Cynthia Feltner, MD, MPH; Christine D. Jones, MD, MS; Crystal W. Cené, MD, MPH; Zhi-Jie Zheng, MD, PhD, MPH; Carla A. Sueta, MD, PhD; Emmanuel J.L. Coker-Schwimmer, MPH; Marina Arvanitis, MD; Kathleen N. Lohr, PhD, MPhil, MA; Jennifer C. Middleton, PhD; Daniel E. Jonas, MD, MPH
Disclaimer: The views expressed in this manuscript do not represent and should not be construed to represent a determination or policy of the AHRQ or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Carol Woodell of RTI International for her project management expertise; Loraine Monroe of RTI International for editing and formatting the technical report; and Christine Chang, MD, MPH, AHRQ task order officer, for her considerable support, commitment, and contributions.
Grant Support: In part by AHRQ (grant HHSA290201200008I) and the U.S. Department of Health and Human Services (contract HHSA29032003T).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0083.
Requests for Single Reprints: Cynthia Feltner, MD, MPH, Department of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, CB 7110, Chapel Hill, NC 27599; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Feltner and Jonas: Department of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, CB 7110, Chapel Hill, NC 27599.
Dr. Jones: University of Colorado School of Medicine, Mail Stop F782, 12401 East 17th Avenue, Aurora, CO 80045.
Drs. Cené and Arvanitis: Division of General Medicine, University of North Carolina at Chapel Hill, 5039 Old Clinic Building, CB 7110, Chapel Hill, NC 27599.
Dr. Zheng: RTI International, 6110 Executive Boulevard, Suite 902, Rockville, MD 20852.
Dr. Sueta: UNC Center for Heart & Vascular Care, 6th Floor, Burnette-Womack Building, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599.
Mr. Coker-Schwimmer and Dr. Middleton: RTI-UNC Evidence-based Practice Center, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, CB 7590, Chapel Hill, NC 27599.
Dr. Lohr: RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709.
Author Contributions: Conception and design: C. Feltner, C.D. Jones, C.W. Cené, Z.J. Zheng, D.E. Jonas.
Analysis and interpretation of the data: C. Feltner, C.D. Jones, C.W. Cené, Z.J. Zheng, C.A. Sueta, E.J.L. Coker-Schwimmer, M. Arvanitis, K.N. Lohr, D.E. Jonas.
Drafting of the article: C. Feltner, C.W. Cené, Z.J. Zheng, E.J.L. Coker-Schwimmer, M. Arvanitis, K.N. Lohr, D.E. Jonas.
Critical revision of the article for important intellectual content: C. Feltner, C.D. Jones, C.W. Cené, Z.J. Zheng, E.J.L. Coker-Schwimmer, K.N. Lohr, D.E. Jonas.
Final approval of the article: C. Feltner, C.D. Jones, C.W. Cené, Z.J. Zheng, C.A. Sueta, M. Arvanitis, K.N. Lohr, D.E. Jonas.
Provision of study materials or patients: Z.J. Zheng.
Statistical expertise: C. Feltner, D.E. Jonas.
Obtaining of funding: D.E. Jonas.
Administrative, technical, or logistic support: C. Feltner, E.J.L. Coker-Schwimmer, K.N. Lohr, J.C. Middleton, D.E. Jonas.
Collection and assembly of data: C. Feltner, C.D. Jones, C.A. Sueta, E.J.L. Coker-Schwimmer, M. Arvanitis, J.C. Middleton, D.E. Jonas.
Feltner C, Jones CD, Cené CW, Zheng Z, Sueta CA, Coker-Schwimmer EJ, et al. Transitional Care Interventions to Prevent Readmissions for Persons With Heart Failure: A Systematic Review and Meta-analysis. Ann Intern Med. 2014;160:774-784. doi: 10.7326/M14-0083
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Published: Ann Intern Med. 2014;160(11):774-784.
Nearly 25% of patients hospitalized with heart failure (HF) are readmitted within 30 days.
To assess the efficacy, comparative effectiveness, and harms of transitional care interventions to reduce readmission and mortality rates for adults hospitalized with HF.
MEDLINE, Cochrane Library, CINAHL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (1 January 1990 to late October 2013).
Two reviewers independently selected randomized, controlled trials published in English reporting a readmission or mortality rate within 6 months of an index hospitalization.
One reviewer extracted data, and another checked accuracy. Two reviewers assessed risk of bias and graded strength of evidence (SOE).
Forty-seven trials were included. Most enrolled adults with moderate to severe HF and a mean age of 70 years. Few trials reported 30-day readmission rates. At 30 days, a high-intensity home-visiting program reduced all-cause readmission and the composite end point (all-cause readmission or death; low SOE). Over 3 to 6 months, home-visiting programs and multidisciplinary heart failure (MDS-HF) clinic interventions reduced all-cause readmission (high SOE). Home-visiting programs reduced HF-specific readmission and the composite end point (moderate SOE). Structured telephone support (STS) interventions reduced HF-specific readmission (high SOE) but not all-cause readmissions (moderate SOE). Home-visiting programs, MDS-HF clinics, and STS interventions produced a mortality benefit. Neither telemonitoring nor primarily educational interventions reduced readmission or mortality rates.
Few trials reported 30-day readmission rates. Usual care was heterogeneous and sometimes not adequately described.
Home-visiting programs and MDS-HF clinics reduced all-cause readmission and mortality; STS reduced HF-specific readmission and mortality. These interventions should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for persons with HF.
Agency for Healthcare Research and Quality.
Table 1. Transitional Care Interventions
Appendix Table 1. Scope and Key Questions*
Appendix Table 2. Inclusion and Exclusion Criteria for Studies of Transitional Care Interventions for Patients Hospitalized for HF
Summary of evidence search and selection.
Appendix Table 3. Characteristics of Included Trials
Table 2. Summary of Key Findings and SOE, by Outcome and Intervention Category*
Table 3. Summary of Key Findings and SOE for Transitional Care Interventions: Readmission Rates and Mortality
All-cause readmissions for transitional care interventions compared with usual care, by intervention category and outcome timing.
Weights are from random-effects analysis. MDS-HF = multidisciplinary heart failure; RR = risk ratio.
* Number of people readmitted per group (not total readmissions per group).
Mortality rate among persons receiving transitional care interventions compared with usual care, by intervention category and outcome timing.
HF readmissions for transitional care interventions compared with usual care, by intervention category and outcome timing.
Weights are from random-effects analysis. HF = heart failure; MDS = multidisciplinary; RR = risk ratio.
Composite all-cause readmission or mortality for transitional care interventions compared with usual care, by intervention category and outcome timing.
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