured telephone support was effective in reducing the risk of all-cause hospitalisation in patients with CHF (RR 0.92, 95% CI 0.85 to 0.99, P = 0.02, I² 24%).

 

Sensitivity analysis: Follow-up period (>6 months), 6 published studies, n=3058, RR 0.91 [0.83, 0.99]:

 

Cleland 2005 (Struct Tele): 0.91 [0.71, 1.16]

 

DeBusk  2004: 1.02 [0.85, 1.22]

 

GESICA 2005 (DIAL): 0.88 [0.77, 1.00]

 

Mortara 2009 (Struct Tele): 1.16 [0.82, 1.65]

 

Sisk 2006: 0.84 [0.64, 1.10]

 

Wakefield 2008: 0.70 [0.50, 0.97]

 

With the addition of one study of structured telephone support published as an abstract only (Krum 2009 (CHAT)), the effect of this intervention on all-cause hospitalisation in patients with CHF increased minimally (RR 0.90, 95% 0.84 to 0.97, P = 0.003, I² =32%.

 

CHF-related hospitalisation outcomes (13 studies, n=4269)

Structured telephone support was effective in reducing the proportion of patients with a CHF-related hospitalisation

RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001, I² = 7%

 

Sensitivity analysis: Follow-up period (>6 months), 6 published studies, n=2948:  RR 0.76 [0.65, 0.89]

 

Cleland 2005 (Struct Tele): 0.70 [0.44, 1.10]

 

DeBusk 2004: 0.91 [0.61, 1.35]

 

GESICA 2005 (DIAL): 0.76 [0.61, 0.93]

 

Mortara 2009 (Struct Tele): 0.97 [0.57, 1.66]

 

Rainville 1999: 0.40 [0.15, 1.05]

 

Sisk 2006: 0.62 [0.36, 1.08]

 

 

 

 

 

In SR published by Clark et al, 2007 { }, based on 9 RCTs data, structured telephone support significantly reduced the rates of admission to hospital for chronic heart failure by 21% (95% confidence interval 11% to 31%), RR 0.78 (0.68 to 0.89), P=0.0003, but not all-cause hospital admission rate (based on 7 RCTs data provided) (Box 2).

 

 

Box 2. All-cause and HF-specific re-hospitalization, structured telephone support in comparison with usual care, in SR published by  Clark et al, 2007 { }

 

All-cause hospital admission RR 0.94 (0.87 to 1.02), P=0.15

 

Cleland et al 2005: RR 0.91 (0.74 to 1.13)

 

Riegel et al 2002: RR 0.86 (0.68 to 1.09)

 

Laramee et al 2003: RR 1.10 (0.79 to 1.53)

 

DeBusk et al 2004: 1.02 (0.85 to 1.22)

 

Tsuyuki et al 2004: 1.12 (0.84 to 1.5

 

GESICA Investigators 2005: 0.88 (0.77 to 1.00)

 

Riegel et al 2006: 0.99 (0.74 to 1.33)

 

HF-related hospital admission RR 0.78 (0.68 to 0.89), P=0.0003

 

Cleland et al 2005: RR 0.70 (0.45 to 1.07)

 

Rainville 1999: RR  0.40 (0.16 to 1.03)

 

Barth et al 2001: RR Not estimable

 

Riegel et al 2002: RR 0.64 (0.42 to 0.98)

 

Laramee et al 2003: RR 0.89 (0.49 to 1.59)

 

DeBusk et al 2004: RR 0.91 (0.61 to 135)

 

Tsuyuki et al 2004: RR 0.95 (0.64 to 1.39)

 

GESICA Investigators 2005: RR 0.76 (0.61 to 0.93)

 

Riegel et al 2006: RR 0.90 (0.55 to 1.47)

 

Angermann et al. 2012 { } showed non statistically significant difference between STS and usual care groups on all-cause, P=0.28 and HF-specific re-hospitalization, P=0.36.

Krum et al, 2013 { } showed for all-cause hospitalization that there were significantly fewer patients hospitalized for any cause (74 vs. 114, adjusted HR 0.67 [95% CI 0.50–0.89], P = 0.006) and who died or were hospitalized (89 vs. 124, adjusted HR 0.70 [95% CI 0.53–0.92], P = 0.011), in the usual care (UC) + intervention group (I) versus UC group. Heart Failure (HF)-hospitalizations were reduced with UC+I (23 vs. 35, adjusted HR 0.81 [95% CI 0.44–1.38]), although this was not significant (P = 0.43). There were 16 deaths in the UC group and 17 in the UC+I group (P = 0.43). Authors concluded that although no difference was observed in the primary endpoint (Packer composite score), UC+I significantly reduced the number of HF patients hospitalized among a rural and remote cohort. These data suggest that telephone support may be an efficacious approach to improve clinical outcomes in rural and remote HF patients.

Details could be found in Appendix 3 and 4.

Important
Partially
Huic M et al. Result Card EFF5 In: Huic M et al. Clinical Effectiveness In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305

References