The WHICH? trial : rationale and design of a pragmatic randomized, multicentre comparison of home- vs. clinic-based management of chronic heart failure patients

Aims: To describe the rationale and design of the Which Heart failure Intervention is most Cost-effective and consumer friendly in reducing Hospital care (WHICH?) trial. Methods: WHICH? is a pragmatic, multicentre, randomized controlled trial that seeks to determine if multidisciplinary management of chronic heart failure (CHF) patients post-acute hospitalization delivered in a patients own home is superior to care delivered via a specialist CHF outpatient clinic. The composite primary endpoint is all-cause, unplanned recurrent hospitalization or death during 1218 months of follow-up. Of 688 eligible patients, 280 patients (73 male and 66 principal diagnosis of CHF) with a mean age of 71 +/- 14 years have been randomized to home- (n 143) or clinic-based (n 137) post-discharge management. This will provide 80 power (two-sided alpha of 0.05) to detect a 15 absolute difference in both the primary end-point and rate of all-cause hospital stay. Preliminary data suggest that the two groups are well matched in nearly all baseline socio-economic and clinical parameters. The majority of patients have significant co-morbidity, including hypertension (63), coronary artery disease (55), and atrial fibrillation (53) with an accordingly high Charlson Index of Comorbidity Score (6.1 +/- 2.4). Perspective: Despite its relatively small size, the WHICH? trial is well placed to examine the relative impact of two of the most commonly applied forms of face-to-face management designed to reduce recurrent hospitalization and prolong survival in CHF patients.