Clinical question
Which transitional care interventions are most effective in preventing readmissions in patients hospitalized with heart failure?
Bottom line
Moderate-to-high strength of evidence supports the use of home-visiting programs and outpatient multidisciplinary heart failure (MDS-HF) clinics to reduce readmission rates and mortality for hospitalized HF patients at 3 months to 6 months. Structured telephone support may also decrease mortality and HF-specific readmissions, but does not affect all-cause readmissions.(LOE = 1a)
Reference
Study design
Meta-analysis (randomized controlled trials)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
These authors searched multiple databases, including MEDLINE and the Cochrane Library, as well as reference lists of pertinent articles to find randomized controlled trials that compared transitional care interventions with either other interventions or usual care for patients hospitalized with HF with a focus on readmission rates and mortality. The interventions had to include at least one of the following components: patient/caregiver education, scheduled outpatient clinic visits, home visits, telemonitoring, structured telephone support, transition coaching, or increased provider continuity. Two authors independently reviewed the 47 selected studies for risk of bias. Studies with high or unclear risk of bias were not included in the meta-analysis. Results for readmission rates and mortality were stratified by intervention category and strength of evidence (SOE) grades were provided. For 30-day outcomes, a high-intensity home-visiting program consisting of 8 scheduled home visits starting at 24 hours after discharge decreased all-cause readmissions (number needed to treat [NNT] = 6) but the SOE was low. For 3-month to 6-month outcomes, data from 9 trials of home-visiting programs with varying intensities showed a reduction in all-cause readmissions (NNT= 9; SOE = high). Similarly, data from 2 trials of scheduled outpatient visits with MDS-HF clinics revealed lower readmission rates (NNT= 8; SOE = high). For HF-specific readmissions, 2 interventions, home-visiting programs and structured telephone support, decreased rates at 3 months to 6 months (home visits: NNT = 7; SOE = moderate; structured telephone support: NNT = 14; SOE = high). Finally, several interventions reduced mortality as compared to usual care at 3 to 6 months with moderate SOE, including home-visiting programs (NNT = 33), MDS-HF clinics (NNT = 18), and structured telephone support (NNT = 27). There were no significant benefits noted with scheduled visits to nurse-led clinics or primary care clinics or with educational interventions, although in most cases, there was insufficient evidence to determine whether these intervention were effective.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.