| Background. Heart failure (HF) is a major chronic health problem linked to multiple hospitalisations, a poor quality of life, as well a high rate of mortality and whose incidence is growing rapidly. Scientific consensus has led to the establishment of clinical practice guidelines that are evidence-based. However, these guidelines are not much applied and the level of compliance among patients is low. The aim of this study is to evaluate the effects of a multidisciplinary outpatient clinic of patients suffering from heart failure, on readmissions, mortality, quality of life and compliance as well as the effects of this clinic on professional practices. Methods. Following a hospitalisation due to HF, 230 subjects were randomized, that is, in a control group receiving the usual external clinical follow-up (n=115) or in an experimental group (n=115). The experimental intervention, 6 months in duration, consisted of a multidisciplinary approach centered on the patient and managed by a clinician nurse, and included a specialized medical follow-up on a regular basis, dietetic and pharmaceutical consultations as well as an experiential learning program. The patient-related variables include readmissions, duration of stay, mortality, quality of life and compliance, whereas professional practice-related variables include medical follow-up, delay in obtaining the follow-up, pharmacological adjustments as well as multidisciplinary follow-up. Results. The average age of the subjects was 69 + 10 years and the average ejection fraction was 35 +/- 15%. Less patients in the experimental group were re-hospitalised than in the control group (45 (39%) versus 66 (75%); RR: 0.59 [C.I. 95%: 0.38-0.92]). The total length of stay was also shorter in the experimental group (514 days versus 815; RR: 0.56 [I.C. 95%: 0.35-0.89]), whereas no difference was found in the number of visits to the emergency department (181 versus 238; RR: 0.77 [I.C. 95%: 0.77-1.43]). No difference was observed with regard to mortality, with 13 deaths in the experimental group as compared to 20 in the control group (RR: 0.65 [C.I. 95%: 0.340-1.243]). An improvement in the quality of life, as measured by the Minnesota Living with Heart Failure Questionnaire, was observed for the subjects in the experimental group (p=0.0000). A similar result was found with regard to compliance, as measured by the Hilbert Compliance Questionnaire, which improved patients in the experimental group on three dimensions (medications: p=0.21; diet: p=0.0000; physical activity: p=0.0000; stress: p=0.0000). As for medical examinations with a cardiologist, they were more numerous in the experimental group (555 versus 165; p=0.0000) and the median time for obtaining a first examination was shorter (8 days versus 61; p<0.0001). No difference was observed between groups concerning the administration of angiotensin converting enzyme inhibitors (ACEI) (p=0.21) nor of beta-blockers (beta-b) (p=0.08), whereas the number of adjustments for these drugs was higher in the experimental group (ACEI: p=0.009; beta-b: p=0.0001). Lastly the subjects of the experimental group benefited from 933 visits with the nurse and other professionals, whereas no such visits were observed in the control group. Conclusions. A multidisciplinary clinical follow-up, managed by a nurse, of older patients strongly affected by HF significantly reduces readmissions and length of stay without adverse effect on mortality, while improving in a marked way the patients' quality of life, compliance, and access to a medical and multidisciplinary follow-up.;Key-words: heart failure, multidisciplinary care, nurse led, outpatient clinic, randomized trial; re-hospitalisations, mortality, compliance, quality of life. |
