Clinical Pearls & Morning Reports
Published July 14, 2021
Kitzman et al. conducted a trial in older adults that assessed physical function and rates of rehospitalization with an early, transitional, tailored, progressive rehabilitation intervention plus usual care (intervention group) as compared with usual care alone (control group) initiated during, or early after, hospitalization for heart failure. Read the NEJM Original Article here.
Q: What were the clinical issues addressed in the trial by Kitzman et al.?
A: Among older patients with acute heart failure, physical function is markedly impaired, and frailty rates and the burden of coexisting conditions are high. Even among older patients with stable and well-compensated heart failure, severe impairments in physical function are often present owing to the combined effects of aging, cardiovascular dysfunction, and skeletal-muscle dysfunction. As patients with chronic heart failure transition to acute decompensated heart failure, physical function worsens further and is exacerbated by hospitalization and bed rest. These deficits often persist. Many patients never recover baseline function, lose independence, and have high risks of rehospitalization and death after discharge.
Q: Describe a key goal of the rehabilitation intervention used in the trial by Kitzman et al.
A: A key goal of the intervention during the first 3 months (the outpatient phase) was to prepare the patient to transition to the independent maintenance phase (months 4 through 6). At the 3-month visit, patients were provided with individualized exercise prescriptions and were subsequently followed every 4 weeks by telephone contact.
A: The primary outcome was the score on the Short Physical Performance Battery (total scores range from 0 to 12, with lower scores indicating more severe physical dysfunction) at 3 months. After adjustment for the baseline Short Physical Performance Battery score and other baseline characteristics, the least-squares mean (±SE) score on the Short Physical Performance Battery at 3 months was 8.3±0.2 in the intervention group and 6.9±0.2 in the control group (mean between-group difference, 1.5; 95% confidence interval [CI], 0.9 to 2.0; P<0.001). This effect appeared to be relatively uniform across a wide variety of prespecified subgroups. All three of the components of the Short Physical Performance Battery — corresponding to balance, strength, and mobility — showed greater improvement in the intervention group than in the control group. The secondary outcome, the rate of rehospitalization for any cause at 6 months, showed no appreciable difference between the intervention group and the control group, with rates of 1.18 and 1.28, respectively (rate ratio, 0.93; 95% CI, 0.66 to 1.19).
A: The results of the analyses of 6-minute walk distance, frailty status, quality of life, and depression also suggested clinical benefits of the intervention. The suggested benefit for depression is of interest, since depression is common among patients with heart failure and is associated with frequent rehospitalization. At 6 months, 83% of the patients in the intervention group who were alive and were being followed by telephone contact reported regular home exercise, which suggested that behavioral change — a requisite for long-term adherence — may have occurred.