Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study.
ABSTRACT To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure.
Prospective, randomized clinical trial, with 2:1 assignment to the study intervention or usual care.
550-bed secondary and tertiary care university teaching hospital.
98 patients > or = 70 years of age (mean 79 +/- 6 years) admitted with documented congestive heart failure.
Comprehensive multidisciplinary treatment strategy consisting of intensive teaching by a geriatric cardiac nurse, a detailed review of medications by a geriatric cardiologist with specific recommendations designed to improve medication compliance and reduce side effects, early consultation with social services to facilitate discharge planning, dietary teaching by a hospital dietician, and close follow-up after discharge by home care and the study team.
All patients were followed for 90 days after initial hospital discharge. The primary study endpoints were rehospitalization within the 90-day interval and the cumulative number of days hospitalized during follow-up. The 90-day readmission rate was 33.3% (21.7%-44.9%) for the patients receiving the study intervention (n = 63) compared with 45.7% (29.2%-62.2%) for the control patients (n = 35). The mean number of days hospitalized was 4.3 +/- 1.1 (2.1-6.5) for the treated patients vs 5.7 +/- 2.0 (1.8-9.6) for the usual-care patients. In a prospectively defined subgroup of patients at intermediate risk for readmission (n = 61), readmissions were reduced by 42.2% (from 47.6% to 27.5%; p = 0.10), and the average number of hospital days during follow-up decreased from 6.7 +/- 3.2 days to 3.2 +/- 1.2 days (p = NS).
These pilot data suggest that a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization. Further evaluation of this treatment strategy, including an assessment of the cost-effectiveness, is warranted.
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ABSTRACT: Objective: To investigate the effect of a heart failure disease management program for patients >=18 years of age enrolled in a commercial health plan. Background: Disease management provides a framework for managing the chronic illness of large populations. Evaluating the comparative benefits of disease management program participation remains a central challenge for researchers, clinicians, and administrators. A growing consensus in the field of disease management is that more rigorous methodologies are required to assess program outcomes. However, many heart failure disease management programs have been evaluated by the use of non-experimental designs (pre-/post-methodologies), or matching and stratification methods that have been used with limited success. Methods: To investigate the program effects of a heart failure care support program, we conducted a matched-cohort study on 521 participants using propensity scores. This methodology constructed matched samples of treated and control pairs for a wide range of observed characteristics and may reduce the bias in estimates of treatment effects to provide a relatively more accurate assessment of program outcomes. Administrative claims provided the source data for evaluating rates of hospitalizations, emergency department visits, and physician office visits. The study also included selected clinical indicators from administrative claims data to estimate the effects of program enrollment. Results: Participants exhibited significantly fewer cardiac-related inpatient admissions and bed days compared with those for matched cohorts. A greater proportion of participants received cardiography testing and pneumococcal and influenza immunizations compared with matched cohorts. Participants experienced less use of medical services overall, suggesting that there were beneficial effects with monitoring and education for this group. Conclusions: This study documents the beneficial outcomes of participation in a commercially delivered heart failure care support program. In those cases where controlled randomized clinical trials cannot be performed because of ethical, cost, or feasibility issues, the use of propensity scores provides an alternative for estimating treatment effects based on observational data.Disease Management and Health Outcomes 01/2005; 13(5):327-335. · 0.36 Impact Factor
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ABSTRACT: Older age and higher acuity are associated with prolonged hospital stays and hospital readmissions. Early discharge planning may reduce lengths of hospital stay and hospital readmissions; however, its effectiveness with acutely admitted older adults is unclear. In this systematic review, we compared the effectiveness of early discharge planning to usual care in reducing index length of hospital stay, hospital readmissions, readmission length of hospital stay, and mortality; and increasing satisfaction with discharge planning and quality of life for older adults admitted to hospital with an acute illness or injury.We searched the Cochrane Library, DARE, HTA, NHSEED, ACP, MEDLINE, EMBASE, CINAHL, Proquest Dissertations and Theses, PubMed, Web of Science, SciSearch, PEDro, Sigma Theta Tau International's registry of nursing research, Joanna Briggs Institute, CRISP, OT Seeker, and several internet search engines. Hand-searching was conducted in four gerontological journals and references of all included studies and previous systematic reviews. Two reviewers independently extracted data and assessed risk of bias. Data were pooled using a random-effects meta-analysis. Where meta-analysis was not possible, narrative analysis was performed. Nine trials with a total of 1736 participants were included. Compared to usual care, early discharge planning was associated with fewer hospital readmissions within one to twelve months of index hospital discharge [risk ratio (RR) = 0.78, 95% CI = 0.69 - 0.90]; and lower readmission lengths of hospital stay within three to twelve months of index hospital discharge [weighted mean difference (WMD) = -2.47, 95% confidence intervals (CI) = -4.13 - -0.81)]. No differences were found in index length of hospital stay, mortality or satisfaction with discharge planning. Narrative analysis of four studies indicated that early discharge planning was associated with greater overall quality of life and the general health domain of quality of life two weeks after index hospital discharge. Early discharge planning with acutely admitted older adults improves system level outcomes after index hospital discharge. Service providers can use these findings to design and implement early discharge planning for older adults admitted to hospital with an acute illness or injury.BMC Geriatrics 07/2013; 13(1):70. · 2.34 Impact Factor
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ABSTRACT: Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.Drugs 02/2001; 61(14):2021-33. · 4.13 Impact Factor