Care management interventions for older patients with congestive heart failure

Objectives: To identify interventions and outcome measures that should be included when designing care management programs for older patients with congestive heart failure (CHF) and assessing the overall effectiveness of these programs. Study design: Structured literature review and assessment. Methods: A systematic literature search was conducted to identify articles that described interventions and outcome measures designed to improve care for older patients with CHF. Resultant studies were classified according to design, and interventions and outcome measures were categorized. Finally, the data were analyzed to identify care management strategies and outcome measures associated with effective studies (defined as those that achieved improvement in more than half of the important outcome measures). Results: Thirty-two studies were identified. Most of the effective programs employed both a physician and a nurse; 12 employed a case manager. Hospital utilization was typically reduced by 30% to 80% in studies that measured this factor, although utilization increased in 2 studies. Only 6 studies showed significant reductions in costs. Fifteen of the studies were categorized as effective; 15 showed trends toward improvement; and 2 studies in which intervention subjects worsened appeared to have design flaws and subject selection biases. Conclusion: Care management interventions can be clinically effective, although cost effectiveness remains to be established. Common elements in effective care management programs included the teaming of a physician with a nurse or care manager; frequent patient monitoring for CHF decompensation; and patient education to improve self-assessment skills. Most ineffective programs showed deficiencies in nurse training, study design, or patient selection.