Stopping Heart Failure Readmissions: What Works?

Heart failure (HF) is a leading cause of hospitalization and healthcare costs in the United States. According to 2005 data from the Centers for Medicare & Medicaid Services, it is the most common principal discharge diagnosis among Medicare beneficiaries and the third-highest for hospital reimbursements.¹ Nationally, as many as a quarter of patients hospitalized with HF are readmitted within 30 days.

Transitional Care Interventions to Prevent Readmissions for People With Heart Failure,² a report published in May by the Agency for Healthcare Research and Quality (AHRQ, a division of the Department of Health and Human Services), endeavors to identify the most effective interventions to reduce readmission rates and improve patient care for this population. 

Overall, higher-intensity interventions that include teams of providers appear more effective in reducing all-cause readmissions and mortality than lower-intensity interventions, such as multidisciplinary HF clinic interventions. “We found that the types of programs that most successfully prevent readmission involve visits to the [patient’s] home shortly after discharge, typically by a nurse,” says lead author Cynthia Feltner, MD, MPH.

Feltner, lead investigator at the Research Triangle Institute–University of North Carolina Evidence-Based Practice Center, which prepared the report, is also a physician who treats HF patients. She and her colleagues began their review with background reading and key informant interviews to determine what practices were considered standard of care. The American Heart Association/American College of Cardiology (AHA/ACC) guidelines address post-discharge heart failure interventions,³ focusing on the importance of optimizing HF pharmacotherapy and providing HF education before discharge (including education on self-care) and addressing barriers to care.

Reasonable post-discharge care options include a follow-up visit within 7–14 days of discharge, a telephone follow-up within three days, or both. The AHA/ACC guidelines also recommend initiating multidisciplinary HF disease management programs for patients at high risk for readmission. The 2010 Heart Failure Society of America guidelines are similar. While their guidance emphasizes particular components of discharge planning,^4,5 it offers no specifics on the optimal components of transitional care interventions aimed at preventing readmissions for patients with HF.

Research Objectives and Process

The goal of the report was to conduct a systematic review and meta-analysis of the efficacy, comparative effectiveness and harms of transitional care interventions already in place to reduce readmissions and mortality for adults hospitalized with HF. The investigators also sought to describe the components of interventions that showed efficacy. 

“We realized there hadn’t been a recent review addressing this question for patients with HF,” Feltner says. “The question was, is there an answer already available?”

The team found that, although there is an increasing awareness of the issue, there is no one solution. In fact, a telephone survey of 100 U.S. hospitals found wide variation in education, discharge processes, care transition and quality improvement methods for patients hospitalized with HF.⁶

To determine which types of interventions work best, the investigators began with independently selected randomized, controlled trials conducted from January 1, 1990 through early May 2013. Of the 47 trials reviewed, they found the majority included patients with moderate to severe HF. The mean ages of patients were in the 70s. Most trials reported rates for a period of 3–6 months. Since few trials reported results at a 30-day mark, that information was unavailable. Feltner believes that, as the focus has shifted to 30-day readmissions, future trials will examine that time frame more thoroughly.

To determine the efficacy of specific interventions, each was categorized based on similar features; these categories included home-visiting programs; outpatient clinic-based interventions; structured telephone support; telemonitoring; and primarily educational interventions (see Table 1).

Results

The review found that home-visiting programs involving more than one visit, typically by a nurse, were effective in preventing 30-day all-cause readmissions among patients suffering from HF. Programs that involved telemonitoring or more technologically based approaches were not effective for this outcome.

For outcomes measured over 3–6 months, home-visiting programs reduced all-cause and HF-specific readmissions. Multidisciplinary clinic interventions reduced all-cause readmissions. Structured telephone support interventions reduced HF-specific readmissions but not all-cause readmissions. All three interventions were found to reduce morbidity. Neither telemonitoring nor clinic interventions reduced readmissions or mortality beyond the standard rates.
“The home-visiting programs that worked generally included nurses who had a fair bit of training around heart failure,” Feltner says. Although some used other healthcare providers—such as a pharmacist with particular training in HF—other healthcare workers, such as paramedics paired with a social worker, may also be effective, she says. 

Outpatient clinics were effective if they included a partnership with people of diverse clinical backgrounds. “It is important to make sure people’s needs are met; this is one reason why in-person interventions may be more effective than those that rely on technology,” Feltner says. Identifying and meeting the special needs of a community, such as cultural traditions and socioeconomic requirements, can affect the success of an intervention.

She says she wasn’t surprised to learn that, in practice, telemonitoring programs are frequently offered by insurers or other stakeholders aiming to reduce readmission rates. “They are less expensive,” she says. What did surprise Feltner was that these programs were no more effective in reducing readmissions than the usual care. “There are more and more telemonitoring programs [being implemented], yet there is no literature showing that these programs reduce readmission rates for people with HF,” she notes.

Interpretation of the Results

Feltner warns that because of the way the review was structured, her team was not able to dig too deeply into why some of the programs worked and some did not. She says there are a number of possible variables, including understanding the particular needs of the elderly. Many in this patient population require a personal connection. It could be that in-home visits provided a better assessment tool for both physical and mental health. Visiting the home may help to determine whether social needs are being met and give visiting practitioners the ability to note social issues that could affect readmission, such as whether the patient needed help in preparing meals or organizing medications.

Differences in trial methodology could account for some of the outcomes, especially in the telemonitoring category. “The trials that used telemonitoring tended to focus very narrowly on heart failure symptoms alone, where, perhaps, the others addressed a more comprehensive list of components,” she says. She suggests that future research could further delve into the context to understand if a component of face-to-face interaction would help further understand the role of technology in preventing readmissions. 

The investigators noted certain limitations to the data. To conduct the review in a timely manner and focus on literature considered less biased, they only chose randomized trials to review, and there always had to be a comparison group. That limited the number of trials reviewed and the conclusions drawn.

“There is not enough literature to determine if an intervention worked better in a rural versus an urban setting or for particular patient populations based on demographics or other issues,” Feltner says. Barriers such as transportation difficulties or whether a patient lives alone should be studied in future trials. 

References

1. Centers for Medicare & Medicaid Services, Office of Information Services. Medicare Ranking for All Short-Stay Hospitals by Discharges. Fiscal Year 2005 Versus 2004, www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SSDischarges0405.pdf.
2. Feltner C, Jones CD, Cené CW, et. al. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure. Rockville, MD: Agency for Healthcare Research and Quality, www.effectivehealthcare.ahrq.gov/reports/final.cfm.
3. 2009 Writing Group to Review New Evidence and Update the 2005 Guideline for the Management of Patients With Chronic Heart Failure Writing on Behalf of the 2005 Heart Failure Writing Committee; Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 2009 Apr 14; 119(14): 1,977–2,016.
4. Lindenfeld J, Albert NM, Boehmer JP, et al. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail, 2010 Jun; 16(6): 475–539.
5. Heart Failure Society of America. Executive Summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail, 2006 Feb; 12(1): 10–38.
6. Kociol RD, Peterson ED, Hammill BG, et al. National survey of hospital strategies to reduce heart failure readmissions: findings from the Get With the Guidelines-Heart Failure registry. Circ Heart Fail, 2012 Nov 1; 5(6): 680–7.