Researchers randomly assigned 349 patients 60 years and older hospitalized for heart failure to receive rehabilitation in the hospital (n=175) that continued after discharge with three hour-long sessions per week for 12 weeks, or to receive only usual care (n=174), which consisted of telephone calls every two weeks after discharge and clinic visits at one and three months.
To assess the effectiveness of the intervention, researchers examined results of Short Physical Performance Battery (SPPB; range 0-12 with lower scores indicating more severe dysfunction) at baseline and again three months after discharge. The three components of this test - standing balance, gait speed for 4-minute walk, and strength based on time needed to rise from a chair five times - were each scored on a scale from 0-4.
Scores on the SPPB climbed significantly more in the intervention group (from a mean of 6.0 at baseline to 8.3 at three months) than in the control group (from 6.1 to 6.9), researchers report in the New England Journal of Medicine.
"Usual care for hospitalized heart failure patients doesn't address their physical function impairments, which have been under-recognized," said lead study author Dr. Dalane Kitzman, a professor of cardiovascular medicine and geriatrics at Wake Forest School of Medicine in Winston-Salem, North Carolina.
Earlier, preliminary studies found that older adults hospitalized for heart failure had severe deficits in all domains of function including balance, strength, mobility, and endurance, Dr. Kitzman said by email.
"The deficits in balance and mobility were unexpected, and required a novel intervention, which was developed by our team of experts," Dr. Kitzman said. "Although these findings are exciting, we believe more work needs to be done before this intervention strategy is incorporated into routine clinical practice."
At baseline, participants had a mean of five comorbidities and 97% were frail or prefrail.
For the study intervention, participants received one-on-one outpatient therapy that could start as needed with home-based sessions for anyone with mobility issues and then transitioned to center-based sessions as soon as patients were physically able to do so. On non-intervention days, these patients were encouraged to do low-intensity walking, gradually increasing up to 30 minutes daily.
During the first three months after discharge, controls received a phone call every two weeks and had clinic checkups at one and three months, but no exercise recommendations.
At three months, patients in the intervention group received customized exercises to continue at home over the subsequent three months, with phone check-ins every four weeks.
At six months, intervention participants were significantly less likely to experience rehospitalization for any cause than controls (rate ratio 0.93). There were 21 deaths in the intervention group and 16 in the control group.
One limitation of the study is that it wasn't possible for patients to be blinded to their group assignment, researchers note. It's also possible that unmeasured differences in the amount of support from caregivers influenced the outcomes.
Even so, the results suggest that clinicians should target intervention efforts for the weakest, oldest, and sickest patients - and not reserve rehabilitation for only the highly motivated and physically fitter patients, said Andrew Coats of the faculty of medicine at the University of Warwick in the UK.
"Variations in what patients can do and what they need are so variable only a tailored program can effect changes across a wide range of patients," Coats, co-author of an editorial accompanying the study, said by email. "Therefore, it's not surprising this worked."
SOURCE: https://bit.ly/3ePABGp and https://bit.ly/2TuZC2f New England Journal of Medicine, online July 15, 2021.
By Lisa Rapaport
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