Heart failure management : how much COACH-ing is needed?

• We were glad to find two interesting articles and an editorial in the September 2004 issue of the European Heart Journal on management of patients with heart failure (HF) in specialized programmes, e.g. HF clinics or home-based HF programmes.1–3 HF management programmes are increasingly implemented and considered as a promising method of improving the quality of HF care.1 Both papers and the editorial note that HF management programmes can be effective in improving patient outcomes with regard to readmission.1–3 The authors also point out that there still is a lack of clarity on the necessary components of an HF management programme. Most interventions described in the meta-analysis, and in the review, are heterogeneous and report on combined interventions as one treatment modality comparing this with a ‘care as usual group’. The authors of both papers conclude that ‘clinical trials in future should be conducted to compare different interventions directly’2 and that effectiveness remains to be proved in a clinical trial comparing usual HF clinic care with the combination of HF clinic with home care.3 We are happy to inform the authors that at this moment such information is gathered in a large multi-centre study conducted in the Netherlands evaluating Outcomes of Advising and Counselling in Heart Failure (COACH), financed by the Netherlands Heart Foundation.4 Patients included in COACH are randomized in (i) care as usual (regular follow-up without HF nurse); (ii) an HF clinic (scheduled visits at the HF clinic with an HF nurse added to follow-up by a cardiologist); or (iii) an HF clinic + home care (care at the HF clinic, a multidisciplinary approach, and scheduled home visits).4 Patients are recruited from 17 centres in the Netherlands and patients are followed up for 18 months after discharge. Endpoints of the study are time to first event, readmission, mortality, costs, and quality of life. At this moment (October 2004), more then 900 patients are included in the study and final results are expected at the end of 2006. With this large-scale trial we hope to contribute further to the unanswered questions noted by the groups of Gustafsson3 and Gonseth2 regarding the dose of the intervention, and thereby contribute to the development of an optimal approach for chronic HF patients.

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