Home-visiting programs, multidisciplinary heart failure clinics, and structured telephone support interventions "should receive the greatest consideration by systems or providers seeking to implement transitional care interventions" for people hospitalized for heart failure, according to a report issued May 27 by the Agency for Healthcare Research and Quality Effective Health Care Program.
But for these interventions to be effective, "you need a very mature infrastructure – communication infrastructure, information technology infrastructure, and systems-level infrastructure," Dr. Hiren Shah, medical director of the cardiac telemetry unit at Northwestern Memorial Hospital, Chicago, said in an interview about the implications of the report. "A lot of people point to cost and the fact that these interventions are expensive. But even if you have the ability to invest in these interventions, do you have the infrastructure that’s necessary to implement them?"
Dr. Hiren Shah
Further, the report lacks details on the cost-effectiveness of these interventions, a vital bit of information for hospitals looking to potentially implement them, Dr. Shah said. "It’s very important that not only do we know what may potentially work as an intervention, but we need to know whether that intervention or those interventions are cost effective. Within the scientific literature, we have very little information on the cost effectiveness of interventions."
The report’s conclusions are based on a systematic review and meta-analysis of the efficacy, comparative effectiveness, and harms of transitional care interventions aimed at reducing hospital readmissions and mortality for adults hospitalized with heart failure. The researchers, led by Dr. Cynthia Feltner of Duke University Medical Center in Durham, N.C., drew from 53 published articles on 47 randomized, controlled trials. Most studies compared a transitional care intervention with usual care, though the report notes that usual care was not consistently or well described.
In general, the trials included patients around age 70 years with moderate to severe heart failure. Most patients were prescribed an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker; the percentage of patients prescribed a beta-blocker varied widely across the study populations. Trial settings included academic medical centers, Veteran Affairs hospitals, and community hospitals.
Few trials reported 30-day readmission rates, as most measured outcomes over 3-6 months. Home-visiting programs and multidisciplinary heart failure clinic interventions reduced all-cause readmissions and mortality; structured telephone support reduced heart failure–specific readmissions and mortality.
Successful programs and interventions included heart failure education that emphasized self-care and recognition of symptoms and weight monitoring; patient education about medications and adherence to regimens as well as evidence-based therapies before and after discharge; face-to-face contact with visiting or clinic personnel within a week following discharge; streamlined mechanisms for contacting care delivery personnel outside of scheduled visits; and mechanisms for postdischarge medication adjustment.
"Separating out individual components from the overall categories [or "bundles"] of interventions that showed efficacy was not possible," the report notes.
None of the investigators have affiliations or financial involvements that constitute a conflict of interest with the material presented in the report.