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Heart failure is one of the medical conditions most likely to benefit from care coordination through times of patient transition. As a chronic condition
characterized by periodic hospitalizations, heart failure involves frequent care site transitions accompanied by important changes in management, for
example, new medications or dosage changes. Heart failure patients may experience transitions between different levels of inpatient care (e.g., acute care,
long-term skilled nursing care), between inpatient and outpatient care, and between different levels of outpatient care (e.g., to advanced heart failure
care). While transitions also can occur on the home front (e.g., from not working to returning to work), few of those with heart failure symptoms are
working given their older age. Those heart failure patients who continue working may experience significant fatigue and risk of arrhythmia that require
modification of work duties. For those with advanced heart failure, the appropriate timing of any transition to hospice is difficult to determine given the
uncertainty in prognosis.
The transition with the greatest potential impact on health and resource use is the transition from hospital to home. Not only are changes in care common
during hospitalization but patients are often not yet back to their baseline health status at time of discharge. Close follow-up during the transition from
hospital to home is likely to improve patient outcomes.
The most commonly used measure of quality for hospital care and the transition to home is the all-cause readmission rate at 30 days, which is near 25
percent following a heart failure admission for both the VA and Medicare populations. This measure, with risk adjustment for patient characteristics, is
publically reported at the hospital level by VA and Medicare with the latter imposing financial penalties on those hospitals that fall below the U.S.
average readmission rate.
Given the spotlight on readmissions as a measure of quality, what interventions should hospitals adopt to improve the transition of care for patients with
heart failure? The most powerful data come from randomized controlled trials. A 2011 review of readmission studies identified 16 randomized trials that
evaluated the impact of different interventions on patients' readmission rates. 1 These studies evaluated a variety of interventions, many multifactorial, which included such processes as patient education, medication reconciliation,
early phone calls, a transition coach, home visits, early communication with the primary care provider, and patient-centered discharge instructions.
Unfortunately, only four trials reported statistically significant results demonstrating a reduction in readmission at 30 days as a result of one or more
of these interventions. More importantly, the review found no clear pattern as to which intervention or combination of interventions is effective in
reducing readmissions. In other words, the positive results from one trial were rarely confirmed by a second trial. How could this be given the strong face
validity of low readmission as a measure of a quality transition? First, the benefit of a transition intervention may be smaller than expected and
undetectable given the size of the trials. Second, the benefit may occur later or last longer than 30 days (e.g., education or medication change) and a
longer follow-up time may reveal an impact on readmission. Finally, readmission itself may be a poor measure of quality regardless of the timing. Close
follow up may have unpredictable effects on readmission rates depending on the impact such follow up may have on reducing preventable admissions and
detecting problems for which readmission will improve health (the good readmission).
When researchers examine outcomes beyond readmissions, the evidence suggests that transition of care practices work. Of 19 trials examining patient
outcomes such as health status, medication knowledge, and satisfaction, 11 reported statistically significant results. Three of eight trials significantly
reduced errors or medication 'near misses' using pharmacy-targeted interventions. 2 Trials aimed at improving communication between the inpatient and primary care providers were most likely to be effective (14 of 19 trials reported
statistically significant positive results). Evidence for improved communication included enhanced primary care providers' knowledge of their patients'
inpatient course, medication reconciliation, and subsequent appropriate patient management by the primary care team.
VA has not mandated any particular intervention for the transition of care, though VA facilities have adopted many strategies aimed at improving care
transitions. VA has led the U.S. in pharmacist involvement in the transition of heart failure care, which research demonstrates is one of the best
practices associated with reduced readmission. 3 While the field needs more rigorous studies of transition of care interventions, perhaps the greatest need is to determine the best measure of a quality
transition, both from the health system and patient perspective.
Hansen, L.O. et al. "Interventions to Reduce 30-day Rehospitalization: a Systematic Review,"
Annals of Internal Medicine
Hesselink, G. et al. "Improving Patient Handovers from Hospital to Primary Care: a Systematic Review,"
Annals of Internal Medicine
Bradley, E.H. et al. "Contemporary Evidence about Hospital Strategies for Reducing 30-day Readmissions: a National Study,"
Journal of the American College of Cardiology