IDF21-0244 Multicomponent integrated care and clinical outcomes in people with heart failure: A systematic review and meta-analysis

Abstract

Background: Multicomponent integrated care is associated with sustained improvements in cardiometabolic risk factors among people with type 2 diabetes. However, its effects among people with chronic heart failure are less clear. Aim: To examine the effects of multicomponent integrated care on hard clinical outcomes among people with chronic heart failure. Method: We conducted a meta-analysis involving randomized clinical trials with implementation of multicomponent integrated care for at least 3 months. Eligible trials, published in English language from inception to 1 November 2020, were identified from PubMed, EMBASE, Ovid and the Cochrane Library databases. Multicomponent integrated care was defined as the implementation of at least 2 quality improvement strategies from any 2 domains targeting the healthcare system, healthcare providers or patients. The outcomes of interest were mortality, hospital readmission and emergency department visits, stratified by all-cause, cardiovascular- and heart failure-related, based on available data. We conducted the Mantel-Haenszel test to pool the risk ratio (RR) for the association between multicomponent integrated care and hard clinical outcomes. Results: A total of 104 trials involving 35,376 people with chronic heart failure (mean ± standard deviation age 70.2 ± 3.9 years) were included. The median duration of multicomponent integrated care intervention was 12 months (interquartile range 6-12 months). Compared with usual care, multicomponent integrated care was associated with a reduced risk for all-cause mortality (RR 0.91, 95% confidence interval [CI] 0.86-0.95, p<0.001), cardiovascular mortality (RR 0.70, 95% CI 0.57-0.85, p<0.001), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00, p=0.040), heart failure-related hospital readmission (RR 0.82, 95% CI 0.75-0.90, p<0.001) and all-cause emergency department visits (RR 0.89, 95% CI 0.81-0.98, p=0.010) among people with chronic heart failure. However, there was no significant risk reduction for heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18, p=0.580) and cardiovascular-related hospital readmission (RR 0.88, 95% CI 0.77-1.02, p=0.080). The top 3 quality improvement strategies with the largest effect sizes for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93, p<0.001), facilitated patient-provider communication (RR 0.87, 95% CI 0.82-0.94, p<0.001) and clinician reminder (RR 0.87, CI 95% 0.75-0.99, p=0.040). Discussion: Multicomponent integrated care is an effective approach to reduce risks for mortality and hospital readmission among people with chronic heart failure. Given the growing burden of heart failure, this patient-centred approach should be considered for service planning, tailored to the needs and capacity of the healthcare systems.