Transitional care for heart failure doesn’t dent 30-day readmissions

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Use of home visits and multidisciplinary clinics helped to reduce all-cause readmissions and death up to six months after an index hospitalization for patients with heart failure, while telephone-based interventions also showed some success, according to a review of transitional care trials. But none seemed to lower 30-day readmission rates.

About one in four heart failure patients in the U.S. is readmitted within 30 days of discharge. In response to the numbers of Medicare patients being readmitted for heart failure, the Centers for Medicare & Medicaid Services began to incentivize programs to reduce rehospitalization rates in October 2012. Hospitals with excessive risk-standardized readmission saw decreasing reimbursements, driving a need to improve outpatient care options post-visit. This has spurred a number of studies looking at transitional care interventions, but their effectiveness was unknown.

In a study published May 27 in Annals of Internal Medicine, Cynthia Feltner, MD, MPH, and colleagues from the University of North Carolina at Chapel Hill explored 47 trials on transitional care interventions for heart failure patients and their outcomes published between January 1990 and October 2013.

The types of interventions they reviewed encompassed home-visitation, structured telephone support, telemonitoring, outpatient clinic-based and primarily educational, although there were a few that did not fit into these categories. Interventions were assessed based on their time points (30 days, three to six months) and reviewed for endpoints (mortality, all-cause vs. heart failure readmission, all-cause endpoint). They then graded for strength of evidence based on risk of bias, consistency, directness and precision.

While few of the trials they reviewed reported 30-day readmission rates, of those that did, it appeared the ones that had the highest impact on all-cause readmission and mortality in that period were home visitation programs (two trials). Of the four other trials that reported 30-day all-cause readmission—a structured phone support trial, two telemonitoring trials and one cognitive training trial—none reduced 30-day readmission rates.

At the three-to-six-month time period, however, structured phone support did more for heart failure-specific readmissions and multidisciplinary heart failure clinics saw benefits on all-cause readmission. Feltner et al wrote, “These interventions [home visitation, structured phone support, and multidisciplinary heart failure clinics] should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for persons with HF [heart failure].”

Feltner and colleagues suggested that future studies consider “whether interventions that reduce readmission rates over three to six months also reduce 30-day readmission rates and could directly compare one intervention with another (for example, home-visiting program vs. multidisciplinary clinic).” With many patients unable to access specialty care, they also recommended more reviews of efficacy of transitional care interventions in primary care clinics.