MedicalResearch: What are the main findings of the study?
Dr. Feltner: We conducted a systematic review and meta-analysis to assess the efficacy, comparative effectiveness, and harms of transitional care interventions to reduce readmission and mortality rates for adults hospitalized with heart failure. We included a broad range of intervention types applicable to adults transitioning from hospital to home that aimed to prevent readmissions. Although 30-day readmissions are the focus of quality measures, we also included readmissions measured over 3 to 6 months because these are common, costly, and potentially preventable. Forty-seven trials were included, most enrolled adults with moderate to severe heart failure and a mean age of 70 years. We found that interventions providing multiple home visits soon after hospital discharge can reduce 30-day readmission rates. Both home-visiting programs and multidisciplinary heart failure clinics visits can improve mortality and reduce all-cause readmission in the six months after hospitalization. Telephone support interventions do not appear to reduce all-cause readmission, but can improve survival and reduce readmission related to heart failure. Programs focused on telemonitoring or providing education only did not appear to reduce readmission or improve survival.
MedicalResearch: Were any of the findings unexpected?
Dr. Feltner: One unexpected finding is that we found relatively few trials that report a 30-day readmission rate. To reduce readmissions of Medicare patients, in October 2012, the Centers for Medicare & Medicaid Services began decreasing reimbursements to hospitals with excessive risk-standardized readmission. This policy incentivizes hospitals to develop programs to reduce readmission rates. Heart failure is the most common condition associated with hospital readmissions among Medicare recipients, interventions tailored to people with heart failure are likely to be a focus of programs to reduce readmissions. For these reasons, we expected more trials to report 30-day readmission rates; the majority of trials reported readmission rates over 3 to 6 months.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Feltner: Clinicians and healthcare systems should focus efforts to reduce readmissions on interventions that provide relatively frequent in-person monitoring after discharge—specifically, home-visiting programs and multidisciplinary heart failure clinic interventions. This may be a challenge since these programs are require more resources, however they have the best evidence for reducing unnecessary readmissions and improve survival for patients with heart failure. The evidence suggests that interventions providing telemonitoring or education only may not meet the goals of clinicians or patients in preventing unnecessary readmissions or improving survival following an hospitalization for heart failure.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Feltner: We identified many important gaps in the evidence that future research could address. For example, if 30-day readmission rates remain an important metric for policy, reimbursement, and quality, then future studies should evaluate whether interventions that show efficacy in reducing 3- and 6-month readmission rates (e.g., care in an MDS-HF clinic following discharge) are also effective in reducing 30-day readmission rates. We recommend that future studies evaluate the efficacy of transitional care interventions based in primary care clinics since many patients do not have access to specialty care (e.g., in rural settings) or may prefer to receive care following an heart failure admission in primary care clinics. Future research should also evaluate the effect of interventions on burdens placed on either patients themselves or their caregivers; these may be important considerations to patients, families and clinicians when choosing appropriate interventions to support the transition from hospital to home.
Ann Intern Med. 2014 Jun 3;160(11):774-84. doi: 10.7326/M14-0083.