This article is more than 5 years old. Information may no longer be current.
Transitional care model fails to improve outcomes in HF
Click Here to Manage Email Alerts
A care model to transition patients with HF from the hospital back to home had no significant effect on clinical outcomes compared with the usual care, according to the results of the PACT-HF study.
In the cluster-randomized trial of 10 hospitals in Ontario, Canada, the researchers analyzed 2,494 adults (mean age, 78 years; 50% women) hospitalized for HF between February 2015 and March 2016. Follow-up was conducted until November 2016.
Patients from hospitals assigned the intervention received self-care education led by a nurse, a structured hospital discharge summary and a follow-up appointment with their family physician 1 week after discharge. Patients in the intervention group at high risk also received structured nurse home visits and heart function clinic care. Patients from hospitals assigned the usual care had transitional care at the discretion of their clinicians.
The primary outcomes were hierarchically ordered as all-cause readmission/ED visit/death at 3 months followed by all-cause readmission/ED visit at 30 days.
Harriette G.C. Van Spall, MD, MPH, from the Population Health Research Institute and the departments of medicine and health research, evidence and impact at McMaster University, Hamilton, Ontario, Canada, and colleagues found no difference between the groups in all-cause readmission/ED visit/death at 3 months (intervention, 49.4%; control, 50.2%; HR = 0.99; 95% CI, 0.83-1.19) or in all-cause readmission/ED visit at 30 days (intervention, 27.5%; control. 29.3%; HR = 0.93; 95% CI, 0.73-1.18).
Compared with the control group, the B-PREPARED score was worse in the intervention group (intervention, 16.6; control, 13.9; difference, 2.65; 95% CI, 1.37-3.92), but the three-item Care Transitions Score was better (intervention, 76.5; control, 70.3; difference, 6.16; 95% CI, 0.9-11.43), according to the researchers.
Mean five-level EQ-5D quality of life score was better in the intervention group at 6 weeks and 6 months (P = .02 for both), Van Spall and colleagues wrote.
Mean quality-adjusted life-years did not differ between the groups at 6 months (0.3 for both groups; P = .98), according to the researchers.
“An implication of these results is that health services with demonstrated efficacy in explanatory [randomized controlled trials] may not be effective in improving clinical outcomes when implemented at the level of the health care system,” Van Spall and colleagues wrote. “Whether this type of intervention could be effective in other health care systems or locations requires further research.” – by Erik Swain
Disclosures: Roche Diagnostics provided in-kind support during the conduct of the study. Van Spall reports she receives speaker fees from Roche Diagnostics. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
Javed Butler, MD, MPH, MBA, FACC, FAHA, FESC
Observational data suggest that patients with earlier post discharge follow-up have lower readmission rates. Other observational data also suggest improved outcomes with various aspects of transitions of care optimization. However, observational data can be influenced by confounding or bias. In this randomized control trial, we did not find any improvement with patient centered transitional care services. These data raise the question regarding the purported benefit with focus on early follow-up, but at the same time, perhaps the usual care in the trial setting received better care than usual care in real life.
The model is based on common sense good medical practices, but these data also suggest that a lot of the outcomes in these patients may be driven by the biology of the disease process. Hence, along with transitions of care, development of novel therapies impacting the biology of the disease process may enhance outcomes.
Strong emphasis on aggressive optimization of medical therapy for HF and treatment of comorbidities in addition to transitions of care as an intervention might improve outcomes.
We should be careful making policy decisions and guideline recommendations based primarily on observational data.
Click Here to Manage Email Alerts