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Discharge planning for CHF

Systematic review
Results
Comment

It is common for older people with congestive heart failure (CHF) to be readmitted to hospital within six months of hospital discharge. In the USA, up to half might expect to be readmitted, and it is stressful for the patients themselves, as well as consuming considerable resources. A new systematic review suggests that comprehensive discharge planning with post-discharge support can reduce readmission rates, and probably increase quality of care at lower cost [1].

Systematic review

Seven electronic data sources and reference lists were searched for studies. Included were English-language publications of randomised trials with detailed descriptions of interventions to modify discharge for older inpatients. Older meant study mean age of 55 years or more. Studies specifically addressing heart failure, that described components of inpatient care and of post-discharge support compared with usual care, and which reported readmission rates, were accepted.

Results

Eighteen randomised trials were eligible, from North America, Europe, and Australia. Though most studies could not be double blind, most reported blinded assessment of outcomes and scored well on a common scale of reporting quality, indicating little possibility of bias. All studies had more than 90% of patients participate in the whole study, and study duration was three to 12 months.

There were various interventions, with various components, which were split into five main categories (Table 1). Compared with usual care, most interventions produced lower readmission rates (Figure 1). The average readmission rate was 43% with usual care, reduced to 35% with the intervention.



Table 1: Results for different intervention plans according to post-discharge support



Number of
Readmission (%) with
Type of intervention
Studies
Patients
Intervention
Control
Relative benefit
(95% CI)
NNT
(95% CI)
Single home visit
3
476
41
53
0.8 (0.6 to 0.9)
8 (5 to 29)
Increased clinic follow up and/or frequent telephone contact
4
765
41
39
1.0 (0.9 to 1.2)
64 (19 to -11)
Home visit and/or frequent telephone contact
6
970
38
49
0.8 (0.7 to 0.9)
9 (6 to 22)
Extended home care services
4
859
30
36
0.8 (0.7 to 0.99)
17 (8 to -300)
Day hospital services
1
234
8
30
0.3 (0.1 to 0.5)
4 (3 to 8)
All studies
18
3304
35
43
0.8 (0.7 to 0.9)
13 (9 to 21)




Figure 1: Readmission rates in patients with CHF with post-discharge support







Significantly lower rates were found for all categories except one (Table 1). Overall, one readmission was avoided for every 13 patients included in comprehensive discharge planning with some post-discharge support. In the 13 trials that concentrated on home contacts or services, readmission rates with intervention were 36% compared with 45% in usual care, and the NNT to prevent one readmission was 10 (7 to 17).

Sensitivity analysis showed no significant differences with age, severity of left ventricular function, ACE inhibitor use, duration of follow up, size of trial, or for US versus other countries. Heart failure or cardiovascular specific readmission had similar absolute risk reduction.

Mortality was not significantly different, at 17% for usual care and 14% for intervention patients. The relative risk was 0.9 (0.7 to 1.03). Quality of life was significantly better in intervention patients.

Eleven studies reported medical costs in a variety of ways. The pooled cost difference favoured intervention patients, with a mean reduction of $536 and $359 in US and non-US studies. The cost of delivering the intervention was $81 (range $76 to $116) per patient per month in the US studies, and $56 (range $17 to $104) per patient per month in non-US studies.

Comment

This is a good review on an important topic. It is gratifying that there were as many as 18 randomised trials of a management rather than a clinical intervention, and that there was a clear answer. A better-planned care pathway produced better health outcomes and better quality of life to patients, and at lower cost.

Where comprehensive discharge planning with post-discharge support for older patients with congestive heart failure is routine, participants can be happy that they are doing well. Where such a service does not exist, this provides the framework for thinking about change.

Reference:

  1. CO Phillips et al. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004 291: 1358-1367.

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