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.
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