Article

Prevention of readmission in elderly patients with congestive heart failure - Results of a prospective, randomized pilot study

Geriatric Cardiology Section, Jewish Hospital at Washington University Medical Center, St. Louis, Missouri 63110.
Journal of General Internal Medicine (Impact Factor: 3.45). 12/1993; 8(11):585-90. DOI: 10.1007/BF02599709
Source: PubMed

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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    • "To reduce costly re-admissions and to improve health outcomes, a multidisciplinary approach has been incorporated into a range of heart failure (HF) management programs [3]. These can be delivered in-person (predominantly via specialist clinics [4] [5] [6] [7] [8] or outreach, home visits) [9] [10] [11] [12] [13] [14] [15] or remotely (e.g. via structured telephone support) [16] [17] [18] [19] [20] [21] [22]. Although a recent systematic review and meta-analysis [23] found that home-visiting programs and multidisciplinary HF clinic interventions reduced all-cause readmissions and mortality, prior to the " WHICH? "
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    ABSTRACT: Objective: To assess the long-term cost-effectiveness of two multidisciplinary management programs for elderly patients hospitalized with chronic heart failure (CHF) and how it is influenced by patient characteristics. Methods: A trial-based analysis was conducted alongside a randomized controlled trial of 280 elderly patients with CHF discharged to home from three Australian tertiary hospitals. Two interventions were compared: home-based intervention (HBI) that involved home visiting with community-based care versus specialized clinic-based intervention (CBI). Bootstrapped incremental cost–utility ratios were computed based on quality adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed based on incremental net monetary benefit (NMB). We performed multiple linear regression to explore which patient characteristics may impact patient-level NMB. Results: During median follow-up of 3.2 years, HBI was associated with slightly higher QALYs (+0.26 years per person; p = 0.078) and lower total healthcare costs (AU$ −13,100 per person; p = 0.025) mainly driven by significantly reduced duration of all-cause hospital stay (−10 days; p=0.006). At a willingness-to-pay threshold of AU$ 50,000 per additional QALY, the probability of HBI being better-valued was 96% and the incremental NMB of HBI was AU$ 24,342 (discounted, 5%). The variables associated with increased NMB were HBI (vs. CBI), lower Charlson Comorbidity Index, no hyponatremia, fewer months of HF, fewer prior HF admissions <1 year and a higher patient's self-care confidence. HBI's net benefit further increased in those with fewer comorbidities, a lower self-care confidence or no hyponatremia. Conclusions: Compared with CBI, HBI is likely to be cost-effective in elderly CHF patients with significant comorbidity. http://www.sciencedirect.com/science/article/pii/S0167527315302874
    Full-text · Article · Dec 2015 · International Journal of Cardiology
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    • "To reduce costly re-admissions and to improve health outcomes, a multidisciplinary approach has been incorporated into a range of heart failure (HF) management programs [3]. These can be delivered in-person (predominantly via specialist clinics [4] [5] [6] [7] [8] or outreach, home visits) [9] [10] [11] [12] [13] [14] [15] or remotely (e.g. via structured telephone support) [16] [17] [18] [19] [20] [21] [22]. Although a recent systematic review and meta-analysis [23] found that home-visiting programs and multidisciplinary HF clinic interventions reduced all-cause readmissions and mortality, prior to the " WHICH? "

    Full-text · Dataset · Sep 2015
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    • "To reduce costly re-admissions and to improve health outcomes, a multidisciplinary approach has been incorporated into a range of heart failure (HF) management programs [3]. These can be delivered in-person (predominantly via specialist clinics [4] [5] [6] [7] [8] or outreach, home visits) [9] [10] [11] [12] [13] [14] [15] or remotely (e.g. via structured telephone support) [16] [17] [18] [19] [20] [21] [22]. Although a recent systematic review and meta-analysis [23] found that home-visiting programs and multidisciplinary HF clinic interventions reduced all-cause readmissions and mortality, prior to the " WHICH? "
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess the long-term cost-effectiveness of two multidisciplinary management programs for elderly patients hospitalized with chronic heart failure (CHF) and how it is influenced by patient characteristics. A trial-based analysis was conducted alongside a randomized controlled trial of 280 elderly patients with CHF discharged to home from three Australian tertiary hospitals. Two interventions were compared: home-based intervention (HBI) that involved home visiting with community-based care versus specialized clinic-based intervention (CBI). Bootstrapped incremental cost-utility ratios were computed based on quality-adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed based on incremental net monetary benefit (NMB). We performed multiple linear regression to explore which patient characteristics may impact patient-level NMB. During median follow-up of 3.2years, HBI was associated with slightly higher QALYs (+0.26years per person; p=0.078) and lower total healthcare costs (AU$ -13,100 per person; p=0.025) mainly driven by significantly reduced duration of all-cause hospital stay (-10days; p=0.006). At a willingness-to-pay threshold of AU$ 50,000 per additional QALY, the probability of HBI being better-valued was 96% and the incremental NMB of HBI was AU$ 24,342 (discounted, 5%). The variables associated with increased NMB were HBI (vs. CBI), lower Charlson Comorbidity Index, no hyponatremia, fewer months of HF, fewer prior HF admissions <1year and a higher patient's self-care confidence. HBI's net benefit further increased in those with fewer comorbidities, a lower self-care confidence or no hyponatremia. Compared with CBI, HBI is likely to be cost-effective in elderly CHF patients with significant comorbidity. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Aug 2015 · International Journal of Cardiology
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