Opposite trends in hospitalization and mortality after implementation of a chronic care model-based regional program for the management of patients with heart failure in primary care

Background: The chronic care model (CCM) is an established framework for the management of patients with chronic illness at the individual and population level. Its application has been previously shown to improve clinical outcome in several conditions, but the prognostic impact of CCM-based programs for the management of patients with chronic heart failure (HF) in primary care is still to be elucidated. Methods: We assessed the prognostic impact of a primary-care, CCM-based project applied in Tuscany, Italy, in 1761 patients with chronic HF enrolled in a retrospective matched cohort study. The project was based on predefined working teams including general practitioners and nurses, proactively scheduled regular follow-up visitations for each patient, counseling for therapy adherence and lifestyle modifications, appropriate diagnostic and therapeutic pathways according to international guidelines, and a key supporting role of the nurses, who were responsible for the practical coordination of the follow-up. A matched group of 3522 HF subjects assisted by general practitioners not involved in the project was considered as control group. The endpoints of this study were HF hospitalization and all-cause mortality. Results: Over a 4-year follow-up period, HF hospitalization rate was higher in the CCM group than the controls (12.1 vs 10.3 events/100 patient-years; incidence rate ratio 1.15[ 1.05-1.27], p = 0.0030). Mortality was lower in the CCM group than the controls (10.8 vs 12.6 events/100 patient-years; incidence rate ratio 0.82[0.75-0.91], p < 0.0001). In multivariable analysis, the CCM status was associated with a 34% higher risk of HF hospitalization and 18% lower risk of death (p < 0.0001 for both). The effect on HF hospitalization was mostly driven by a 50% higher rate of planned HF hospitalization. Conclusions: Implementation of a CCM-based program for the management of HF patients in primary care led to reduced mortality and increased HF hospitalization. These findings support the hypothesis that the beneficial effects of CCM on survival might be extended to patients with chronic HF followed in primary care, but also support the need for further strategies aimed at improving the management of these patients in terms of hospitalizations.