The Centre of Research Excellence (CRE) to Reduce Inequality in Heart Disease focuses on improving the heart health and outcomes of groups and communities i.e. Regional Australians, Indigenous Australians and International Health

WHICH? Trial

Research Stream: Older individuals with chronic heart disease

 

WHICHstudyimage.jpg - largeThe Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care Trial was a multicentre randomised trial comparing two different forms of heart failure management to determine which is the best way to prolong survival and reduce hospital care for those affected by this often deadly and disabling condition.

 

Full Study Title

The Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care Trial

 

Trial Registration

Australian New Zealand Clinical Trials Registry number:12607000069459(http://www.anzctr.org.au)

 

Funding Source

National Health and Medical Research Council Project Grant (2007 - 2011) number 418967

 

Rationale for the Study

Chronic heart failure is one of the most common disorders affecting the heart; most commonly occurring due to uncontrolled hypertension (high blood pressure) or following an acute myocardial infarction (heart attack). Those affected can have severely impaired quality of life, require repeated hospital admissions and/or suffer a premature death.

 

Study Aims

To undertake a head-to-head trial of the two most common forms of chronic heart failure management for patients discharged from acute hospital care – a specialist clinic or home-based approach to multidisciplinary care. Our specific aim was to determine if there were advantages in terms of hospitalisation, survival, quality of life, health care costs and patient preferences in providing a home-based model of chronic heart failure care.

 

Study Design

This prospective, multi-center randomised controlled trial with blinded endpoint adjudication comprised 280 hospitalised CHF patients (73% male, aged 71±14 years and 73% with LVEF ≤ 45%) randomised to home-based intervention (HBI) or specialized CHF clinic-based intervention (CBI). The primary endpoint was all-cause, unplanned hospitalisation or death during 12-18 month follow-up. Secondary endpoints included type/duration of hospitalisation and health care costs.

 

Primary Outcomes

The primary endpoint occurred in 102/143 (71%) HBI versus 104/137 (76%) CBI patients (adjusted HR 0.97 [95%CI 0.73-1.30], p=0.861): 96 (67.1%) HBI versus 95 (69.3%) CBI patients had an unplanned hospitalisation (p=0.887) and 31 (21.7%) versus 38 (27.7%) died (p=0.252). The median duration of each unplanned hospitalisation was significantly less in the HBI group (4.0 [IQR 2.0-7.0] vs. 6.0 [IQR 3.5-13] days; p=0.004). Overall, 75% of all hospitalisation was attributable to 64 (22.9%) patients, of whom 43 (67%) were CBI patients (adjusted OR 2.55 [95%CI 1.37-4.73], p=0.003). HBI was associated with significantly fewer days of all-cause hospitalisation (-35%; p=0.003) and from cardiovascular causes (-37%; p=0.025) but not for CHF (-24%; p=0.218). Consequently, health care costs ($AU3.93 vs. $AU5.53 million) were significantly less for the HBI group (median $AU34 [IQR 13-81] vs. $AU41 [13-107] per day; p=0.030).

 

Study Conclusions & Translational Potential

HBI was not superior to CBI in reducing all-cause death or hospitalisation. However, HBI was associated with significantly lower health care costs, attributable to fewer days of hospitalisation. We have recommended that every chronic heart failure management program should consider the provision of at least one home visit post-hospitalisation to maximize the potential of these programs to improve health outcomes in those affected by this often deadly and disabling condition.

 

Ongoing Research

The WHICH? Trial Investigators are currently investigating the long-term impact of home versus clinic-based management of chronic heart failure via prolonged follow-up of the WHICH? Trial cohort – results from this extended study will be posted on this web-page in the near future.

 

A follow-up trial (the WHICH? II Trial) arising from this key study has been funded by the NHMRC of Australia and will commence in the near future – WHICH? II Trial.

 

Key Collaborators

  • Professor Simon Stewart: Australian Catholic University, Australia
  • Professor Paul Scuffham: Griffith University, Population and Social Health Research Unit
  • Professor Thomas Marwick: Director, Menzies Research Institute, Tasmania
  • Professor John Horowitz: The University of Adelaide
  • Professor Henry Krum: Monash University, Epidemiology and Preventative Medicine
  • Professor Patricia Davidson: St Vincent’s Hospital Sydney, Faculty of Health
  • Professor Peter Macdonald: St Vincent’s Hospital Sydney, Cardiology Unit
  • Prof Christopher Reid: Monash University, Epidemiology and Preventative Medicine

 

Study Publications

  1. Stewart S, Carrington MJ, Horowitz JD, Marwick TH, Newton PJ, Davidson PM, Macdonald PM, Thompson DR, Chan YK, Krum H, Reid C, Scuffham PA. Prolonged impact of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort. Int J Cardiol.   Jul 2014; 174(3):600-10. doi: 10.1016/j.ijcard.2014.04.164.
  2. Whitty JA, Stewart S, Carrington MJ, Calderone A, Marwick T, Horowitz JD, Krum H, Davidson PM, Macdonald PS, Reid C, Scuffham PA. Patient preferences and willingness-to-pay for a home or clinic based program of chronic heart failure management: findings from the Which? Trial. PLoS One. 2013;8(3):e58347.
  3. Stewart S, Carrington MJ, Marwick TH, Davidson PM, Macdonald P, Horowitz JD, Krum H, Newton PJ, Reid C, Chan YK, Scuffham PA. Impact of Home Versus Clinic-Based Management of Chronic Heart Failure: The WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care) Multicenter, Randomized Trial. J Am Coll Cardiol. 2012;60(14):1239-48.
  4. Stewart S, Carrington MJ, Marwick T, Davidson PM, Macdonald P, Horowitz J, Krum H, Newton PJ, Reid C, Scuffham PA. The WHICH? trial: rationale and design of a pragmatic randomized, multicentre comparison of home- vs. clinic-based management of chronic heart failure patients. Eur J Heart Fail. 2011;13(8):909-916.
  5. Whitty JA, Carrington MJ, Stewart S, Holliday J, Marwick TH, Scuffham PA. Patient Preferences for the Delivery of Disease Management in Chronic Heart Failure: A Qualitative Study. J Cardiovasc Nurs. 2012;27(3):201-207.