Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

Gerontological Nursing Science Center, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.22). 05/2004; 52(5):675-84. DOI: 10.1111/j.1532-5415.2004.52202.x
Source: PubMed

ABSTRACT To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure.
Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge.
Six Philadelphia academic and community hospitals.
Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure.
A 3-month APN-directed discharge planning and home follow-up protocol.
Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care.
Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001).
A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.

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    • "Although the nurse practitioner role has not been specifically evaluated in secondary prevention, results of many studies have demonstrated improvements in outcomes (patient health, quality of life, coordination and continuity of care, use of health services, access times, wait times, patient and family satisfaction with care and health care costs) when advanced practice nursing roles that include nurse practitioners complement existing care provider roles and are designed to address gaps in the delivery of health care services (Bredin et al., 1999; Brooten et al., 2002) or focus on chronic disease management (Litaker et al., 2003; Schuttelaar et al., 2010). Evidence shows that: (1) nurse practitioners are more effective than physicians in areas related to patient compliance with treatment recommendations (Horrocks et al., 2002); (2) nurse practitioner-run lipid management programmes have been associated with significant reductions in low density lipoprotein cholesterol levels (Allen et al., 2002; DeBusk et al., 1994; Mason, 2005); (3) transitional care provided by advanced practice nurses improves outcomes such as readmission rates in cardiac patients (Naylor et al., 2004); (4) nurse practitioners contributed to high quality chronic disease management (Russell et al., 2009); and (5) nurse-led secondary prevention clinics have been shown to improve adherence to secondary prevention strategies when compared to usual care (Murchie et al., 2003). The role of nurse practitioners in the implementation of secondary prevention post acute myocardial infarction and their success in achieving beneficial outcomes have not been investigated. "
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    ABSTRACT: Background Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death. Therapies that have been shown to reduce these risks (secondary prevention) continue to be underutilized. Nurse practitioners are well positioned to provide secondary prevention during and following hospitalization Objectives The purpose of this study was to evaluate the effects of NP care on the rate of provider implementation and patient achievement of evidence-based secondary prevention target goals. Design A prospective cohort design was used, which compared achievement of target goals between patients who received secondary prevention care from an NP to those who received usual care. Participants The sample consisted of 65 patients with AMI, admitted to a large community hospital. Patients meeting eligibility criteria were recruited consecutively Methods The intervention was delivered by the NP before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge. Data on patients’ achievement of goals were obtained before discharge from hospital and 3 months after discharge from both groups. Results This study's results provide preliminary evidence that an NP delivered secondary prevention intervention can significantly improve achievement of the following target goals when compared to usual care: smoking cessation (OR 5), blood pressure (OR 15), attendance at cardiac rehabilitation (OR 7), physical activity five days a week (OR 17), physical activity ≥ five days a week (OR 34), achieving a glycated hemoglobin < 7% in those with diabetes (OR 10), triglyceride levels (p = 02), statin use at follow-up (p = .05), and number of weeks to cardiac rehabilitation (p .05). Conclusion NP-led interventions such as this warrant duplication to evaluate reproducibility of the intervention and to determine if short-term improvements in secondary prevention goals translate into morbidity and mortality benefits.
    The Canadian journal of cardiology 12/2014; 51(12). DOI:10.1016/j.ijnurstu.2014.04.004 · 3.94 Impact Factor
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    • "Translation into clinical practice, however, has not been easy. Contemporary debate has focused on essential components of care and mechanisms of benefit [9] including the role of home visits as part of a transitional care approach to post-discharge management [10]. "
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    ABSTRACT: We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF). We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368±216days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay. 280 patients (73% male, aged 71±14years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n=143) or clinic-based (n=137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p=0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p=0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p=0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p<0.01 for rate and duration of hospital stay). Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term. Australian New Zealand Clinical Trials Registry number 12607000069459 (
    International journal of cardiology 04/2014; 174(3). DOI:10.1016/j.ijcard.2014.04.164 · 6.18 Impact Factor
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    • "), specialized assessment and multicomponent interventions (Inouye et al., 2000), and programs of early discharge planning and transitional care (Naylor et al., 2004; Coleman et al., 2006). In addition, Nurses Improving Care for Healthsystem Elders (NICHE) hospitals have embedded infrastructures that support the development, evaluation, and sustainability of a geriatric acute care initiative to promote the implementation and sustainability of evidence-based care (Boltz et al., 2008b; Leff et al., 2012). "
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    ABSTRACT: Nurses Improving Care of Healthsystem Elders (NICHE) provides hospitals with tools and resources to implement an initiative to improve health outcomes in older adults and their families. Beginning in 2011, members have engaged in a process of program self-evaluation, designed to evaluate internal progress toward developing, sustaining, and disseminating NICHE. This manuscript describes the NICHE Site Self-evaluation and reports the inaugural self-evaluation data in 180 North American hospitals. NICHE members evaluate their program utilizing the following dimensions of a geriatric acute care program: guiding principles, organizational structures, leadership, geriatric staff competence, interdisciplinary resources and processes, patient- and family-centered approaches, environment of care, and quality metrics. The majority of NICHE sites were at the progressive implementation level (n = 100, 55.6%), having implemented interdisciplinary geriatric education and the geriatric resource nurse (GRN) model on at least one unit; 29% have implemented the GRN model on multiple units, including specialty areas. Bed size, teaching status, and Magnet status were not associated with level of implementation, suggesting that NICHE implementation can be successful in a variety of settings and communities.
    Nursing and Health Sciences 05/2013; 15(4). DOI:10.1111/nhs.12067 · 0.85 Impact Factor
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