Differential impact of a nurse-led, home-based intervention for optimal secondary cardiac prevention on recurrent hospitalization in men and women: the Young @ Heart multicentre, randomized trial

Abstract

Background: We examined the impact of a two year secondary prevention program on recurrent hospitalization in cardiac patients with ready access to specialist care. Methods: The Young at Heart Study was a multicentre, randomized controlled trial comparing usual post-discharge care (UC) with a flexible, nurse-led, home-based intervention (HBI). The primary endpoint was rate of all-cause hospital stay during 31.5±7.5 months follow-up. Results: Overall, 602 (mean age 70±10 years, 72% men and 62% hospitalized for coronary artery disease of whom 39% underwent coronary revascularization) patients were randomized to UC (n=296) or HBI (n=306 - 96% received at least one home visit). Women were on average 5 years older (p<0.001) and had greater levels of co-morbidity (p=0.009) than men; these differences were consistent across the two study groups. At 2 years, more HBI versus UC (39 vs. 27%; OR 1.67; 95% CI 1.15 – 2.41; p=0.007) patients were assessed as stable and optimally managed. Overall, 42 patients (7.0%) died and 492 patients (82%) were hospitalized with 2338 all-cause admissions and 10,045 days of hospitalization. There were no group differences (HBI vs. UC) in the primary endpoint of all-cause hospital stay (0.78±2.01 vs. 0.68±1.96/month; p=0.546) or all-cause hospitalization (0.14±0.20 vs. 0.14±0.30/month; p=0.867). Overall, men in the HBI group (40/215 [19%]) were significantly less likely to experience a cardiovascular admission compared to UC (61/216 [28%]) with the reverse situation for women in the HBI group (30/91 [33%]) vs. UC (20/80 [25%]). Independent correlates of cardiovascular admission were living alone (HR 1.62, 95% CI 1.03-2.54; p=0.038) and increasing comorbidity (HR 1.09, 95% CI 1.02 – 1.16 per unit score; p=0.013) for men and women combined. For men only, assignment to the HBI group (HR 0.61, 95% CI 0.41-0.93 for HBI vs. UC; p=0.019) and advancing age was associated with reduced likelihood of a cardiovascular readmission (HR 0.97, 95% CI 0.94-1.00 per year; p=0.05) with 583 less days of (p=0.036) hospital stay. In women, advancing age (HR 1.06, 95% CI 1.01-1.10 per year; p=0.012) and study site (HR 0.57, 95% CI 0.40-0.82, site A vs. B; p=0.002) were the only significant correlates, with assignment to HBI associated with a non-significant 1.4-fold increased risk of such an event. Conclusions: Despite high levels of engagement and potential clinical improvements at 2 years, HBI did not reduce levels of recurrent hospital stay compared to usual care. However, improved cardiovascular outcomes in men, but not women, requires further investigation.