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Transitional Care Interventions To Prevent Readmissions for People With Heart Failure

Policymaker Summary
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Key Issue

Readmissions for people with heart failure (HF) are common, costly, and potentially preventable. Targeting preventable HF readmissions is a potential strategy for reducing overall health care costs from both societal and payer perspectives. This is a summary of a systematic review evaluating the evidence regarding the efficacy, comparative effectiveness, and harms of transitional care interventions (defined in Table 1) that aim to reduce readmissions and mortality for adults hospitalized with HF. The systematic review included 47 studies published from 1990 to October 29, 2013.


Heart failure (HF) is a major clinical and public health problem and a leading cause of hospitalization and health care costs in the United States. Despite a decline in HF-related hospitalizations during the past decade, readmission rates for patients with HF have not decreased. Up to 25 percent of patients hospitalized with HF are readmitted within 30 days.

A preventable readmission is defined as one occurring within 30 days of discharge and is clinically related to the previous admission if there was a reasonable expectation that it could have been prevented by providing quality care in the initial hospitalization, adequate discharge planning, adequate postdischarge followup, or improved coordination between inpatient and outpatient health care teams. Beginning in 2012, the Centers for Medicare & Medicaid Services implemented the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess readmissions for HF.

The rate of preventable readmissions may be reduced by transitional care interventions, which are defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer from the inpatient setting to alternative care (see Table 1). Some transitional care interventions may be used in combination with each other.

The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for the Management of Heart Failure focuses on the importance of optimizing HF pharmacotherapy and providing HF education before discharge and recommends a followup visit within 7 to 14 days of discharge. This guideline also recommends initiating multidisciplinary-HF disease-management programs for patients at high risk for readmission. This systematic review adds to our understanding about components of transitional care interventions that improve outcomes in patients with HF.

Summary of Evidence from the Systematic Review

Within 30 days after discharge

Evaluating 30-day readmission rates is important to hospitals, patients, payers, and quality improvement organizations. However, few studies have evaluated 30-day readmission rates. Limited evidence suggests that home- visiting programs may reduce all-cause readmissions.

At 3 to 6 months after discharge (see Table 2)

  • Home-visiting programs improved all outcomes: all-cause readmissions, HF- specific readmissions, the composite endpoint (which comprises all-cause readmission or death), and mortality.
  • Multidisciplinary-HF clinic-based interventions reduced all-cause readmissions and mortality but not the composite endpoint.
  • Structured telephone support reduced HF-specific readmissions and mortality but not all-cause readmissions or the composite endpoint.
  • Multicomponent interventions such as home-visiting programs and multidisciplinary- HF clinic interventions were effective in reducing all-cause readmissions and mortality.
    • The key components of these interventions included HF education emphasizing self-care, HF pharmacotherapy emphasizing adherence, face-to-face contact after hospital discharge, mechanisms for postdischarge medication adjustment, and streamlined mechanisms to contact care delivery personnel.
    • These interventions were of higher intensity and were delivered by teams of providers.

Considerations for Programs and Policies

  • The findings of this review might be informative for health care systems and insurance carriers (including Medicare Advantage plans and Medicare supplemental plans) seeking to implement programs to improve transitional care interventions for patients with HF.
    • Health care systems may wish to start with multicomponent interventions, as these interventions are effective on all-cause readmissions and mortality.
  • Organizations that work with patients who have HF may consider informing these patients of the availability and benefits of transitional care interventions to prevent hospital readmissions.
  • Readmission rates vary by both geographic location and insurance coverage. Having a better understanding of the role of these and other patient factors in postdischarge outcomes may aid health care systems in selecting specific transitional care interventions.

These considerations were not evaluated in the systematic review but are offered to assist policymakers in applying this evidence.

Table 1: Categories and Definitions of Transitional Care Interventions
Category Definition
CD-ROM = compact disc read-only memory; HF = heart failure
Home-visiting programs Home visits by clinicians, such as nurses or physician assistants, who deliver education, reinforce self-care instructions, perform a physical examination, or provide other care (e.g., physical therapy, medication reconciliation).
Structured telephone support Patient followup, education, or self-care management (or combinations thereof) after discharge using telephone technology in a structured format (e.g., scheduled telephone calls with structured questions).
Telemonitoring Remote monitoring of physiological data (e.g., electrical activity of the heart, blood pressure, weight, pulse, respiratory rate) with digital, broadband, satellite, wireless, or Bluetooth® transmission to a monitoring center with or without remote clinical visits (e.g., video monitoring).
Outpatient clinic-based interventions Services provided in an outpatient clinic such as a multidisciplinary-HF clinic, a nurse-led HF clinic, or a primary care clinic. Multidisciplinary-HF clinics involve access to a multidisciplinary care team (cardiologists, nurses, advanced practice nurses, dieticians, and pharmacists). Nurse-led clinics are managed by a nurse and may also offer unstructured telephone support (e.g., a patient hotline) outside clinic hours.
Primarily educational interventions Patient education (and self-care training) delivered before or upon hospital discharge by various personnel or modes of delivery (in-person, interactive CD-ROM, or video education) but without home visiting.
Other Unique interventions or interventions that did not fit into any of the other categories (e.g., individual peer support for patients with HF or cognitive training for patients with HF and cognitive dysfunction).
Table 2: Summary of Key Findings and Strength of Evidence for Transitional Care Interventions Versus Usual Care for HF
Intervention Outcome at 3-6 Months N Studies N Subjects Finding NNT* SOE
HF = heart failure; N = number; NA = not available; NNT = number needed to treat to prevent readmission; SOE = strength of evidence; − = data are insufficient
* An NA entry for NNT indicates that the relative risk (95% confidence interval) was not statistically significant and that an NNT was not calculated.
** The composite endpoint comprises all-cause readmission or death.
Home-visiting programs All-cause readmission 9 1,563 Reduced 9 [evidence high]
HF-specific readmission 1 282 Reduced 7 [evidence medium]
Composite endpoint** 4 824 Reduced 10 [evidence medium]
Mortality 8 1,693 Reduced 33 [evidence medium]
Number of hospital days at readmission 3 403 Reduced NA [evidence low]
Structured telephone support All-cause readmission 8 2,166 No benefit NA [evidence medium]
HF-specific readmission 7 1,790 Reduced 14 [evidence high]
Composite endpoint 3 977 No benefit NA [evidence low]
Mortality 7 2,011 Reduced 27 [evidence medium]
Number of hospital days at readmission 5 1,189 Reduced NA [evidence medium]
Telemonitoring All-cause readmission 3 434 No benefit NA [evidence medium]
HF-specific readmission 1 182 No benefit NA [evidence medium]
Mortality 3 564 No benefit NA [evidence low]
Multidisciplinary-HF clinic All-cause readmission 2 336 Reduced 8 [evidence high]
HF-specific readmission 1 106 NA [evidence insufficient]
Composite endpoint 2 306 No benefit NA [evidence medium]
Mortality 3 536 Reduced 18 [evidence medium]
Nurse-led HF clinic All-cause readmission 2 264 No benefit NA [evidence low]
HF-specific readmission 1 158 NA [evidence insufficient]
Composite endpoint 1 106 NA [evidence insufficient]
Mortality 2 264 No benefit NA [evidence low]
Primarily educational interventions All-cause readmission 1 200 NA [evidence insufficient]
HF-specific readmission 1 223 NA [evidence insufficient]
Composite endpoint 2 423 No benefit NA [evidence low]
Mortality 2 423 No benefit NA [evidence low]

Strength of Evidence Scale

High: [evidence high]
High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.

Moderate: [evidence medium]
Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.

Low: [evidence low]
Low confidence that the evidence reflects the true effect. Further research is likely to change our confidence in the estimate of effect and is likely to change the estimate.

Insufficient:[evidence insufficient]
Evidence is either unavailable or does not permit a conclusion.


The information in this summary is based on Feltner C, Jones CD, Cené CW, Zheng Z-J, Sueta CA, Coker-Schwimmer EJL, Arvanitis M, Lohr KN, Middleton JC, Jonas DE. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure. Comparative Effectiveness Review No. 133. (Prepared by the RTI–University of North Carolina Evidence-based Practice Center under Contract No. 290-2012-00008-I). AHRQ Publication No. 14-EHC021-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2014.

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Geetha Achanta, Ph.D., Winifred W. Yu, Ph.D., R.D., Biykem Bozkurt, M.D., Trudy Millard Krause, Dr.P.H., CPHQ, and Michael Fordis, M.D.