September 7, 2020Open Access

Intensified ambulatory cardiology care: effects on mortality and hospitalisation—a comparative observational study

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Chronic heart failure and coronary artery disease (n=43712). Intervention: Intensified ambulatory cardiology care programme vs. Usual ambulatory cardiology care. Primary outcome: All-cause mortality (CHF cohort) (HR 0.84, 95% CI 0.77-0.91, p=<0.0001).

OSOlga A. SawickiGoethe University Frankfurt AMAngelina MuellerGoethe University Frankfurt AGAnastasiya GlushanGoethe University Frankfurt

Key Result

Intensified ambulatory cardiology care reduced all-cause mortality in patients with chronic heart failure (HR 0.84) and coronary artery disease (HR 0.81) compared to usual care.

Study Design

Type

Observational (n=43,712)

Multicenter

Yes

Structured PICO

Does an intensified ambulatory cardiology care programme reduce mortality and hospitalisation in patients with chronic heart failure or coronary artery disease?

Population

43,712 adults (≥18 years) with chronic heart failure (CHF) and/or coronary artery disease (CAD) insured by AOK in Baden-Wuerttemberg, Germany. Mean age 72.16, 58.3% male. The cohorts included 13,404 CHF and 19,537 CAD patients in the intervention group, and 8,776 CHF and 16,696 CAD patients in the control group. Key inclusion: insured at AOK without interruption during the observation period.

Intervention

Intensified ambulatory cardiology care programme featuring structured disease management, promotion of guideline-recommended care, new ambulatory medical services (e.g., electrical cardioversion, loop recorders), morbidity-adapted reimbursement, and coordinated care pathways with standardised communication between general practitioners and cardiologists.

Comparator

Usual ambulatory cardiology care (patients not enrolled in the intensified programme or GP-centred healthcare programme, receiving care from cardiologists not participating in the programme).

Outcome

All-cause mortalityhard clinical

An intensified ambulatory cardiology care program featuring structured disease management and GP-cardiologist coordination significantly reduced all-cause mortality and hospitalizations in patients with heart failure and coronary artery disease.

Main Result

Effect estimate: HR 0.84 (95% CI 0.77-0.91)

p-value: p=<0.0001

Limitations

Reliance on administrative claims data and potential miscoding
Lack of data on cause of death
Potential residual confounding from unmeasured confounders
Possible self-selection bias due to voluntary participation

Abstract

Since 2010, an intensified ambulatory cardiology care programme has been implemented in southern Germany. To improve patient management, the structure of cardiac disease management was improved, guideline-recommended care was supported, new ambulatory medical services and a morbidity-adapted reimbursement system were set up. Our aim was to determine the effects of this programme on the mortality and hospitalisation of enrolled patients with cardiac disorders. We conducted a comparative observational study in 2015 and 2016, based on insurance claims data. Overall, 13,404 enrolled patients with chronic heart failure (CHF) and 19,537 with coronary artery disease (CAD) were compared, respectively, to 8,776 and 16,696 patients that were receiving usual ambulatory cardiology care. Compared to the control group, patients enrolled in the programme had lower mortality (Hazard Ratio: 0.84; 95% CI: 0.77-0.91) and fewer all-cause hospitalisations (Rate Ratio: 0.94; 95% CI: 0.90-0.97). CHF-related hospitalisations in patients with CHF were also reduced (Rate Ratio: 0.76; 95% CI: 0.69-0.84). CAD patients showed a similar reduction in mortality rates (Hazard Ratio: 0.81; 95% CI: 0.76-0.88) and all-cause hospitalisation (Rate Ratio: 0.94; 95% CI: 0.91-0.97), but there was no effect on CAD-related hospitalisation. We conclude that intensified ambulatory care reduced mortality and hospitalisation in cardiology patients.

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