Agency for Healthcare Research and Quality just came out with draft report on interventions to prevent readmissions for people with heart failure, with a systematic review of the literature through May 2013 (see http://www.effectivehealthcare.ahrq.gov/ehc/products/510/1738/Heart-Failure-Transition-Care-Draft-131029.pdf for document). this review included 47 randomized controlled trials, most with patients with moderate to severe heart failure, with mean age in the 70s. the individual reports in the literature have highly mixed results, so this review is a welcome review. the background is that heart failure is a leading cause of hospitalization and has a significant mortality with approximately 50% dying within 5 years of diagnosis (30% of Medicare beneficiaries with heart failure die within one year after hospitalization), and up to 25% of patients hospitalized with heart failure are readmitted within 30 days. this systematic review assesses several key questions including what the effect of post-hospital interventions have regarding healthcare utilization rates (eg readmission rates, acute care visits), clinical outcomes (eg mortality rates, functional status, quality of life), which components of these interventions were effective, and does the intensity or manner of providing these interventions matter. Their results:
–high-intensity home visiting programs reduced all-cause readmission rates and the combined endpoint of all-cause readmission or death at 30 days (though the strength of the evidence was felt to be low for 30 day readmission rates, noting that very few studies have really looked at them). Home visiting reduced all-cause readmission rates at 3 and 6 months.
–Structured telephone support interventions (eg series of structured calls with specific goals, questioning, or using decisions for software) reduced heart failure specific readmission rates at 3 and 6 months as well as mortality at 6 months.
–multidisciplinary heart failure clinic interventions reduced all-cause readmission rates and mortality at 6 months.
–the number needed to treat to prevent 1 all-cause readmission ranged from 5-12 for home visiting programs over 1-6 month. The number needed to treat for the multidisciplinary heart failure clinic intervention was 7 for 3-6 months.
–Current evidence does not support the efficacy of telemonitoring or primarily educational interventions
–Components of the intervention showing efficacy for reducing all-cause readmissions or mortality include: Heart failure education, emphasizing self-care; pharmacotherapy, emphasizing promotion of adherence and use of evidence-based pharmacotherapy; and streamlined mechanisms to contact health care personnel (eg, patient hot-line). in general they found that interventions that reduced all-cause readmission or mortality are more likely to be of higher intensity, delivered in a face-to-face manner, and provided by a multidisciplinary team. these interventions specifically targeted self-care, recognition of symptoms, and weight monitoring; promotion of adherence to medications; direct contact with the patient within 7 days of discharge; and streamlined approach to being able to contact medical personnel.
–not enough data on the comparative effectiveness of individual interventions. there are also very few trials that assessed 30 day all-cause readmission outcomes. There also was not enough data to see if primary care clinic based interventions were helpful.
so, pretty useful. not enough community-based intervention data. my guess (strongly supported by my own experience at the health center) is that an integrated program which includes easy patient access to a nurse (including being able to send a nurse practitioner to the house to see the patient right away, or even an ambulance ride to bring the patient to the health center), easy access to the primary care provider, an integrated home-care program without significant limitations or obstacles to services, and social programs when appropriate (eg senior home care) dramatically decrease ER visits and subsequent admissions. there are many such programs in boston, including the PACE (program for all-inclusive care for the elderly) and SCO programs (senior care options) available through many health centers in the US.
geoff