Patient-centered transitional care services unlikely to benefit hospitalized heart failure patients
1. In this randomized controlled trial, patient-centered transitional care services did not improve a composite of clinical outcomes in hospitalized heart failure patients.
2. Patients who received transitional care had improved discharge readiness scores.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Heart failure (HF) is a leading cause of hospitalizations in older adults. A retrospective chart review showed 40% of early readmissions following HF hospitalization were related to suboptimal transitional care, though it is unknown if transitional care would be beneficial for these patients. In this randomized controlled trial, HF patients that received patient-centered transitional care did not have improved time to first all-cause readmission, fewer ED visits, or reduced mortality at 3 months. Patients who received transitional care did have improved discharge readiness scores.
Though prior explanatory trials had showed that these health services influenced clinical outcomes, this study suggests that these services may be less impactful when implemented on the health systems level. Services here were also titrated to risk, and it is possible there was benefit to patients that was not measureable by the employed indices. The study has several limitations, including being confined to urban hospitals in a single-payer system. Further, there was a wide distribution of resource intensity weights, a measure of resource utilization, in the intervention group. Improvements with usual care just prior to onset of the trial could have contributed to a ceiling effect.
Click to read the study in JAMA
Relevant Reading: Home-Time After Discharge Among Patients Hospitalized With Heart Failure
In-Depth [randomized clinical trial]: 2494 patients with HF in 10 hospitals in Ontario, Canada were included in the Patient-Centered Care Transitions in HF (PACT-HF) trial. During intervention phase, Boston criteria and/or serum thresholds of brain natriuretic peptide (BNP) or N-terminal prohormone BNP were used to exclude the diagnosis of HF. The interventions were introduced to 10 hospitals in a randomized sequence. Clinicians were unblinded to treatment allocation, and patients were considered unblinded. Primary clinical outcomes were hierarchically ordered as time to first composite all-cause readmission, ED visit, or death at 3 months and all-cause readmission or ED visit at 30 days among patients. Secondary patient-reported outcomes were the B-PREPARED score for discharge preparedness at 6 weeks (a higher score indicates a higher level of preparedness). There was no significant difference between the intervention and usual care group for the first primary outcome of time to first composite all-cause readmission, ED visit, or death at 3 months (HR 0.99; CI95 0.83 to 1.19). There was no significant difference between the intervention and usual care group in time to first composite all-cause readmission or ED visit at 30 days (HR 0.93; CI95 0.73-1.18). There were significant differences between the intervention and usual care groups in mean B-PREPARED scores (difference 2.65; CI95 1.37 to 3.92).
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