Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials

BACKGROUND

Heart failure (HF) imposes a substantial burden on patients and healthcare systems. Hospital-to-home transitional care, involving time-limited interventions delivered predominantly by nurses, was introduced to lighten this burden. This study aimed to examine the effectiveness and dose-response of nurse-led transitional care interventions (TCIs) on healthcare utilization among patients with HF.

METHODS

Health-related databases were systematically searched for articles published from January 2000 to June 2020. We included randomized controlled trials (RCTs) that compared nurse-led TCIs with usual care for adults hospitalized with HF and reported the following healthcare utilization outcomes: all-cause readmissions, HF-specific readmissions, emergency department visits, or length of hospital stay. Random-effects meta-analysis, meta-regression analysis, and dose-response analysis were performed to estimate the treatment effects and explain the heterogeneity.

RESULTS

Twenty-five RCTs including 8422 patients with HF were included. Nurse-led TCIs for patients with HF resulted in a mean 9% (RR = 0.91; 95% CI = 0.82 to 0.99; p = 0.04; I2 = 46%) and 29% (RR = 0.71; 95% CI = 0.60 to 0.84; p < 0.0001; I2 = 0%) reduction in all-cause and HF-specific readmission risks respectively compared to usual care. The interventions were also effective in shortening the length of hospital stay (MD = -2.37; 95% CI = -3.16 to -1.58; p < 0.0001; I2 = 14%). However, no significant reduction was found for emergency department visits (RR = 0.96; 95% CI = 0.84 to 1.10; p = 0.58; I2 = 0%). The effect of meta-regression coefficients on all-cause and HF-specific readmissions was not statistically significant for any prespecified trial-level characteristic. Dose-response analysis revealed that the HF-specific readmission risk decreased in a dose-dependent manner with the complexity and intensity of nurse-led TCIs.

CONCLUSIONS

Nurse-led TCIs were effective in decreasing all-cause and HF-specific readmission risks, as well as in reducing the length of hospital stay; however, the interventions were not effective in reducing the frequency of emergency department visits.

Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities

BACKGROUND

The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known.

OBJECTIVES

Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals.

RESEARCH DESIGN

Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans.

SUBJECTS

Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient.

MEASURES

Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge.

RESULTS

Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission.

CONCLUSIONS

While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.

Trends in Utilization of Transitional Care Management in the United States

This economic evaluation uses Medicare claims data to evaluate changes in utilization of and Medicare payments for transitional care management services from 2013 to 2018.

Transitional Care Home Visits Among Underserved Patients With Heart Failure

Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination.

Healthcare needs and programmatic gaps in transition from pediatric to adult care of vertically transmitted HIV infected adolescents in India

Treatment transition for 'adolescents living with perinatally acquired HIV' (ALPH) from paediatric to adult care is not addressed adequately. This study explores the ALPH's health care needs and programmatic gaps in health systems for the care of ALPH in India. Forty-nine in-depth interviews were conducted with purposively selected primary and key stakeholders in India. Thematic analysis utilizing grounded theory was performed in QSR NUD*IST 6. Stakeholders explicitly recognized adolescent HIV to be a critical public health issue which requires a separate mandate in India. It was found that none of the health policies in India focus on adolescent age group; ALPH is therefore even more neglected population. No/partial HIV disclosure to ALPH is the first crisis for retention in care continuum and adherence to the treatment becomes sub-optimal. Unmet needs of transitioning from paediatric to adult care in existing settings was the major gap. Age-specific counselling guidelines and counselling skills among HCPs were found lacking where tailored counseling and capacity building of HCPs was an expectation. Need of holistic approach for adolescents led to consensus on establishing 'adolescent transition clinic' with a strict 'no' for 'standalone Adolescent HIV' clinics. School setting having peer-based counselling provision was recommended. Age disaggregated health data is required to inform the policymakers about adolescents’ specific needs for developing interventions. Situational analysis to identify and shape health priorities of adolescents is recommended.

Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol of a prospective single centre quasi-experimental study

BACKGROUND

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed.

METHODS

The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality.

DISCUSSION

URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive.

TRIAL REGISTRATION

The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).

Transitioning Together: A Multi-family Group Psychoeducation Program for Adolescents with ASD and Their Parents

Currently there are few evidence-based programs available for families of individuals with ASD during the transition to adulthood. The present study provided a preliminary evaluation of a multi-family group psychoeducation intervention using a randomized waitlist control design (n = 41). Families in the intervention condition participated in Transitioning Together, an 8-week program designed to reduce family distress and improve social functioning for adolescents. Findings indicated significant improvements in parental depressive symptoms and problem solving from pre- to post-intervention for parents in the intervention condition but not for parents in the control condition. Social interactions also improved for youth in the intervention condition relative to controls. Parents reported satisfaction with the program and particularly valued the opportunity to interact with other families.