Implementing AHRQ Effective Health Care Reviews
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Transitional Care Interventions to Prevent Readmissions for Patients with Heart Failure
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Am Fam Physician. 2016 Mar 1;93(5):401-403A.
Author disclosure: No relevant financial affiliations.
Key Clinical Issue
What are the benefits and adverse effects of transitional care interventions that aim to reduce readmission and mortality in adult patients hospitalized for heart failure?
Home visiting programs and multidisciplinary clinic interventions for adult patients with heart failure reduced all-cause readmissions and mortality over three to six months. (Strength of recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Structured telephone support reduced heart failure–specific readmissions and mortality over three to six months. (SOR: A, based on consistent, good-quality patient-oriented evidence.) However, structured telephone support did not reduce all-cause readmissions over a similar period. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)
Multicomponent interventions such as home visiting programs and multidisciplinary clinic interventions for heart failure reduced all-cause readmissions and mortality over three to six months. Key components of these interventions included heart failure education emphasizing self-care, heart failure pharmacotherapy emphasizing adherence, face-to-face contact after hospital discharge, mechanisms for postdischarge medication adjustment, and streamlined mechanisms to contact care delivery personnel (e.g., a patient hotline). These higher-intensity interventions were delivered by teams of clinicians.
Clinical Bottom Line: Summary of Key Findings for Transitional Care Interventions vs. Usual Care for Heart Failure
Home visiting programs
Decreased all-cause readmission: RR = 0.75 (95% CI, 0.68 to 0.86), NNT = 9 ● ● ●
Decreased heart failure–specific readmission: RR = 0.51 (95% CI, 0.31 to 0.82), NNT = 7 ● ● ○
Improved composite endpoint: RR = 0.78 (95% CI, 0.65 to 0.94), NNT = 10 ● ● ○
Reduced mortality: RR = 0.77 (95% CI, 0.60 to 0.997), NNT = 33 ● ● ○
Reduced number of hospital days at readmissions: WMD = −1.17 (95% CI, −2.44 to 0.09) ● ○ ○
Structured telephone support
No significant difference in all-cause readmission: RR = 0.92 (95% CI, 0.77 to 1.10) ● ● ○
Decreased heart failure–specific readmission: RR = 0.74 (95% CI, 0.61 to 0.90), NNT = 14 ● ● ●
No significant difference in composite endpoint: RR = 0.81 (95% CI, 0.58 to 1.12) ● ○ ○
Reduced mortality: RR = 0.74 (95% CI, 0.56 to 0.97), NNT = 27 ● ● ○
Reduced number of hospital days at readmissions: WMD = −0.95 (95% CI, −2.43 to 0.53) ● ● ○
Multidisciplinary heart failure clinics
Decreased all-cause readmission: RR = 0.70 (95% CI, 0.55 to 0.89), NNT = 8 ● ● ●
Insufficient evidence of the effect on heart failure–specific readmission ○ ○ ○
No significant difference in composite endpoint: RR = 0.80 (95% CI, 0.43 to 1.01) ● ● ○
Reduced mortality: RR = 0.56 (95% CI, 0.34 to 0.92), NNT = 18 ● ● ○
No significant difference in all-cause readmission: RR = 1.11 (95% CI, 0.87 to 1.42) ● ● ○
No significant difference in heart failure–specific readmission: RR = 1.70 (95% CI, 0.82 to 3.51) ● ● ○
No significant difference in mortality: RR = 0.93 (95% CI, 0.25 to 3.48) ● ○ ○
Nurse-led heart failure clinics
No significant difference in all-cause readmission: RR = 0.88 (95% CI, 0.57 to 1.37) ● ○ ○
Insufficient evidence of an effect on heart failure–specific readmission or composite endpoint
No significant difference in mortality: RR = 0.59 (95% CI, 0.12 to 3.03) ● ○ ○
Primarily educational interventions
Insufficient evidence of an effect on all-cause readmission or heart failure–specific readmission
No significant difference in composite endpoint: RR = 0.92 (95% CI, 0.58 to 1.47) ● ○ ○
No significant difference in mortality: RR = 1.20 (95% CI, 0.52 to 2.76) ● ○ ○
note: Outcomes measured at three to six months. The composite endpoint comprises all-cause readmission or death.
CI = confidence interval; NNT = number needed to treat; RR = relative risk; WMD = weighted mean difference.
Strength of evidence scale
High: ● ● ● There are consistent results from good-quality studies. Further research is very unlikely to change the conclusions.
Moderate: ● ● ○ Findings are supported, but further research could change the conclusions.
Low: ● ○ ○ There are very few studies, or existing studies are flawed.
Insufficient: ○ ○ ○Research is either unavailable or does not permit estimation of a treatment effect.
Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Transitional care interventions to prevent readmissions for people with heart failure. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; May 2014. http://www.effectivehealthcare.ahrq.gov/ehc/products/510/2134/heart-failure-transition-care-clinician-151013.pdf. Accessed December 15, 2015
REFERENCESshow all references
1. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355–363....
2. Centers for Medicare & Medicaid Services Readmissions reduction program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed October 22, 2015.
3. Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent readmissions for people with heart failure. Comparative Effectiveness Review No. 133. Rockville, Md.: Agency for Healthcare Research and Quality; May 2014.
4. Vedel I, Khanassov V. Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. Ann Fam Med. 2015;13(6):562–571.
5. Albert NM, Barnason S, Deswal A, et al.; American Heart Association Complex Cardiovascular Patient and Family Care Committee of the Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Transitions of care in heart failure: a scientific statement from the American Heart Association. Circ Heart Fail. 2015;8(2):384–409.
The Agency for Health-care Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to organize knowledge and make it available to inform decisions about health care. A key clinical question based on the AHRQ Effective Health Care Program review is presented, followed by an evidence-based answer and an interpretation that will help guide clinicians in making treatment decisions. For the full review, clinician summary, consumer summary, and CME activity, go to http://www.effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviews-and-reports/?pageAction=displayProduct&productID=2134.
This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.
A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at http://www.aafp.org/afp/ahrq.
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