Manuel R. Blum, MD, MSc *; Henning Øien, PhD *; Harris L. Carmichael, MD; Paul Heidenreich, MD; Douglas K. Owens, MD, MS; Jeremy D. Goldhaber-Fiebert, PhD
Disclaimer: The views expressed in this paper are those of the authors and not necessarily the U.S. Department of Veterans Affairs or the U.S. government.
Financial Support: Dr. Øien's work was supported by the Research Council of Norway: Project 256644, “A cross-sectoral approach to high quality health care transitions for older people.” Dr. Blum's work was supported by a grant from the Swiss National Science Foundation (P2BEP3_175289). Dr. Carmichael's work was supported by the Intermountain–Stanford Collaboration Fellowship in Population Health and Care Delivery Science. Drs. Heidenreich and Owens were supported by the U.S. Department of Veterans Affairs.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1980.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code and data set: Available on the Open Science Framework (Center for Open Science) Web site (https://osf.io/pngc5/?view_only=6e6f52ef2f93486d99c343dd68a9c1f1).
Corresponding Author: Jeremy D. Goldhaber-Fiebert, PhD, Stanford Health Policy, Centers for Primary Care and Outcomes Research and Health Policy, Stanford University, 615 Crothers Way, Encina Commons, MC6019, Stanford, CA 94305; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Blum: Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland.
Dr. Øien: Norwegian Institute of Public Health, P.O. Box 222 Skøyen, 0213 Oslo, Norway.
Dr. Carmichael: Intermountain Healthcare Delivery Institute, 5026 South State Street, 3rd Floor, Murray, UT 84107.
Dr. Heidenreich: 111C Cardiology, Palo Alto VA Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.
Drs. Owens and Goldhaber-Fiebert: Stanford University, 615 Crothers Way, Encina Commons, MC6019, Stanford, CA 94305.
Author Contributions: Conception and design: final concept and design—M.R. Blum, H. Øien, H.L. Carmichael, D.K. Owens, J.D. Goldhaber-Fiebert; original concept—H.L. Carmichael.
Analysis and interpretation of the data: M.R. Blum, H. Øien, H.L. Carmichael, P. Heidenreich, D.K. Owens, J.D. Goldhaber-Fiebert.
Drafting of the article: M.R. Blum, H. Øien, H.L. Carmichael.
Critical revision for important intellectual content: M.R. Blum, H. Øien, H.L. Carmichael, P. Heidenreich, D.K. Owens, J.D. Goldhaber-Fiebert.
Final approval of the article: M.R. Blum, H. Øien, H.L. Carmichael, P. Heidenreich, D.K. Owens, J.D. Goldhaber-Fiebert.
Statistical expertise: M.R. Blum, H. Øien, D.K. Owens, J.D. Goldhaber-Fiebert.
Obtaining of funding: M.R. Blum, H. Øien.
Administrative, technical, or logistic support: J.D. Goldhaber-Fiebert.
Collection and assembly of data: M.R. Blum, H. Øien, H.L. Carmichael.
Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.
To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care.
Decision analytic microsimulation model.
Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data.
Patients with HF who were aged 75 years at hospital discharge.
Health care sector.
Disease management clinics, nurse home visits (NHVs), and nurse case management.
Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs).
All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained.
Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained.
Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings.
In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF.
Swiss National Science Foundation, Research Council of Norway, and an Intermountain–Stanford collaboration.
Blum MR, Øien H, Carmichael HL, et al. Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure. Ann Intern Med. 2020;172:248–257. [Epub ahead of print 28 January 2020]. doi: https://doi.org/10.7326/M19-1980
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Published: Ann Intern Med. 2020;172(4):248-257.
Published at www.annals.org on 28 January 2020
Cardiology, Heart Failure, High Value Care, Hospital Medicine.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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