Determining the Necessary Care to Prevent Readmission for Heart Failure

In the United States, heart failure is a leading cause of hospitalization, as 25% of patients hospitalized for heart failure are readmitted within 30 days. A recent systematic review was conducted for the Effective Health Care Program of the Agency for Healthcare Research and Quality to assess the efficacy, comparative effectiveness, and harms of transitional care interventions intended to reduce readmission and mortality rates for adults hospitalized with heart failure [Ann Intern Med. 2014; DOI:10.7326/M14-0083.].

The review included English-language and human-only randomized, controlled trials published from July 2007 to late October 2013, obtained through searches of MEDLINE, the Cochrane Library, CINAHL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform.

Only studies including adults recruited during or within 1 week of an index hospitalization for heart failure that compared a transitional care intervention with another eligible intervention or with usual care were used for the review (See Table below). Additionally, interventions required 1 of the following components: (1) education of patient or caregiver delivered before or after discharge; (2) planned or scheduled outpatient clinic visits; (3) home visits; (4) telemonitoring; (5) structured telephone support (STS); (6) transition coach or case management; or (7) interventions to increase provider continuity. Studies also had to report a readmission rate, mortality rate, or the composite outcome.

A total of 47 randomized, controlled trials were included in the review. Most trials included adults with a mean age of 70 years who were hospitalized with a primary diagnosis of heart failure and compared a transitional care intervention with usual care. Trials were conducted in a range of settings, including academic medical centers, Veterans Affairs hospitals, and community hospitals. To determine readmission and mortality rates, the researchers calculated risk ratios. Analyses were stratified for each intervention category by outcome timing and separated rates reported at 30 days from those after 30 days. The number needed to treat for readmission and mortality outcomes was also assessed.

The study’s authors concluded that high-intensity home-visiting programs reduced all-cause readmissions, with a number needed to treat of 6. Both home-visit programs and multidisciplinary heart failure clinic interventions reduced all-cause readmissions over 3 to 6 months, with a number needed to treat of 7 to 9. However, the STS and telemonitoring interventions were not effective in reducing the risk for all-cause readmission. Similarly, nurse-led clinic interventions were not effective in reducing the risk for all-cause readmission.

Potential limitations of the review included publication bias and selective reporting. The trials may have had any 1 of the following: methodological limitations introducing some risk of bias, limited explanation of methods used for assessing readmissions, and methods for handling missing data varied. Additional limitations existed in the heterogeneity of outcome measures across trials. The authors also noted that few trials reported 30-day readmission rates and suggested future studies should evaluate whether interventions that reduce readmission rates over 3 to 6 months also reduce 30-day readmission rates.

According to the authors, based on the results of the review, home-visiting programs, multidisciplinary-heart failure, and STS interventions should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for persons with heart failure.