Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition

The Validity of Patient-Reported Outcome Measures of Quality of Life in Palliative Care: A Systematic Review

Importance: A recent systematic review and meta-analysis found that palliative care was not associated with improvement in quality of life (QOL) in terminal noncancer illness. Among potential reasons for a null effect, it is unclear if patient-reported outcome measures (PROMs) measuring QOL were derived or validated among populations with advanced life-limiting illness (ALLI). Objective: To systematically review the derivation and validation of QOL PROMs from a recent meta-analysis of randomized controlled trials (RCT) of palliative care interventions in people with terminal noncancer illness. Evidence Review: EMBASE, MEDLINE, and PsycINFO were searched from inception to January 8, 2023 for primary validation studies of QOL PROMs in populations with ALLI, defined as adults with a progressive terminal condition and an estimated median survival of less than or equal to one year. The primary outcome was the proportion of PROMs that were derived or validated in ≥1 ALLI population. Findings: Twenty-one unique studies of derivation (n = 13) and validation (n = 11, 3 studies evaluated both) provided data on 9657 participants (mean age 63 years, 50% female) across 15 unique QOL PROMs and subscales. Among studies of validation, 9 were in people with cancer (n = 2289, n = 5 PROMs), 1 in neurodegenerative disease (n = 23, n = 1 PROM), and 1 with mixed diseases (n = 248, n = 1 PROM). Across 15 QOL PROMs and subscales, 47% (n = 7) were derived or validated in an ALLI population. The majority of these seven PROMs were exclusively derived or validated among people with cancer (57%, n = 4). QOL PROMs such as Quality of Life at End of Life, EuroQoL-5 Dimension 5-level, and 36-item Short Form Survey demonstrated validity in more than one terminal noncancer illness. Conclusions: Most QOL PROMs that measured the effect of palliative care on QOL in RCTs were neither derived nor validated in an ALLI population. These findings raise questions about the inferences that palliative care does not improve QOL among people with terminal noncancer illness.

Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs

Although patient centredness is part of providing high-quality health care, little is known about the effectiveness of care transition interventions that involve patients and their families on readmissions to the hospital or emergency visits post-discharge. This systematic review (SR) aimed to examine the evidence on patient- and family-centred (PFC) care transition interventions and evaluate their effectiveness on adults' hospital readmissions and emergency department (ED) visits after discharge. Searches of Medline, CINAHL, and Embase databases were conducted from the earliest available online year of indexing up to and including 14 March 2021. The studies included: (i) were about care transitions (hospital to home) of ≥18-year-old patients; (ii) had components of patient-centred care and care transition frameworks; (iii) reported on one or more outcomes were among hospital readmissions and ED visits after discharge; and (iv) were cluster-, pilot- or randomized-controlled trials published in English or French. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers. A narrative synthesis was performed, and pooled odd ratios, standardized mean differences, and mean differences were calculated using a random-effects meta-analysis. Of the 10,021 citations screened, 50 trials were included in the SR and 44 were included in the meta-analyses. Care transition intervention types included health assessment, symptom and disease management, medication reconciliation, discharge planning, risk management, complication detection, and emotional support. Results showed that PFC care transition interventions significantly reduced the risk of hospital readmission rates compared to usual care [incident rate ratio (IRR), 0.86; 95% confidence interval (CI), 0.75-0.98; I2 = 73%] regardless of time elapsed since discharge. However, these same interventions had minimal impact on the risk of ED visit rates compared to usual care group regardless of time passed after discharge (IRR, 1.00; 95% CI, 0.85-1.18; I2 = 29%). PFC care transition interventions containing a greater number of patient-centred care (IRR, 0.73; 95% CI, 0.57-0.94; I2 = 59%) and care transition components (IRR, 0.76; 95% CI, 0.64-0.91; I2 = 4%) significantly decreased the risk of patients being readmitted. However, these interventions did not significantly increase the risk of patients visiting the ED after discharge (IRR, 1.54; CI 95%, 0.91-2.61). Future interventions should focus on patients' and families' values, beliefs, needs, preferences, race, age, gender, and social determinants of health to improve the quality of adults' care transitions.

Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis

Importance

Discharge from the hospital to the community has been associated with serious patient risks and excess service costs.

Objective

To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community.

Data Sources

CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022.

Study Selection

Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified.

Data Extraction and Synthesis

At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Main Outcomes and Measures

The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake.

Results

Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits.

Conclusions and Relevance

These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.

Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers' Evolutionary Approach

Objective

The purpose of this study was to clarify the concept of transitional care in patients with heart failure.

Background

Transitional care is increasingly being applied in patients with heart failure, but the concept of transitional care in heart failure patients is not uniform and confused with other definitions, which limits further research and practice on transitional care for these patients.

Design

Rodgers' evolutionary concept analysis.

Methods

A comprehensive literature search was conducted using the PUBMED, EMBASE, EBSCO, Chinese Biological Medicine (CBM), CNKI, and WANFANG databases (up to January 26, 2023). We used Rodgers' evolutionary concept analysis method to identify related concepts, attributes, antecedents, and consequences of transitional care in patients with heart failure.

Results

A total of 33 articles were included. The following attributes belonging to transitional care in patients with heart failure were extracted from the literature: self-care, multidisciplinary collaboration, and information transmission. The antecedents were patients' health status, the health literacy of patients and caregivers, the role functions of the main implementer and social and medical resources. Consequences were separated into two categories: patient-centered health outcomes (all-cause mortality, health-related quality of life, discharge preparedness, self-care behaviors, satisfaction of patients) and healthcare utilization outcomes (hospital readmission, length of hospital stay, emergency department visits).

Conclusion

This study found that transitional care in heart failure patients is a systemic care process during a vulnerable period that improves patient self-management and coordination between hospital resources and social support systems for continuous management to promote smooth patient transitions between different locations. This concept analysis will inform healthcare providers in designing evidence-based interventions and quality improvement strategies to ensure that transition processes lead to desired outcomes. In addition, this study will also be helpful for developing specific assessment tools to identify patients with HF who need transitional care.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Multicomponent integrated care for patients with chronic heart failure: systematic review and meta-analysis

To investigate the effectiveness of multicomponent integrated care on clinical outcomes among patients with chronic heart failure. We conducted a meta-analysis of randomized clinical trials, published in English language from inception to 20 April 2022, with at least 3-month implementation of multicomponent integrated care (defined as two or more quality improvement strategies from different domains, viz. the healthcare system, healthcare providers, and patients). The study outcomes were mortality (all-cause or cardiovascular) and healthcare utilization (hospital readmission or emergency department visits). We pooled the risk ratio (RR) using Mantel-Haenszel test. A total of 105 trials (n = 37 607 patients with chronic heart failure; mean age 67.9 ± 7.3 years; median duration of intervention 12 months [interquartile range 6-12 months]) were analysed. Compared with usual care, multicomponent integrated care was associated with reduced risk for all-cause mortality [RR 0.90, 95% confidence interval (CI) 0.86-0.95], cardiovascular mortality (RR 0.73, 95% CI 0.60-0.88), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00), heart failure-related hospital readmission (RR 0.84, 95% CI 0.79-0.89), and all-cause emergency department visits (RR 0.91, 95% CI 0.84-0.98). Heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18) and cardiovascular-related hospital readmission (RR 0.90, 95% CI 0.79-1.03) were not significant. The top three quality improvement strategies for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93), facilitated patient-provider communication (RR 0.87, 95% CI 0.81-0.93), and e-health (RR 0.88, 95% CI 0.81-0.96). Multicomponent integrated care reduced risks for mortality (all-cause and cardiovascular related), hospital readmission (all-cause and heart failure related), and all-cause emergency department visits among patients with chronic heart failure.

The benefits of transitional care in older patients with chronic diseases: a systematic review and meta-analysis

BACKGROUND

Transitional care (TC) has become increasingly important for elders with chronic diseases (CDs) discharged from hospital as the population ages. This study aims to analyze the health quality of life (HQoL) in elders received TC based on the Short Form-36 (SF-36) indicator.

METHODS

PubMed, EMBASE, Web of Science and Science Direct were systematically search for studies. Studies compared HQoL used SF-36 between TC and usual care on elders discharged for CDs were included. Analysis was performed with respect to the 8 dimensions of SF-36.

RESULTS

A total of 16 studies were included. Compared with usual care, (1) the scores of SF-36 outcomes increase as follow-up time extending; (2) transitional care significantly improved mental health, physical functioning and vitality at both short and long term after discharge; (3) transitional care only significantly improved general health and social function at long term; and role limitation due to emotional problems and bodily pain at short term; (4) transitional care significantly improved general health, mental health, physical functioning, social function and vitality for patients with hip fracture at long term.

CONCLUSION

TC can significantly improve physically and mentally HQoL for elder patients discharge for CDs compared with usual care.

Effects of a Nurse-Led Telehealth Self-care Promotion Program on the Quality of Life of Community-Dwelling Older Adults: Systematic Review and Meta-analysis

BACKGROUND

In recent years, telehealth has become a common channel for health care professionals to use to promote health and provide distance care. COVID-19 has further fostered the widespread use of this new technology, which can improve access to care while protecting the community from exposure to infection by direct personal contact, and reduce the time and cost of traveling for both health care users and providers. This is especially true for community-dwelling older adults who have multiple chronic diseases and require frequent hospital visits. Nurses are globally recognized as health care professionals who provide effective community-based care to older adults, facilitating their desire to age in place. However, to date, it is unclear whether the use of telehealth can facilitate their work of promoting self-care to community-dwelling older adults.

OBJECTIVE

This review aims to summarize findings from randomized controlled trials on the effect of nurse-led telehealth self-care promotion programs compared with the usual on-site or face-to-face services on the quality of life (QoL), self-efficacy, depression, and hospital admissions among community-dwelling older adults.

METHODS

A search of 6 major databases was undertaken of relevant studies published from May 2011 to April 2021. Standardized mean differences (SMDs) and their 95% CIs were calculated from postintervention outcomes for continuous data, while the odds ratio was obtained for dichotomous data using the Mantel-Haenszel test.

RESULTS

From 1173 possible publications, 13 trials involving a total of 4097 participants were included in this meta-analysis. Compared with the control groups, the intervention groups of community-dwelling older adults significantly improved in overall QoL (SMD 0.12; 95% CI 0.03 to 0.20; P=.006; I2=21%), self-efficacy (SMD 0.19; 95% CI 0.08 to 0.30; P<.001; I2=0%), and depression level (SMD -0.22; 95% CI -0.36 to -0.08; P=.003; I2=89%).

CONCLUSIONS

This meta-analysis suggests that employing telehealth in nurse-led self-care promotion programs may have a positive impact on older adults, although more studies are needed to strengthen the evidence base, particularly regarding organization and delivery.

TRIAL REGISTRATION

PROSPERO (Prospective International Register of Systematic Reviews) CRD42021257299; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=257299.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

Association of Palliative Care Intervention With Health Care Use, Symptom Burden and Advance Care Planning in Adults With Heart Failure and Other Noncancer Chronic Illness

CONTEXT

Palliative care (PC) improves outcomes in noncancer illness. We hypothesized the benefit is driven by studies of heart failure (HF) patients exclusively versus studies of other noncancer illnesses.

OBJECTIVES

To assess difference in outcomes in trials with HF patients exclusively vs studies of other noncancer chronic illness.

METHODS

We performed a meta-analysis of studies that assessed association of PC with hospital admissions, emergency department (ED) visits and advance care planning in noncancer chronic illness and compared studies of HF patients versus those with other noncancer chronic illness.

RESULTS

Our analysis included 10 HF studies (n = 4,057) and 16 non-HF studies (11 mixed conditions, 3 dementia, 2 COPD, n = 10,235). PC led to reduction in hospital admissions in HF studies (OR = 0.67 [95% CI = 0.48-0.95]) but not in other noncancer illness studies (OR = 0.86 [95% CI = 0.62-1.21]). PC intervention was nonsignificant for change in ED visits in either HF (OR = 0.70 [95% CI = 0.38-1.28]) or other noncancer studies (OR = 0.86 [95% CI = 0.69-1.07]). Increase in advance care planning was noted in both HF (OR = 4.29 [95% CI = 1.44-12.76]) and other studies (OR = 2.67 [95% CI = 1.29-5.52]). Nonsignificant reductions in symptom burden were noted for both HF-studies and non-HF studies, though overall there was a significant improvement in symptom burden (weighted mean difference -1.15 [95% CI = -1.65, -0.65]). Similar results were noted when studies of mixed populations were excluded from the non-HF studies.

CONCLUSION

PC is particularly effective at reducing potentially unwanted hospital admissions for patients with HF compared to other noncancer illnesses. Our findings should further encourage efforts to increase PC access to HF patients.

A Home Hospitalisation Strategy for Patients with an Acute Episode of Heart Failure Using a Digital Health-Supported Platform: A Multicentre Feasibility Study - A Rationale and Study Design

BACKGROUND

Heart failure (HF) is a common cause of hospitalisation and mortality in elderly. The frequent rehospitalisations put a serious burden on patients, health-care budgets, and health-care capacity. Frequent hospital admissions are also associated with a substantial additional hazard for serious complications and reduced quality of life. The NWE-Chance project will explore the feasibility and scalability of providing home hospitalisation supported by a newly developed digital health-supported platform and daily visits of specialised nurses.

METHODS/DESIGN

Hundred patients with chronic HF will be recruited over a 1-year period. The digital health-supported home hospitalisation strategy will be tested in 3 hospitals with different experience in delivering home hospitalisation: Isala Zwolle, Maastricht UMC+, both in The Netherlands, and Jessa Hospital, Hasselt in Belgium. The home hospitalisation intervention will have a maximal duration of 14 days. Feasibility will be measured with acceptability, satisfaction, and usability questionnaires for patients, nurses, and physicians. Furthermore, safety and costs will be assessed for 30 days after the start of the home hospitalisation intervention.

DISCUSSION

The NWE-Chance project will be one of the first studies to examine the feasibility of a digital health-supported home hospitalisation platform for HF patients. It has the potential to augment current standard HF care and quality of life of HF patients and to innovate the standard HF care to potentially lower the hospitalisation-related complications, the burden of HF on health-care systems, and to potentially implement more patient-centred care strategies.

An integrated model of care utilizing community health workers to promote safe transitions of care

BACKGROUND/OBJECTIVES

Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost-prohibitive resource needs. Cost-effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs.

DESIGN

A cohort study with a pre-post intervention evaluation of the intervention group.

SETTING

A 953-bed academic urban safety-net hospital.

PARTICIPANTS

Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission.

INTERVENTION

Promotion of self-management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self-management education.

MEASUREMENTS

Outcome measures were readmissions, ER visits, and PCP establishment.

RESULTS

Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z = 9.6, p < 0.001), also observed at 30-day (Z = 5.5, p < 0.001), 3-month (Z = 4.3, p < 0.001), 6-month (Z = 4.0, p = 0.001), and 1-year (Z = 5.4, p < 0.001) post-intervention. There was a significant reduction in the overall number of ER visits (Z = 5.5, p < 0.001), also seen at 3-month (Z = 3.3, p < 0.001), 6-month (Z = 3.0, p < 0.001), and 1-year (Z = 4.0, p < 0.001) intervals. Care with a PCP was established in 86.6% of participants. Utilization costs were significantly lower post-intervention ($11,530,376.39 vs $4,017,493.17, p < 0.001).

CONCLUSION

Use of CHWs during transitions of care may be a cost-effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems.

Effectiveness of person- and family-centred care transition interventions on patient- oriented outcomes: A systematic review

AIM

The aim was to critically analyse the body of evidence regarding the effectiveness of PFCC transition interventions on the quality of care and the experience of patients.

DESIGN

We conducted a systematic review using the Cochrane Handbook's guidelines and adhered to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

METHODS

Four databases and grey literature were searched. Following a two-step screening process, data from the eligible studies were extracted. Risk of bias and quality of the studies were also assessed. Narrative synthesis and vote counting were used for the data analysis.

RESULTS

A total of 28 articles met our inclusion criteria. Interventions varied in regards to the extent of the PFCC focus and the comprehensiveness of the transition of care. Educating patients to promote self-management was the most commonly included component and it was described in all 28 interventions.

Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: a systematic literature review

BACKGROUND

Although transitional care interventions can improve health among patients hospitalized with acute conditions, few interventions use patient quality of life (QOL) as the primary outcome. Existing interventions use a variety of intervention components, are not effective for patients of all races and ethnicities, do not address age-related patient needs, and do not incorporate the needs of families. The purpose of this study was to systematically review characteristics of transitional care intervention studies that aimed to improve QOL for younger adult patients of all race and ethnicities who were hospitalized with acute conditions.

METHODS

A systematic review was conducted of empirical literature available in PubMed, Embase, CINAHL, and PsycINFO by November 19, 2019 to identify studies of hospital to home care transitions with QOL as the primary outcome. Data extraction on study design and intervention components was limited to studies of patients aged 18-64.

RESULTS

Nineteen articles comprising 17 studies met inclusion criteria. There were a total of 3,122 patients across all studies (range: 28-536). Populations of focus included cardiovascular disease, chronic obstructive pulmonary disease, stroke, breast cancer, and kidney disease. Seven QOL instruments were identified. All interventions were multi-component with a total of 31 different strategies used. Most interventions were facilitated by a registered nurse. Seven studies discussed intervention facilitator training and eight discussed intervention materials utilized. No studies specified cultural tailoring of interventions or analyzed findings by racial/ethnic subgroup.

CONCLUSIONS

Future research is needed to determine which intervention components, either in isolation or in combination, are effective in improving QOL. Future studies should also elaborate on the background and training of intervention facilitators and on materials utilized and may also consider incorporating differences in culture, race and ethnicity into all phases of the research process in an effort to address and reduce any health disparities.

The Effectiveness of Transition Interventions to Support Older Patients From Hospital to Home: A Systematic Scoping Review

BACKGROUND

Interventions supporting older adults' transition from hospital to home can address geriatric needs. Yet this evidence base is fragmented. This review describes transitional interventions that provide pre- and post-discharge support for older adults and evaluates their implementation and effectiveness in improving health and well-being.

METHOD

Articles were included if they examined the extent to which transitional interventions were effective in improving health and well-being outcomes and reducing hospital readmission rates among older adults.

RESULTS

Twenty studies met the inclusion criteria. Four types of interventions were identified: education-based (10/20); goal-oriented (4/20); exercise (4/20); and social support interventions (2/20). Education and goal-oriented interventions were effective in improving health and well-being outcomes. The impact of interventions on mitigating hospital readmissions was inconclusive. Only five studies examined implementation.

DISCUSSION

Older adults transitioning from hospital to home would benefit from tailored education and goal-oriented interventions that promote their capacity for self-care.

Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

IMPORTANCE

The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.

OBJECTIVE

To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.

STUDY SELECTION

Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).

RESULTS

Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

Impact of hospitalisation on health-related quality of life in patients with chronic heart failure

BACKGROUND

Empirical identification of the direct impact of hospitalisation in the change in utility could provide an interpretation for some of the unexplained variance in quality of life responses in clinical practice and clinical trials and provide assistance to researchers in assessing the impact of a hospitalisation in the context of economic evaluations. This study had the goal of determining the impact of nonfatal hospitalisations on the quality of life of a cohort of patients previously diagnosed with heart failure by using their quality of life measurements before and after hospitalisation.

METHODS

The impact of hospitalisation on health-related quality of life was estimated by calculating the difference in utility measured using the EQ-5D-3L in patients that were hospitalised and had records of utility before and after hospitalisation. The variation in differences between the utilities pre and post hospitalisation was explained through two multiple linear regression models using (1) the individual patient characteristics and (2) the hospitalisation characteristics as explanatory variables.

RESULTS

The mean difference between health-related quality of life measurement pre and post hospitalisation was found to be 0.020 [95% CI: - 0.020, 0.059] when measured with the EQ-5D index, while there was a mean decrease of - 0.012 [95% CI: - 0.043, 0.020] in the utility measured with the visual analogue scale. Differences in utility variation according to the primary cause for hospitalisation were found. Regression models showed a statistically significant impact of body mass index and serum creatinine in the index utility differences and of serum creatinine for utilities measured with the visual analogue scale.

CONCLUSIONS

Knowing the impact of hospitalisation on health-related quality of life is particularly relevant for informing cost-effectiveness studies designed to assess health technologies aimed at reducing hospital admissions. Through using patient-level data it was possible to estimate the variation in utilities before and after the average hospitalisation and for hospitalisations due to the most common causes for hospital admission. These estimates for (dis) utility could be used in the calculations of effectiveness on economic evaluations, especially when discrete event simulations are the employed modelling technique.

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

OBJECTIVE

To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level.

DESIGN

Population based matched cohort study.

SETTING

Ontario, Canada between 2010 and 2015.

PARTICIPANTS

113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex.

MAIN OUTCOME MEASURES

Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities).

RESULTS

In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home.

CONCLUSIONS

These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.

Impact of Critical Illness on Resource Utilization: A Comparison of Use in the Year Before and After ICU Admission

Supplemental Digital Content is available in the text.

Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual’s resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission.

The Effect of Continuous Care Model Implementation on the Quality of Life of Patients with Heart Failure: A Randomized Controlled Trial

BACKGROUND

Heart failure is an important chronic and progressive disease worldwide. Patients are faced with several stressors that decrease their quality of life (QoL). The present study aimed to determine the effectiveness of implementing a continuous care model on improving the QoL of patients with heart failure.

METHODS

In the present randomized controlled trial, 72 patients with heart failure admitted to Shahid Chamran Hospital of Isfahan (in Central Iran) were randomly divided into 36-individual two groups: the experimental (continuous care model) and control (normal care) groups. In the experimental group, the continuous care model was implemented for 3 months. Data were collected using the standard Minnesota Living with Heart Failure Questionnaire for patients with heart failure. Subsequently, the collected data were entered into the IBM SPSS ver. 20.0 (IBM Corp., Armonk, NY, USA) and analyzed using the Mann-Whitney U-test, chi-square test, and independent and paired t-test at a significance level of α≤0.05.

RESULTS

The results indicated that the mean scores of QoL before the implementation of continuous care model were 43.3±6.1 in the experimental group and 42.7±5.1 in the control group, indicating no statistically significant difference between the two groups. After the implementation of continuous care model, the mean score of QoL of the experimental group was significantly higher than that of the control group.

CONCLUSION

Considering the results obtained in the present study, model implementation could improve the overall scores of QoL in patients with chronic heart failure.

Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in complex comorbidities. Hospital readmissions for HF, including emergency department (ED) visits, are considered preventable. Majority of the patients with HF are often discharged early in the recovery period with inadequate self-care instructions. To address these issues, transitional care interventions have been implemented with the common objective of reducing the rate of hospital readmission, including ED visits. However, there is a lack of evidence regarding the benefits and adverse effects of transitional care interventions on clinical outcomes and patient-related outcomes of patients with HF. This integrative review aims to identify the components of transitional care interventions and the effectiveness of these interventions in improving health outcomes of patients with HF. Five databases were searched from January 2000 to December 2019, and 25 articles were included.

Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis

BACKGROUND

Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term.

OBJECTIVE

To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge.

DESIGN

Meta-analysis of randomized controlled trials.

DATA SOURCES

A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits.

REVIEW METHODS

RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model.

RESULTS

Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity.

CONCLUSIONS

Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.

Collaborative care intervention for patients with chronic heart failure: A systematic review and meta-analysis

INTRODUCTION

Patients with chronic heart failure (HF) show many symptoms that worsen the quality of life (QoL). Collaborative care intervention (CCI) aims to improve the QoL and symptoms by integrating psychosocial and palliative strategies in chronic care.

METHODS

The PubMed, EMBASE, and Cochrane library databases were searched from inception to September 2018. The included studies were used to determine pooled standard mean differences (SMDs) and associated 95% confidence intervals (CIs). The data were assessed by fixed- and random effects models, respectively.

RESULTS

Twenty-one studies including 2999 patients with chronic heart failure were included. The results showed significantly improved QoL in the CCI group compared with the routine care group (SMD = 0.60, 95%CI 0.27-0.94, Pheterogeneity < .001, I = 94.1%). The patients who received face-to-face interventions experienced a significant improvement (SMD = 0.54, 95%CI 0.24-0.85, Pheterogeneity < .001, I = 88.7%) in terms of QoL compared with those administered only telephone interventions. Furthermore, significantly improved anxiety level (SMD = 0.33, 95%CI 0.12-0.55, Pheterogeneity = .612, I = 0%) and 6-min walk test (SMD = 0.46, 95%CI 0.29-0.64, Pheterogeneity = .458, I = 0%) were found in the CCI group compared with the routine care group.

CONCLUSION

These findings confirmed that collaborative care intervention effectively improves the quality of life as well as psychological (anxiety) and physical (6-min walk test) functions in patients with chronic heart failure compared with routine care. Furthermore, face-to-face interventions show a greater improvement of QoL compared with telephone-only interventions.

Implications of Transitional Care Interventions on Hospital Readmissions in Patients With Destination Therapy Left Ventricular Assist Devices

BACKGROUND

The rising number of patients with a left ventricular assist device (LVAD) require care management to successfully transition home after implantation. These patients and their families need to manage their heart failure, and the complexities of an LVAD and the associated lifestyle modifications. Translating knowledge of transitional care interventions in patients with chronic diseases to those with an LVAD may provide valuable insight. To help inform the furthering of care transitions in the LVAD patient population, an integrative review was conducted.

AIM

The aim of this review was to explore the transitions of care interventions of care in patients and its potential for application in the destination therapy LVAD.

METHODS

This integrative review was guided by the Whittemore and Knafl's methodology.

RESULTS

A total of 12 articles from 264 retrieved articles met inclusion criteria and were included in the literature review.

DISCUSSION

This review identified that evidence-based transitional care interventions have been shown to decrease avoidable rehospitalization, the associated costs, and improve quality of life when compared to usual care.

IMPLICATIONS FOR PRACTICE

A common feature of transitional care interventions is the inclusion of nurse leadership. Nurses should be prepared to participate in transitional care interventions to optimally improve outcomes for patients with heart failure and potentially those with an LVAD. Additionally, to make transitional care interventions more effective they should be implemented with moderate intensity or greater.

CONCLUSION

This review provided information supporting the trialing of transitional care interventions in patients with an LVAD and suggests pilot research to optimize interventions for this population.

Disease management interventions for heart failure

BACKGROUND

Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012.

OBJECTIVES

To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness.

MAIN RESULTS

We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective.

AUTHORS' CONCLUSIONS

We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.

Systematic review of economic burden of heart failure

The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.

The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial

Background

Cardiac rehabilitation improves health-related quality of life (HRQoL) and reduces hospitalizations in patients with heart failure, but international uptake of cardiac rehabilitation for heart failure remains low.

Design and methods

The aim of this multicentre randomized trial was to compare the REACH-HF (Rehabilitation EnAblement in CHronicHeart Failure) intervention, a facilitated self-care and home-based cardiac rehabilitation programme to usual care for adults with heart failure with reduced ejection fraction (HFrEF). The study primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL (Minnesota Living with Heart Failure questionnaire (MLHFQ)) at 12 months compared with usual care alone.

Results

The study recruited 216 participants, predominantly men (78%), with an average age of 70 years and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of –5.7 points (95% confidence interval –10.6 to –0.7) in favour of the REACH-HF intervention group (p = 0.025). With the exception of patient self-care (p < 0.001) there was no significant difference in other secondary outcomes, including clinical events (p > 0.05) at follow-up compared with usual care. The mean cost of the REACH-HF intervention was £418 per participant.

Conclusions

The novel REACH-HF home-based facilitated intervention for HFrEF was clinically superior in disease-specific HRQoL at 12 months and offers an affordable alternative to traditional centre-based programmes to address current low cardiac rehabilitation uptake rates for heart failure.

Identifying cut-off scores for interpretation of the Heart Failure Impact Questionnaire

AIMS

Heart failure (HF) influences health-related quality of life. However, the factors that contribute to health-related quality of life remain unclear in Taiwan. We aim to identify the factors influencing health-related quality of life in HF patients.

METHODS

Hospitalized HF (N = 225) patients were included from April 2011 to April 2014. Health-related quality of life was assessed by using the 36-Item Short-Form Health Survey (SF-36) and the Minnesota Living with Heart Failure Questionnaire. A new cut-off was conducted based on the combination of SF-36 and Minnesota Living with Heart Failure questionnaire.

RESULTS

There were significant differences between good and poor quality groups on age, gender, education levels, occupational classification caregiver, New York Heart Association classes, and the numbers of comorbidities. The logistic regression analysis showed that the number of comorbidities was more than three and New York Heart Association class IV were significantly associated with health-related quality of life.

Development of a Path to Home Mobile App for the Geriatric Rehabilitation Program at Bruyère Continuing Care: Protocol for User-Centered Design and Feasibility Testing Studies

Background

As the population ages, the need for appropriate geriatric rehabilitation services will also increase. Pressures faced by hospitals to reduce length of stay and reduce costs have driven the need for more complex care being delivered in the home or community setting. As a result, a multifaceted approach that can provide geriatric rehabilitation patients with safe and effective person- and family-centered care during transitions from hospital to home is required. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to safely manage their personalized needs during care transitions from hospital to home.

Objective

The purpose of this study is to design and test the feasibility of a novel Path to Home mobile app to manage the personalized needs of geriatric rehabilitation patients during their transitions from hospital to home.

Methods

This study will consist of (1) codesigning a patient- and provider-tailored mobile app, and (2) feasibility pilot testing of the mobile app to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we will follow a user-centered design process integrated with a modern agile software development methodology to iteratively codesign the personalized care transition Path to Home mobile app. In phase 2, we will conduct a single-arm feasibility pilot test with geriatric rehabilitation patients using the personalized care transition Path to Home mobile app to manage their needs during the transition from hospital to home.

Results

The project was funded in May 2018, and enrollment and data analysis are underway. First results are expected to be submitted for publication in 2019.

Conclusions

Our findings will help validate the use of this technology for geriatric rehabilitation patients discharged from the hospital to home. Future research will more rigorously evaluate the health and economic benefits to inform wide-scale adoption of the technology.

Registered Report Identifier

RR1-10.2196/11031

Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population

PURPOSE

The utility of a transitions-of-care (TOC) pharmacist intervention focused on improving the quality and safety of the medication process for high-risk cardiovascular patients was evaluated.

METHODS

A quality-improvement initiative was developed for patients with heart failure or acute coronary syndrome followed longitudinally at a hospital's outpatient cardiovascular clinic. The TOC pharmacist intervention occurred either before a patient's outpatient cardiovascular clinic appointment or during a hospitalization. The major outcome analyzed was the number of unplanned hospital readmissions within 30 days. Additional endpoints evaluated included the time to healthcare utilization, number of medication discrepancies identified, percentage of therapeutic recommendations accepted by a provider, number of medication access issues resolved, patient cost savings, patient satisfaction, and mean time spent on an intervention by the pharmacist per patient encounter.

RESULTS

A total of 118 patients received the TOC pharmacist intervention. A total of 516 medication discrepancies were identified and corrected, with 55.6% of discrepancies involving cardiovascular medications. A total of 244 recommendations for therapeutic optimization were provided, with an 81% provider acceptance rate and a 100% patient satisfaction rate. Fifty-five patients were provided with medication cost savings, and medication-access issues were resolved for 8 patients. A TOC pharmacist spent means of 98 and 73 minutes on patient education and coordination of care during inpatient and ambulatory encounters, respectively. The 30-day hospital readmission rate for patients with heart failure was reduced by 20%.

CONCLUSION

A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high-risk cardiovascular patients at our institution.

Impact of Pharmacy Student-Driven Postdischarge Telephone Calls on Heart Failure Hospital Readmission Rates: A Pilot Program

Background: Heart failure (HF) hospitalization rates have remained high in the past 10 years. Numerous studies have shown significant improvement in HF readmission rates when pharmacists or pharmacy residents conduct postdischarge telephone calls. Objective: The purpose of this retrospective review of a pilot program was to evaluate the impact of pharmacy student-driven postdischarge phone calls on 30- and 90-day hospital readmission rates in patients recently discharged with HF. Methods: A retrospective manual chart review was conducted for all patients who received a telephone call from the pharmacy students. The primary endpoint compared historical readmissions, 30 and 90 days prior to hospital discharge, with 30 and 90 days post discharge readmissions. For the secondary endpoints, historical and postdischarge 30-day and 90-day readmission rates were compared for patients with a primary diagnosis of HF and for patients with a secondary diagnosis of HF. Descriptive statistics were calculated in the form of means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Results: Statistically significant decrease was observed for both the 30-day (P = .006) and 90-day (P = .007) readmission periods. Prior to the pharmacy students' phone calls, the overall group of 131 patients had historical readmission rates of 24.43% within 30 days and 38.17% within 90 days after hospital discharge. After the postdischarge phone calls, the readmission rates decreased to 11.45%, for 30 days, and 22.90%, for 90 days. Conclusion: Postdischarge phone calls, specifically made by pharmacy students, demonstrated a positive impact on reducing HF-associated hospital readmissions, adding to the growing body of evidence of different methods of pharmacy interventions and highlighting the clinical impact pharmacy students may have in transition of care services.

Use of software applications to improve medication adherence and achieve more integrated disease management in heart failure

The treatment and management of heart failure is associated with high mortality rates and treatment costs. Poor medication adherence is a major barrier to improving care and traditional interventions addressing non-adherence have not consistently demonstrated improvement in health care outcomes like readmission. The reasons for non-adherence are complicated and illustrate the broader challenges patients face when managing a complex disease like heart failure. In this review, a digitally enabled heart failure management platform consisting of medical digital tools and software solutions that are designed to be patient-facing and continuously accessed is explored as a way to integrate the multiple components of heart failure care and deliver personalized patient management tools.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device

BACKGROUND

The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%.

PROBLEM STATEMENT

Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices.

METHODS

Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team.

OUTCOMES

The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%.

IMPLICATIONS FOR PRACTICE

Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients

BACKGROUND

Heart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients.

METHODS

HF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively.

RESULTS

Of the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03).

CONCLUSION

An ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients.

Effect of cardiac rehabilitation on cardiovascular risk factors in chronic heart failure patients

Introduction

Cardiac rehabilitation improves disease-related symptoms, quality of life, and clinical outcomes. This study was done to evaluate the effect of cardiac rehabilitation program on cardiovascular risk factors in chronic heart failure patients as well as functional capacity and health related quality of life.

Methods

The study was conducted on 80 Patients with chronic stable heart failure. All patients had full history and thorough physical examination. Body mass index (BMI), waist circumference, glycated hemoglobin (HbA1c), lipid profile, and echocardiography, all of which were done before and after recruitment in a 2 months cardiac rehabilitation program (through prescribed exercise training, 2 sessions/week for 2 months). The changes in functional capacity were evaluated by 6-min walk test (6MWT) and the changes in the health related quality of life were measured by Minnesota living with heart failure questionnaire (MLHFQ), both were done before and after the rehabilitation program.

Results

There was a highly significant reduction in the blood pressure, heart rate, BMI, waist circumference, the smokers' number and the glycated hemoglobin (HbA1c) (P < 0.01). However, there was no statistically significant reductions in low density lipoproteins (LDL), Triglycerides (P > 0.05). Highly significant improvements were noted in the functional capacity and the health related quality of life as evidenced by improvement in the 6MWT and the MLHFQ scores (total score, physical and psychological domains, P < 0.01).

Conclusion

Cardiac rehabilitation had a significant improvement of cardiovascular risk factors, functional capacity and Health related quality of life in patients with chronic heart failure.

The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review

OBJECTIVE

The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life (QoL), readmission rates and healthcare costs for adults with heart failure (HF) living independently in the community.

METHOD

A systematic review of randomised control trials was undertaken. Using the search terms nurse, education, heart failure, hospitalisation, readmission, rehospitalisation, economic burden, cost, expenditure and quality of life in PubMed, CINAHL and Google Scholar databases were searched. Papers pertaining to nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were reviewed.

RESULT

The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions, reduction in hospitalisation and a cost benefit. Additionally, higher functioning and improved QoL were also identified.

CONCLUSION

These results suggest that nurse-led patient education for adults with HF improves QoL and reduces hospital admissions and readmissions.

PRACTICE IMPLICATIONS

Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation.

Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review

BACKGROUND

Many discharge interventions are developed to reduce unplanned hospital readmissions, but it is unclear which interventions are more effective.

OBJECTIVES

The objective of this review was to identify discharge interventions from hospital to home that reduce hospital readmissions within three months and to understand their effect on secondary outcome measures.

INCLUSION CRITERIA

Participants were adults (18 years or older) discharged from a medical or surgical ward.The included interventions had to be designed to ease the care transition from hospital to home or to prevent problems after hospital discharge.This review considered only randomized controlled trials.The primary outcome measure was hospital readmission within three months after discharge. Secondary outcomes included patient satisfaction, return to emergency departments and mortality.

SEARCH STRATEGY

Studies in English between January 1990 and July 2014 were considered for inclusion. The databases searched were PubMed, Web of Science, Embase and CINAHL.

METHODOLOGICAL QUALITY

Methodological validity was assessed by two reviewers prior to inclusion using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Quantitative data were independently extracted by the two reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

Meta-analysis was performed by using a random effect model; data were pooled using Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of seven or more were selected.

RESULTS

Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01] (p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six studies evaluating patient satisfaction.Exploratory subgroup analysis found that interventions starting during hospital stay and continuing after discharge were more effective in reducing readmissions compared to interventions starting after discharge (between subgroup difference p=0.01). Multicomponent interventions were not more effective compared to single component interventions (between subgroup difference p=0.54). Interventions oriented towards patient empowerment were more effective compared to all other interventions (between subgroup difference p=0.02).

CONCLUSIONS

Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.

Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction

BACKGROUND:

Pharmacists may assist with reducing 30-day readmission rates for patients with heart failure (HF) exacerbation or acute myocardial infarction (AMI) by promoting medication adherence.

OBJECTIVE:

To determine the change in 30-day readmission rates for patients with HF exacerbation or AMI after implementation of a "high-touch" standard of care.

METHODS:

Patients admitted with HF exacerbation, non-ST-segment elevation AMI, or ST-segment elevation AMI from August 1, 2013, to June 30, 2015, were included in this prospective study. Patients were educated while in the inpatient setting and followed up in the outpatient setting through telephone contact and scheduling a medication therapy management (MTM) appointment with a pharmacist. Data were collected by pharmacy personnel involved in the implementation of the intervention.

RESULTS:

Within the HF and AMI arms, 100 and 93 patients, respectively, were included in the study. The 30-day readmission rates were 24% and 17.2% for HF and AMI, respectively, which were not statistically significant when compared to historical institutional readmission rates prior to study initiation (18.2% for HF, P = .238; 11.4% for AMI, P = .252).

CONCLUSION:

A "high-touch" pharmacist-driven transitions of care program may affect 30-day readmission rates for patients with HF exacerbation or AMI; potential processes for initiating transitions of care programs are provided.

Effectiveness of a multidisciplinary disease management program on outcomes in patients with heart failure in China: A randomized controlled single center study

BACKGROUND

Multidisciplinary disease management programs (MDMP) for patients with heart failure (HF) have been delivered, but evidence of their effectiveness in China is limited.

OBJECTIVE

To determine if a MDMP improves quality of life (QoL), physical performance, depressive symptoms, self-care behaviors and mortality or rehospitalization in patients with HF in China.

METHODS

This is a randomized controlled single center trial in which patients with HF received either MDMP with discharge education, physical training, follow-up visits and telephone calls for 180 days (n = 31) or standard care (SC, n = 31).

RESULTS

Compared with SC, QoL, depressive symptoms, and self-care behaviors were significantly improved by MDMP from baseline to 180 days (37% vs 66%, 20% vs 61%, and 8% vs 33%, respectively, all p < 0.001). There were no differences in physical performance and mortality or rehospitalization during follow-up.

CONCLUSIONS

A HF MDMP can improve QoL, depressive symptoms and self-care behaviors in China.

The E-Coach technology-assisted care transition system: a pragmatic randomized trial

Care transitions from the hospital to home remain a vulnerable time for many patients, especially for those with heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Despite regular use in chronic disease management, it remains unclear how technology can best support patients during their transition from the hospital. We sought to evaluate the impact of a technology-supported care transition support program on hospitalizations, days out of the community and mortality. Using a pragmatic randomized trial, we enrolled patients (511 enrolled, 478 analyzed) hospitalized with CHF/COPD to "E-Coach," an intervention with condition-specific customization and in-hospital and post-discharge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up versus usual post-discharge care (UC). The primary outcome was 30-day rehospitalization. Secondary outcomes included (1) rehospitalization and death and (2) days in the hospital and out of the community. E-Coach and UC groups were similar at baseline except for gender imbalance (p = 0.02). After adjustment for gender, our primary outcome, 30-day rehospitalization rates did not differ between the E-Coach and UC groups (15.0 vs. 16.3 %, adjusted hazard ratio [95 % confidence interval]: 0.94 [0.60, 1.49]). However, in the COPD subgroup, E-Coach was associated with significantly fewer days in the hospital (0.5 vs. 1.6, p = 0.03). E-Coach, an IVR-augmented care transition intervention did not reduce rehospitalization. The positive impact on our secondary outcome (days in hospital) among COPD patients, but not in CHF, may suggest that E-Coach may be more beneficial among patients with COPD.NIH trial registry number: NCT01135381Trial Protocol: http://dx.doi.org/ 10.1016/j.cct.2012.08.007.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions

Background

Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies.

Method

Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy.

Results

Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital’s side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients.

Conclusion

Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

Strategies to Modify the Risk of Heart Failure Readmission: A Systematic Review and Meta-Analysis

Background:

Human factors play an important role in health-care outcomes of heart failure (HF) patients. A systematic review and meta-analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies.

Purpose:

To investigate how the 8 guiding principles of choice, rest, environment, activity, trust, interpersonal relationships, outlook, and nutrition reduce HF readmissions.

Basic Procedures:

Appropriate keywords were identified related to the (1) independent variable of hospitalization and treatment, (2) the moderating variable of care management principles, (3) the dependent variable of readmission, and (4) the disease of HF to conduct searches in 9 databases. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ERIC, MEDLINE, PubMed, PsycInfo, Science Direct, and Web of Science. Only prospective studies associated with HF hospitalization and readmissions, published in English, Chinese, Spanish, and German journals between January 1, 1990, and August 31, 2015, were included in the systematic review. In the meta-analysis, data were collected from studies that measured HF readmission for individual patients.

Main Findings:

The results indicate that an intervention involving any human factor principles may nearly double an individual’s probability of not being readmitted. Participants in interventions that incorporated single or combined principles were 1.4 to 6.8 times less likely to be readmitted.

Principal Conclusions:

Interventions with human factor principles reduce readmissions among HF patients. Overall, this review may help reconfigure the design, implementation, and evaluation of clinical practice for reducing HF readmissions in the future.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.