MULTIDISCIPLINARY CONGESTIVE HEART FAILURE CLINIC FOR OLDER WOMEN: A RANDOMIZED, CONTROLLED TRIAL

To the Editor: In the past few decades, congestive heart failure (CHF), principally a cardiogeriatric syndrome, has become a major chronic illness for older adults.1, 2 Women constitute a larger proportion of older individuals, but women have historically been underrepresented in cardiovascular research.3 Women have a unique risk-factor profile and different clinical manifestations of heart failure symptoms from those of men.5, 6 The mean length of hospital stay for women is longer than for men. In addition, women present with a wider range of symptoms, are more likely to delay seeking medical care, and are less likely to be investigated and treated with evidence-based medications and therapies than men.4, 5 A recent survey demonstrated variability in the approach to outpatient management of CHF employed by members of the Canadian CHF Clinics Network.6 An enhanced approach routinely incorporating disciplines such as physiotherapy, occupational therapy, social work, dietary, and pharmacy in a standardized clinical pathway merits further investigation, particularly in older women. Measurement of diverse clinical outcomes, including function, quality of life, mood, and cognition may assist in evaluating the effect of such a structured and standardized intervention. The objective of this study was to determine whether a multidisciplinary clinical pathway, a blueprint of the patient-care processes for female patients aged 65 and older, will improve patients' quality of life and functional capacities more than usual care for CHF. In this randomized, controlled trial, the intervention consisted of a series of 12 visits over 6 weeks to optimize medical care and to engage in an exercise program with strong education, counseling, and dietary management, involving physician, nursing, dietary, physiotherapy, pharmacy, occupational therapy, and social work. Patients with a diagnosis of CHF were referred from the Ottawa Hospital and the community and were screened to ensure that they met the eligibility criteria. The inclusion criteria included patients who were deemed medically stable and capable of engaging in an exercise program. The exclusion criteria included those with significant cognitive impairment and New York Heart Association (NYHA) Class IV or at palliative stage. Ninety-one community-dwelling women aged 63 to 89 with the diagnosis of CHF were enrolled in this study. The primary outcome measure was the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The secondary outcome measures included the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Folstein Mini-Mental State Examination (MMSE), the 15-item Geriatric Depression Scale (GDS), the Physical Self-Maintenance Scale (PSMS), and survival and health service utilization over 6 months. There was no difference between the two groups in MMSE or GDS scores by the end of 6 weeks. Comparison of change from baseline MLHFQ score, including physical and emotional components, did not show a difference (P<.47). There was also no difference between the two groups in functional outcome as measured by change from baseline PSMS score (P<.32). The treatment group had a tendency to have more emergency department visits (for all reasons and for CHF) and hospitalizations. The treatment group had significantly more cardiologist visits during the study period (P<.001). In conclusion, this study demonstrates that it is feasible to conduct a randomized, controlled trial in a frail community-based older female population and to test a complex multidisciplinary pathway. Negative trials are as important as positive trials in determining the factors that verify intervention effectiveness. These factors have been reported generally to fall into three categories: target population, quality of usual care, and program design.7 We can further expand on this framework as follows. First of all, in our study, only 40% of patients were in NYHA Class II, the group previously reported to respond best to similar interventions. Second, it is also possible that the there is high usual quality of care in our community, thus leaving little opportunity for improvement. Last, the program design was limited to 6 weeks duration, and most patients did not complete all the sessions, suggesting that a longer, more-flexible design may be desirable. Future studies should provide further insight into the optimal intensity and duration of heart failure management programs and which patients derive the greatest benefit.8 We are grateful to the Ontario Women's Health Council for providing funding for this study. We would also like to recognize the contributions of the multidisciplinary team: Dr. Susan Livergant, Kathy Bouchard, Joan Bailey, Myrella Roy, Ann Smutylo, Jan McGee, Sylvie Perrault, Jennifer Clinch, Joan Evans, Marion Agnew, and Sharon MacLaren. Financial Disclosures: Drs. Azad, Molnar, and Byszewski state none to receiving any financial support related to research reported here. Author Contributions: Nahid A. Azad: lead role in study concept and design, acquisition of subjects, management of the project, and preparation of manuscript. Frank J. Molnar: a role in study concept and design, data analysis, interpretation of data, and preparation of manuscript. Anna M. Byszewski: a role in study concept and design, acquisition of subjects, and contributed to manuscript preparation. Sponsor's Role: Ontario Women's Health Council provided the funding for the project but did not have any role in the design, methods, subject recruitment, data collections, analysis, or preparation of the manuscript.

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