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Am Fam Physician. 2016;94(2):168a-169

Clinical Question

Does a care transition intervention using telephone coaching and telemonitoring reduce readmissions for patients with heart failure?

Bottom Line

A care transition intervention that incorporates remote monitoring of weight, blood pressure, and heart rate with scheduled telephone coaching did not reduce readmission rates at 30 days or 180 days for patients with heart failure. However, patients in the study were only modestly adherent to the intervention strategies. (Level of Evidence = 1b)


Hospitalized patients 50 years and older who were being actively treated for heart failure with expected discharge to home were randomized, using concealed allocation, to receive the care transition intervention (n = 715) or usual care (n = 722). The intervention consisted of the following: (1) predischarge heart failure education using teach-back methods, (2) postdischarge scheduled telephone coaching calls weekly for one month, then monthly for five months, and (3) home telemonitoring using a Bluetooth-enabled weight scale and blood pressure/heart rate monitor with texting ability. All interventions were conducted by registered nurses. Usual care included predischarge education and one postdischarge telephone call. There were no significant differences at baseline in the two groups. The median age was 73 years, and most of the participants were in New York Heart Association class III or IV. In the intervention group, adherence to the intervention strategies was modest; only 61% and 55% were adherent to telephone calls and telemonitoring, respectively, at 30 days. For the primary outcome of all-cause readmission at 180 days, there was no significant difference detected, with a high readmission rate in both groups of approximately 50%. Mortality was also similar at 180 days. Quality-of-life scores were improved in the intervention group at the end of the study; however, this likely reflects differences in survey respondents vs. nonrespondents.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Reference: OngMKRomanoPSEdgingtonSet alEffectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the Better Effectiveness After Transition-Heart Failure (BEAT-HF) randomized clinical trial. JAMA Intern Med2016;176(3):310–318.

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