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(Circulation. 2004;110:1450-1455.)
© 2004 American Heart Association, Inc.

Original Articles

Randomized, Controlled Evaluation of Short- and Long-Term Benefits of Heart Failure Disease Management Within a Diverse Provider Network

The SPAN-CHF Trial

Carey Kimmelstiel, MD; Daniel Levine, MD; Kathleen Perry, RN; Ayan R. Patel, MD; Ara Sadaniantz, MD; Noreen Gorham, RN; Margaret Cunnie, RN; Lynne Duggan, RN; Linda Cotter, MS RN; Patricia Shea-Albright, RNP; Athena Poppas, MD; Kenneth LaBresh, MD; Daniel Forman, MD; David Brill, MD; William Rand, PhD; Douglas Gregory, PhD; James E. Udelson, MD; Beverly Lorell, MD; Varda Konstam, PhD; Kathleen Furlong, RN; Marvin A. Konstam, MD

From the Division of Cardiology, Tufts-New England Medical Center, and Tufts University School of Medicine (C.K., K.P., A.R.P., L.C., W.R., D.G., J.E.U., M.A.K.); Brown University Medical School (D.L., A.S., N.G., P.C., L.D., P.S.-A., A.P., K.L., D.F., D.B.); and Beth Israel Deaconess Medical Center and Harvard Medical School (B.L.), Boston, Mass.

Correspondence to Marvin A. Konstam, MD, Tufts-New England Medical Center, Box 108, 750 Washington St, Boston, MA 02111. E-mail mkonstam{at}tufts-nemc.org

Received November 18, 2002; de novo received February 15, 2004; revision received June 10, 2004; accepted June 17, 2004.

Background— Several trials support the usefulness of disease management (DM) for improving clinical outcomes in heart failure (HF). Most of these studies are limited by small sample size; absence of concurrent, randomized controls; limited follow-up; restriction to urban academic centers; and low baseline use of effective medications.

Methods and Results— We performed a prospective, randomized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy. During a 90-day follow-up, patients randomized to DM experienced fewer hospitalizations for HF [primary end point, 0.55±0.15 per patient-year alive versus 1.14±0.22 per patient-year alive in control subjects; relative risk (RR), 0.48, P=0.027]. Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF (4.3±0.4 versus 7.8±0.6 days hospitalized per patient-year; RR, 0.54; P<0.001), cardiovascular hospitalizations (0.81±0.19 versus 1.43±0.24 per patient-year alive; RR, 0.57; P=0.043), and days in hospital per patient-year alive for cardiovascular cause (RR, 0.64; P<0.001). Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days. On long-term (mean, 283 days) follow-up, there was substantial attrition of the 3-month gain in outcomes, with sustained significant reduction only in days in hospital for cardiac cause.

Conclusions— In a population with high background use of standard HF therapy, a DM intervention, uniformly delivered across varied clinical sites, produced significant short-term improvement in HF-related clinical outcomes. Longer-term benefit likely requires more active chronic intervention, even among patients who appear clinically stable.

Key Words: disease management • heart failure • cardiovascular diseases

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