A Systematic Meta-Analysis of the Efficacy and Heterogeneity of Disease Management Programs in Congestive Heart Failure

Göhler, Alexander; Januzzi, James L.; Worrell, Stewart S.; Osterziel, Karl Josef; Scott Gazelle, G.; Dietz, Rainer; Siebert, Uwe

doi:10.1016/j.cardfail.2006.03.003

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Volume 12, Issue 7 , Pages 554-567, September 2006

A Systematic Meta-Analysis of the Efficacy and Heterogeneity of Disease Management Programs in Congestive Heart Failure

Alexander Göhler, MD
- From the Institute for Technology Assessment and Department of Radiology
- Division of Cardiology, Charité Campus Virchow-Klinikum, Humboldt Medical School, Berlin, Germany
- Department for Public Health, Medical Decision Making and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
James L. Januzzi, MD
- Department of Medicine and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Stewart S. Worrell, MD, MPH
- From the Institute for Technology Assessment and Department of Radiology
Karl Josef Osterziel, MD, PhD
- Division of Cardiology, Charité Campus Virchow-Klinikum, Humboldt Medical School, Berlin, Germany
G. Scott Gazelle, MD, MPH, PhD
- From the Institute for Technology Assessment and Department of Radiology
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
Rainer Dietz, MD, PhD
- Division of Cardiology, Charité Campus Virchow-Klinikum, Humboldt Medical School, Berlin, Germany
Uwe Siebert, MD, MPH, MSc, ScD
- From the Institute for Technology Assessment and Department of Radiology
- Department for Public Health, Medical Decision Making and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Reprint requests: Uwe Siebert, MD, MPH, MSc, ScD, Associate Professor of Radiology, Director, Cardiovascular Research Program, MGH Institute for Technology Assessment, Harvard Medical School; 101 Merrimac Street, 10th floor, Boston, MA 02114-4724.

Received 15 May 2005; received in revised form 7 February 2006; accepted 6 March 2006.

Boston, Massachusetts; Berlin, Germany; Hall, Austria

Abstract

Background

We sought to systematically combine the evidence on efficacy of disease management programs (DMPs) in the treatment of congestive heart failure (CHF), to identify and explain heterogeneity of results from prior studies of DMPs, and to assess potential publication bias from these studies.

Methods and Results

We conducted a systematic literature search on randomized clinical trials investigating the effect of DMPs on CHF outcomes and performed meta-analyses and meta-regressions comparing DMPs and standard care for mortality and rehospitalization. We included 36 studies from 13 different countries (with data from 8341 patients). Our meta-analysis yielded a pooled risk difference of 3% (95% confidence interval [CI] 1–6%, P < .01) for mortality and of 8% (95% CI 5–11%, P < .0001) for rehospitalization, both favoring DMP. Factors explaining heterogeneity between studies included severity of disease, proportion of β-blocker at baseline, country, duration of follow-up, and mode of postdischarge contact. No statistically significant publication bias was detected.

Conclusion

DMPs have the potential to reduce morbidity and mortality for patients with CHF. The benefit of the intervention depends on age, severity of disease, guideline-based treatment at baseline, and DMP modalities. Future studies should directly compare the effect of different aspects of disease management programs for different populations.

Key Words: Congestive heart failure, Disease management program, Meta-analysis, Mortality, Heterogeneity, Publication bias