Transitional care services ‘preferred’ over standard care after HF discharge
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Among older patients hospitalized with heart failure, transitional care services, particularly nurse home visits, improved health outcomes and appeared to be more cost effective than standard care, according to research published in the Annals of Internal Medicine.
The findings demonstrate that postdischarge transitional care services are “preferred to standard care” in this patient population, Manuel R. Blum, MD, MSc, of the Stanford University School of Medicine and Bern University Hospital and University of Bern, Switzerland, and colleagues wrote.
“Patients with HF requiring inpatient admission are a vulnerable population and have a poor long-term prognosis, with a 2-year readmission-free survival rate as low as 17%,” they wrote. “Risks for death and rehospitalization are accentuated immediately after inpatient discharge, with much of the economic burden in HF resulting from costly hospital readmissions.”
Blum and colleagues created a decision analytic microsimulation model to determine whether patients with HF aged 75 years or older should receive standard care after hospital discharge or follow-up transitional care. They used data from randomized controlled trials, clinical registries, cohort studies, CDC tables, CMS data and information from the National Inpatient Sample.
The model compared three interventions to standard care for patients with HF discharged from the hospital — nurse home visits, which consisted of a nurse visiting patients’ homes for clinical assessments and education; nurse case management, a nurse-led multifaceted disease management program that provided self-care education, telephone support and occasionally nurse home visits; and disease management clinics, where patients went to follow-up visits at clinics for team-based, multidisciplinary HF management.
The model showed that all three transitional care interventions were more costly and more effective compared with standard care. However, nurse home visits were the most costly and effective of the three.
Compared with standard care, nurse home visits increased QALYs by approximately 0.24 (2.49 vs. 2.25), survival by approximately 4 months and lifetime health care costs by $4,622 ($81,327 vs. $76,705). Cost increases were primarily attributed to longer periods of care for HF stemming from increased life expectancy. The incremental cost-effectiveness ratio was $19,570 per QALY gained.
Results were mostly insensitive to variations in in-hospital mortality, patient age at baseline or rehospitalization costs.
A probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care for 99.8% of 10,000 samples with willingness-to-pay thresholds over $50,000 or more per QALY.
Blum and colleagues noted that as the relative differences between the three services identified in the study were small, “one of the transitional care services in this analysis should become part of standard care for post-discharge management of patients with HF, but the best implementation choice among [nurse home visits, nurse case management, and disease management clinics] may depend on setting-specic features.”
Leora I. Horwitz, MD, MHS, associate professor in the departments of population health and medicine at the New York University Grossman School of Medicine, made a few suggestions for incorporating these services into standard care, in an editorial accompanying the study.
“Standardized program protocols and training materials might help increase intervention delity and effectiveness,” she explained. “Explicit insurance coverage or incentives for dedicated transitions programs — perhaps after certication or training based on a recognized standard — would also spur uptake.” – by Erin Michael
Disclosures: The study authors report no relevant financial disclosures. Horwitz reports receiving royalties from UpToDate outside the submitted work and previously working under contract to CMS to develop readmission measures for public reporting, including the hospital-wide readmission measure and excess days in acute care measures.