Technology Assessment: Non-Pharmacological Interventions for Post-Discharge Care in Heart Failure

Table of Contents

Appendix B

Table B1. Interventions on recruited patients inpatient

Study, Year Country	Followup Duration (Intervention y)	Total N Analyzed	Mean Age/% Male	Severity of CHF	Intervention components	Control Description	Quality Applicability
Atienza 2004 Ojeda 2005 Spain	1.4y (1999-2000)	338	69/62%	NYHA III/IV 50% LVEF% 36	Cardiologist led education on disease management and reinforcement; individual strategies to self-care, medication compliance telephone followup; heartclinic visit every 3 mo	Received discharge planning with routine hospital protocol and followed by PCP and cardiologists not participating in the study	A Mod
Barth, 2001 USA	3 mo	34	78/59%	NYHA: nd LVEF%: nd	At the time of discharge as per the hospital procedure, routine discharge teaching by the hospital nursing staff included instructions on activity, diet, activities of daily living, medication, follow up appointments and when to contact the physician. Nurse led telephone reinforcement of the education on daily weight assessment, CHF symptoms, fluid and salt intake, and medication adherence. Made phone contact for first 72 hrs post discharge and 72 hrs later and then every 2 weeks for 3 mo	Routine care: received only the routine discharge teaching at the time of discharge (as described in the intervention arm)	C Nar
Capomolla 2002 Italy	12 mo (1999-2000)	234	57/93%	NYHA III/IV 35% LVEF% 29	Multidisciplinary interventions including cardiovascular risk stratification, tailored therapy, physical training, counseling, checking clinical stability, correction of risk factors for hemodynamic instability, and health care educationA	At discharge patients were referred to their community primary care physician and cardiologists or cardiology dept	B Mod
Cleland, 2005 EU	7-8 mo (2000-2002)	333	67/72%	NYHA III/IV 31% LVEF <25% = 48%	Home telemonitoring with electronic weighing scales; an automated sphygmomanometer; single lead ECG and Nurses telephone support	Management plan sent to primary care physician who implemented it Usual care + Nurses telesupport	B Wide
Cleland, 2005 EU	7-8 mo (2000-2002)	248	67/72%	NYHA III/IV 31% LVEF <25% = 48%	Home telemonitoring with electronic weighing scales; an automated sphygmomanometer; single lead ECG and Nurses telephone support	Management plan sent to primary care physician who implemented it	B Wide
Cline, 1998 Sweden	12 mo (1991-1993)	190	76/53%	NYHA 2.6 LVEF mean 31.6%	Patients received an education programmed from HF nurse consisting of two 30-minute visits. 2 weeks after discharge patients and their families were invited to a one-hour group education session led by the HF nurse. Patients were also offered a 7 day medication dispenser if deemed appropriate. Patients were followed up at a nurse directed o/p clinic and there was a single prescheduled visit by the nurse at 8 mo. after discharge. Patients encouraged contacting the study nurse at their discretion, if unsure, if diuretic adjustments did not ameliorate symptoms in 2-3 d, or if there were “profound changes in self management variables.” Patients were offered cardiology outpatient visits 1 and 4 months after discharge.	Followed up at the outpatient clinic in the department of cardiology by either cardiologists in private practice or by primary care physicians as considered appropriate by the discharging consultant.	C Mod
Del Sindaco, 2007 USA	2 y (2001-2002)	236	77/51%	NYHA: II 32 (37.2%), III 44 (51.2%), IV 10 (11.6%) LVEF%: mean 33.5 ± 11	Managed by a cardiologist, two to four nurses and patient's primary care physician. 1) According to the guidelines components were discharge planning, continuing education, therapy optimization, improved communication with healthcare providers, early notice to signs and symptoms, and flexible diuretic regimen. 1. Nurses home phone calls 2. Visit with a primary care physician 1 to 2 weeks of discharge including reinforcement of education and optimization of therapy.	Usual care: all treatments and services ordered by their primary care physician and/or personal cardiologist Vital status and events were recorded by means of phone calls every 6 mo	A Wide
Dunagan, 2005 USA	6 mo (1999)	151	76/41%	NYHA: 78% LVEF% <40%: 74%	Nurse led education intervention, promotion of self management skills, appropriate diet and adherence to prescribed meds and telephone followup + Usual care	Usual care as provided by primary physician who provided educational packets at the time of hospitalization	C Wide
Goldberg, 2003 US	6 mo (1998-2000)	280	58/70	NYHA III/IV 100% LVEF% <21%	Nurse led education about heart failure, including advice on daily weights, dietary restrictions including sodium and fluid, and signs and symptoms of heart failure decompensation, increased communication with providers encouraged, Technology- based telephone HF monitoring (AlereNe monitoring using the DayLink monitor)	Standard outpatient heart failure therapy in dedicated heart failure program. This included additional nursing resources.	B Wide
Harrison, 2002 Canada	12 wk (1996-1998)	192	76/55%	NYHA III/IV: 77% LVEF: nd	Comprehensive, evidence based education programmed for heart failure self-management. A nursing transfer letter to the home care nurse detailing clinical status and self-management needs. Phone call from hospital nurse to patient within 24 hours of discharge. Minimum of two-community nurse visits within two weeks of discharge.	Ideally a multidisciplinary discharge plan within 24 hours of admission and weekly discharge planning meetings. Regional home care co-coordinator consults with hospital team as required and may meet patients and their families. Immediately before discharge physician completes referral form for home care and necessary services and supplies are communicated with the home nursing agency.	A Wide
Jaarsma, 2000 Netherlands	9 mo (1994-1997)	179	72/60%	NYHA III/IV 100% LVEF% 36	Nurse led intensive education including symptoms of CHF, sodium restriction, fluid balance and compliance, telephone contact, home visits once per week and education, increased communication with providers	Nurse or physician provided education about medication and lifestyle	C Wide
Kasper 2002 USA	~9 mo (1996-1998)	200	64/61%	NYHA III 56% LVEF% 27	Cardiologists designed individualized treatment plan (Usual care) + Nurse telephone followup; monthly clinic visits with nurses; patients received pill sorter, correct medications, list of dietary and exercise recommendations, and education material	CHF cardiologist designed treatment plan for each patient and documented this in patient's chart	B Mod
Koelling 2005 USA	~6 mo (2001-2002)	223	65/58%	LVEF%: 26	Patient education program including 60 min one on one and one time session with a nurse educator, disease and pharmacotherapy management, Salt and water intake management, daily weight monitoring, self-care behaviors + usual care	Standard heart failure specific discharge information Usual care	A Mod
Laramee, 2003	3 mo (1999-2001)	287	71/54%	NYHA III/IV 38% LVEF Mod/severe 90%	Education and early discharge planning and co-ordination of care by nurse case manager; patients received a educational booklet, weight logs, medication lists, a guide for measuring sodium intake, weigh scales and pill boxes; reinforced educational plan and telephone followup	Standard terr1tary hospital care, including opportunity for social services evaluation, dietician consult etc. and home care service on discharge. Post-discharge care conducted by primary care physician	B Mod
Ledwidge, 2005 Ireland	2 y	130	68/68%	NYHA: IV LVEF%: 39+12	Extended heart failure program (EP) 12 weeks of weekly telephone calls from specialist HF nurses (mostly the nurse who had managed the pt during the 1st 3 months following discharge) Specialist nurse-led education and specialist dietician consults on 3 or more occasions during index admission Telephone contact by HF nurse specialist weekly until 12 weeks. Telephone calls determined clinical stability, address questions/concerns and revise key education points deemed necessary by nurse (on daily weight monitoring, disease and medication understanding, compliance with therapy and dietary salt restriction.)	Standard care (SP) group.	B Mod
McDonald 2002; Ledwidge, 2003 Ireland	3 mo (1998-2000)	98	71/63%	NYHA nd LVEF% 36	Specialist nurse-led education including daily weight monitoring, disease and medication understanding and salt restriction. Telephone followup and education reinforcement + usual care	Usual care description not documented	B Mod
Linne 2006 Sweden	6 mo (1998-2002)	224	70/66%	LVEF <40%	Standard information + Additional interactive CD-educational program at and 2 wk after discharge. CD educational program includes disease symptoms and treatment, reasons for deterioration of disease, fluid intake, medication understanding	Standard information on the inpatient ward	C Mod
Lopez, 2006 Spain	(2000-2002)	134	75/41%	NYHA III 56% LVEF% 27	Active Intervention program Information: the day of hospital discharge, a personal interview with patient and his caregiver a. information on the disease b.diet education c. information on drug therapy contact telephone Telephone strengthening monthly during the first 6 mos of followup and subsequently ever 2 months, a telephone call was made to the home of the patient.	“standard care” not further defined. However, during regular followup visits (at 2,6, and 12 months after discharge) the cardiologist carried out a conventional clinical assessment according to the standard practice. Pharmacists evaluated the following parameters: treatment compliance (was patient reliable, partially reliable, non-reliable), quality of life measurement *EuroQoL scale), patient satisfaction with the care received (Catalan Health Department, asking patient about the care and information received and asking patient to score 0 to 10 in an analogical scale).	B Mod
Naylor, 2004 USA	12 mo (1997-2001)	239	76/40%	NYHA nd LVEF<45% 86%	A standard orientation and training program guided by a multidisciplinary team of heart failure experts to prepare advanced practice nurse (APN); Use of care management strategies; home visits by APN	Non advanced practice nurse care. Attending physician planned the discharge date, liaison nurses facilitated referrals to home care services in patients' residencies	B Wide
Nucifora 2006 Italy	6 mo (1999-2001)	200	73/62%	NYHA III/IV: 67% LVEF <45%: 58%	Nurse led education including disease and pharmacological treatment, sodium restriction and fluid intake management, Weight control and physical activities, and Other self-care behaviors; facilitated telephone followup; scheduled visits with an internist	Preexisting routine post-discharge care Follow up with their primary care physician as usual	B Wide
Rich 1993 US	3 mo (1988-1989)	98	79/40%	NYHA: mean=2.7	During index hospitalization: Daily education visits by study nurse specialist. Dietician visit with individualized 1.5-2.0 g sodium diet. Medication review by geriatric cardiologist with patient/care givers. Study nurse taught patients about meds and dosing cards. Social worker and home care team visited patient. After discharge: Home care team nurse visited within 48 hrs. 2 more home care team nurse visit in 1st wk. Study nurse phone patient to assess progress.	Conventional medical care determined by patient's physician.	B Mod
Rich 1995 USA	3 mo (1990-1994)	282	79/26%	NYHA mean 2.4 LVEF% 44	Multidisciplinary treatment strategy including inpatient visits by specialist nurse, dietician, medication review by geriatric cardiologist, nurse led education about medications, dosing, and adverse effects; weigh scales, instruction and daily weight charts; social worker and the home care team visits	Standard treatment and services ordered by primary physician	B Mod
Rainville 1999 USA	12 mo (1996-1997)	34	73/50%	NYHA III/IV: 94% LVEF: nd	Before discharge, pharmacist reviewed pathology and treatment of HF, weight monitoring and risk modifications with patient/care giver. Patient given brochure, video, weight log and medication organizer. After discharge, pharmacist phoned within 3 days, at 7, 90 days and 12 months	Routine care and preparation for discharge including: written prescription, physician discharge instructions, nurse review of diet, treatment plans, medications, and drug info sheets	C Mod
Sethares 2004 US	3 mo (1999-2000)	70	76/52%	LVEF%: 41.45 ± 18 SD	Research nurse tailored intervention to perceived benefits and barriers to self-care of HF that were identified by persons with HF at each time period (in hospital, 1 week and 1 month after discharge).	Usual care: discharge teaching by a unit staff nurse and written educational sheets describing the uses, side effects, and frequency of any ordered mediations.	B Wide
Stewart 1998 Australia	6 mo (nd)	97	76/45%	NYHA III/IV 51% LVEF%: 38	Before discharge, study nurse counseled treatment regimen compliance and reporting of any sign of clinical deterioration. 1 week after discharge a single home visit by the study nurse and pharmacist. Patients assessed for medication knowledge and compliance. Patients with poor knowledge were offered counseling, a pill remainder container, monitoring by caregivers, medication information and remainder card and referral to a community pharmacist for more regular review. The study nurse coordinated with the primary care physician for any further intensive followup thereafter	Appointments with the primary care physician or cardiologist within 2 weeks of discharge. 27% received home support by domiciliary care or community nurse visits	B Mod
Tsuyuki 2004 USA	6 mo (1999-2000)	276	81/58%	NYHA III or IV: 40% LVEF%: mean EF 32%	Before discharge: Evaluation if dosage of ACE-I was appropriate, all meds were reviewed, recommendations made to optimize other HF therapies and monitored daily thereafter. After discharge: Patient support program covered 5 basic areas: salt and fluid restriction, daily weighing, exercise alternating with rest periods, proper medication use, early recognition of worsening of symptoms Education material available on website for download. Patients received adherence aids: a medication organizer, medication administration schedule, daily weight log. Telephone followup to reinforce the education for self care behaviors, newsletters, clinical events, physician contact for ACE-I initiation and titration	General heart disease pamphlet before discharge, but no formal counseling. Followup consisted of monthly telephone contact for a period of 6 mo to ascertain clinical events	B Mod

 

Table B2: Interventions post discharge

Study, Year Country	Followup Duration (Intervention y)	No. Analyzed		Mean Age	Severity of CHF	Intervention components	Control Description	Quality Applicability
		Int	Cont	Male%
Benatar 2003 USA	3 mo (1997-2000)	108	108	67/39%	NYHA III or IV: 100% LVEF%: 38.1	Daily home telemonitor through internet monitored by cardiac nurse	Home nurse visits (specialized cardiac nurses): Detailed discussions during first 4 visits: diet, symptom recognition, and compliance with medication regimens Further visits: on patients' symptoms and vital signs with physician notification if needed	B Wide
Blue 2001 Scotland	12 mo (1997-1998)	84	81	74/64%	NYHA III or IV:76% LVEF%: nd	Specialist HF nurse visited home within 48 hrs of discharge, with visits every 3 months after 6 week visit. Patient educated bout HF and treatment, self-monitoring, medication review and psychological support. Scheduled telesupport every other month.	Patients managed as usual by the admitting physician and then primary care physician	A Wide
Capomolla 2004 Italy	11 mo (2000-2001)	67	66	57/93%	NYHA III/IV 49% LVEF% 29	Telemonitoring. Nurse led education about the illness; therapeutic programs, self management of signs and symptoms, diet and fluid recommendations, domestic and activities counseling	Community care. At discharge patients were referred to their community primary care physician and cardiologists or cardiology dept	C Mod
DeBusk 2004 USA	12 mo (1998-2000)	228	234	72/48%	NYHA III/IV 50% LVEF %:28%<0.40 and 31% >0.40	Nurse led standardized telephone mediated intervention including initial education session with a videotape, baseline telephone counseling session, nurse initiated followup telephone contacts, pharmacologic treatment management, nurse initiated communication with physicians + usual care	Usual care Instruction on diet, drug adherence, physical activity and response to changing symptoms	B Mod
Doughty 2002 New Zealand	12 mo (1997-1998)	100	97	60%	NYHA III 76% LVEF% 30.6	General practitioner led outpatient review at the heart failure clinic; one to one education with the study nurse, education booklet provided; patient diary for daily weights, treatment records, telephone followup with GP, 6 wkly clinic visits, group education session with cardiologist and nurse about disease, monitoring daily weight, action plan for weight changes, medication, exercise, diet	Usual care. Continued care of their GP with additional follow-up measures as usually recommended by the medical team responsible for their in-patient care.	A Wide
Ducharme 2005 Canada	6 mo (1998-2000)	115	115	68/73%	NYHA: III or IV LVEF%: 35%	Mulitidisciplinary care clinic: cardiologists, nurses, dieticians, social worker, etc; Evaluated and observed for up to 5 hrs; Nurse telephone followup 72 hr post discharge and monthly once, or frequently as needed basis; One to one education by study nurse about clinical condition to the patient/ family members complimented with a record maintenance by the patient; Reinforcement of patient education, dietary instructions, interaction of OTC with meds at each subsequent clinic visit	Patients received treatment and appropriate follow-up according to attending cardiologist	B Mod
Ekman 1998 Sweden	5 mo (1994-1996)	79	79	80/58%	NYHA mean 3.2 LVEF% 43	Specialist nurse led patient education about their treatment and symptoms of clinical deterioration, tailored care plan with individualized treatment goals, access to clinic nurses during business hours, notebook for daily weight monitoring, treatment and information about clinical deterioration, and nurse initiated telephone followup	The patients were managed in accordance with current clinical practice, i.e., the patient was treated and followed by a general practitioner and visited the emergency room if symptoms worsened.	B Narrow
Holland 2007 UK	6 mo	149	144	78/64%	NYHA: III/IV: 67% LVEF%: nd	Community Pharmacist arranged home visit, within 2 weeks of discharge; Educated patient/carer about HF and their drugs; Gave basic exercise, dietary, and smoking cessation advice; Encouraged completing of sign and symptom monitoring diary; Fed back recommendations to GP; Fed back need for drug adherence aid to local pharmacist	Usual care not described in the study	A Mod
Jerant 2001 USA	6 mo (1998-2000)	13/12	12	67/71: 46%/42%	NYHA (III/IV): 31%/33% LVEF% 54%/50%	Intervn 1: Home telecare with video-conferencing and electronic stethoscope. Nurse telephone support home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope; received scheduled home telecare visits Intervn 2: nurse telephone calls; received scheduled phones calls During all in-person, telecare, and telephone encounters, the study nurse used the Visiting Nurse Association CCHF Care Steps to guide patient assessment: vital signs, ADL, med use, dietary factors etc.	‘Usual outpatient care' was not described further	C Narrow
Krumholz, 2002 USA	12 mo (1997-1998)	44	44	76/57%	NYHA(III/IV) LVEF% 38	Cardiac nurse led consultation on five sequential care domains including patient knowledge of illness, relation between medication and illness, relation between health behaviors and illness, symptoms and signs of deterioration, nurse initiated scheduled telephone calls	Received all usual care treatments and services ordered by their physicians.	C Mod
Mejhert 2004 Sweden	18 mo (1996-1999)	103	105	76/56%	NYHA III or IV: 42% LVEF%: 34%	When patient pays visits to the outpatient program, he/she is encouraged to keep in contact with the nurse. Each visit the nurse: vital signs, weight, lab, ECG workup; optimizes meds if needed; instructs patients to monitor weight, symptoms of deterioration, good compliance of meds, diet advice, and other self care behaviors Information repeated in booklets and computerized educational programs	Undergo initial evaluation with their general practitioners and are monitored by a heart failure plan in the primary care setting	B Mod
Morcillo 2005 Spain	6 mo (2001-2002)	34	36	70/64%	NYHA III or IV: 74% LVEF% (mean): 35.4%	One week after discharge the nurse visited patient's home one time for: education of medication, signs and symptoms of the disease and treatment compliance; fluid and diet management and self care habits; discussion of prophylactic vaccinations + identical conventional care as the control group	Conventional care based on best available evidence + scheduled outpatient followup with attending physicians	C Mod
Rieigel 2002 USA	6 mo (nd)	130	228	73/49&	NYHA III or IV: 98% LVEF% (mean): nd	Telephonic case management by a RN case manager using decision-support software. RN contact patient at a frequency guided by software and judgment of case manager based on patient's symptoms, needs.	Usual care not described	C Mod
Riegel 2006 USA	6 mo (2002-2004)	69	65	72/42%	NYHA III or IV: 82.6% LVEF%: 42.3%	Nurse case manager contacts patient 5 days post-discharge. Software assists nurse in setting priorities for the timing of the next telephone call, content of patient education, and documentation. Nurse case manager assesses poor adherence with meds and diet recommendations	Usual care was not standardized, and before discharge the nurse educated patients about heart failure management typical discharge instructions included medication list, institutional specific discharge instruction sheet and hand written notes to follow a low sodium diet and contact physician if symptoms occur	A Wide
Stewart 1999 Australia	6 mo (1997-1998)	100	100	75/62%	NYHA III or IV: 88% LVEF mean%: 37%	Multidisciplinary, home-based intervention. Assessed by cardiac nurse 7-14 days after discharge. Assessment of clinical status, understanding of disease and psychological support. Counseling on strategies to improve adherence where necessary	Regular outpatient review by the cardiologist	A Wide
Stromberg 2003 Sweden	12 mo (1997-1999)	52	54	77/63%	NYHA III or IV:87% LVEF%: nd	Patients scheduled for first visit 2-3 weeks after discharge. 1 hr visit: nurse evaluated status and optimized treatment; educated patient/family about: heart failure and social support to the patient/ family, dietary changes as restricted fluid, sodium and other self care behaviors; monitor symptoms, weight gain and improve patients self care regimen; Psychosocial support by creating a supporting relationship between nurse and patient	Usual care - managed with current clinical practice and received conventional followup with primary health care physician	A Wide
Thompson 2005 England	6 mo (nd)	58	48	73/72%	NYHA: III/ IV 76% LVEF%: mean 31%	A nurse led Clinic ( monthly for 6 mo) plus home based intervention. Patients seen by the study specialist nurses prior to discharge and received a home visit within 10 days of hospital discharge; received and educational packet, and a contact card	Usual care patients received standard care by explanation of their condition and prescribed meds by the ward nurse and referral to appropriate post-discharge support	C Mod
Wierzchowiecki 2006 Poland	12 mo (nd)	80	80	67/60%	NYHA: III/IV 84% LVEF%:<45% n=66 (82.5%)	At clinic: assessment by the cardiologist; nurse assessment for medication compliance; weight mgt; signs of CHF; telephone followup; home visits as needed; QOL and self care questionnaires; eucational - one to one education at patient's home or by telephone; physiotherapist's assistance for exercise rehabilitation programme; psychologist's assistance group and individual educational activities	Routine care: cared by primary care physicians only. Patient did not participate in any educational or therapeutic activities of the program	C Mod

 

Table B3: Interventions on recruited patients in OPD clinic

Study, Year Country	Followup Duration (Intervention y)	No. Analyzed		Mean /%	Severity of CHF	Intervention components	Control Description	Quality Applicability
		Int	Cont	Age Male
Bouvy 2003 Netherlands	6 mo (1998-2000)	74	78	69/72%	NYHA: III/IV: 57% LVEF%: nd	Community pharmacist-led intervention; Pharmacist gave a structured interview to patient on initial visit. Computerized medication history was used to discuss drug use, reasons for non-compliance to reinforce medication compliance. Pharmacist contacted subject monthly. + Usual care.	Patient received medication in a medicine- container with a microchip that recorded the time and date of opening	B Wide
Gattis 1999 USA	6 mo (1996-1997)	90	91	72/69%	NYHA III or IV: 33% LVEF%: 30%	Pharmacist led intervention and followup: medication evaluation; therapeutic recommendations; patient education on medication use and compliance; followup telemonitoring	Usual care: patient assessment and education provided by the attending physician and/or physician assistant or nurse practitioner	A Mod
GESICA 2005 Argentina	16 mo (2000-2001)	760	758	65/73%	NYHA III or IV: 50% LVEF<40%: 78.6	Recruited from outpatient centers: nurse led telephone followup program + Usual care: education, counseling, and monitoring; adherence to the diet; adherence to the drug treatment; monitoring of symptoms; control of daily weight and edema; daily physical activity	Usual care: followup with cardiologist	A Mod
Murray 2007 USA	12 mo (2001-2004)	122	192	62/39%	NYHA: III/IV: 39% LVEF mean%: 49	Pharmacist led intervention to improve medication adherence. Patients recruited from outpatient clinics; pharmacists received training from multidisciplinary team on treatment of heart failure, key concepts for pharmaceutical care of older adults, communication techniques	Usual care: patients received prescription services from pharmacists who had not received the specialized training and did not have patient centered study materials	C Mod
Sisk 2006 USA	12 mo (2000-2002)	203	203	60/55%	NYHA III or IV: 57.7% LVEF%: nd	Patients recruited during a scheduled clinic appnts; One nurse per patient: initial onetime appointment to educate patient about disease, counsel self management, referral to social services, review nurse's future role; Referral to social services if needed; Telephone followup; administering food frequency questionnaire; reinforce self management; Coordinate patient care with patient's clinician	Usual care - received federal consumer guidelines for managing systolic dysfunction	A Mod
Varma 1999 Northern Ireland	12 mo (nd)	42	41	76/51%	NYHA: nd LVEF%: nd	Patients were recruited from both inpatient admissions and outpatient clinic Results of a 2 minute walk test were recorded. Body weight, blood pressure pulse and forced vital capacity were measured. In clinic: Patients received education from a pharmacist on the disease and its treatment, and lifestyle changes that could help control symptoms. Patients instructed on self monitoring, maintaining daily weight in cards, instructed to take an extra dose of diuretic if needed Only physicians and community pharmacists were contacted to assess compliance.	Standard management that excluded all above mentioned interventions	C Mod