What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Congestive Heart Failure (n=10863). Intervention: Transitional care interventions (TCIs) vs. Usual care. Primary outcome: All-cause hospital readmission (RR 0.92, 95% CI 0.87-0.98, p=0.006).

November 1, 2015Open Access

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Key Result

Transitional care interventions significantly reduced the risk of all-cause hospital readmissions by 8% (RR 0.92) and emergency department visits by 29% (RR 0.71) compared to usual care in patients with congestive heart failure.

Study Design

Type

Meta-Analysis (n=10,863)

Blinding

Not possible

Randomization

Randomized

Structured PICO

Do transitional care interventions reduce all-cause hospital readmissions and emergency department visits in patients with congestive heart failure discharged to home?

Population

Patients with congestive heart failure (CHF) discharged from inpatient departments to home. Pooled from 41 RCTs. Mean age ranged from 57.9 to 81.0 years, 65.6% men. Multinational (Americas, Europe, Oceania, Asia).

Intervention

Transitional care interventions (TCIs) of varying intensities (low, moderate, high) including predischarge education, discharge plan, and structured follow-up (home visits, telephone, clinic, or telecare) for 1 to 24 months.

Comparator

Usual care consisting of predischarge education on CHF self-management and usual follow-up with the family physician or cardiologist as required.

Outcome

All-cause hospital readmissions and all-cause emergency department (ED) visits at last provided follow-up time.hard clinical

High-intensity transitional care interventions significantly reduce hospital readmissions and emergency department visits for patients with congestive heart failure recently discharged to home.

Main Result

Effect estimate: RR 0.92 (95% CI 0.87-0.98)

Absolute Event Rate: 45.9% vs 47.8%

p-value: p=0.006

Limitations

Not able to include articles in languages other than English and French
Not all studies systematically reported the number of contacts to allow for an objective measure of intensity
Patient characteristics, including diagnosis, comorbidities, and severity of CHF, were missing in some studies
Lack of published studies on 'oldest-old' patients (those aged 85 years and older)
Could not adjust the meta-analyses for mean age of patients or follow-up duration due to the number of studies

Abstract

PURPOSE: We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration. RESULTS: We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious. CONCLUSIONS: Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

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