Aims It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients
with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional
post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive
network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT),
Methods and results The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously
in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively
matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6 months. Multivariable
Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients
(19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in
the primary endpoint (adjusted HR 0.54; 95% CI 0.370.77; P < 0.001). Subgroup analyses revealed consistent effectiveness.
The composite of recurrent HF hospitalization and death within 6 months per 100 patient-years was 64.2 in HMT and 108.2
in UC (adjusted HR 0.41; 95% CI 0.290.55; P < 0.001 with death considered as a competing risk). After 1 year, 25 (10%)
patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.230.61, P < 0.001).
Conclusions A multidimensional post-discharge disease management programme, comprising a telemedical monitoring
system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and
effective in clinical practice.
- Exploration of Digital Health
- Heart failure
- Disease Management programme
- Transitional care