A patient-centered care model designed to transition patients with heart failure (HF) from hospital-to-home failed to improve outcomes compared to a usual care program, according to research published in JAMA.
Researchers for this study surmised that implementing a viable health care service that supports transition from hospital stay to home stands to improve outcomes in people with HF. Therefore, they sought to test the effectiveness of a patient-centered care transitions model on hospitalized HF patients.
Important trial showing that unfortunately these generic transition of care models for HF don’t actually work. Effect of Transitional Care Services on Outcomes Among Inpatients With Heart Failure https://t.co/qEkvPKxwtR @JJheart_doc @NMHheartdoc @JavedButler1 @coconnormd
— Gregg Fonarow MD (@gcfmd) February 26, 2019
Gauging Model Effectiveness
In this stepped-wedge cluster randomized trial of 2,494 patients (mean age, 77.7 years, 50.4% women) with HF across Ontario, between February 2015 and March 2016, researchers randomized 10 hospitals to implement the care model intervention (n= 1,104). The patient-centered program consisted of nurse-led self-care education, a structured hospital discharge summary, a family physician follow-up appointment within one week of discharge, as well as structured nurse home-visits and a heart function clinic for high-risk patients. In the usual care control group (n= 1,390), the transition plan was left to the discretion of physicians.
The primary study outcomes were ranked ordered as a composite of all-cause readmission, emergency department (ED) visit, or death at three months; and a composite all-cause readmission or ED visit at 30 days. Secondary outcomes included a B-PREPARED score for rating discharge preparedness (range: 0 [most prepared] to 22 [least prepared]); the 3-Item Care Transitions Measure (CTM-3) for quality transition (range: 0 [worst transition] to 100 [best transition]); the 5-level (EQ-5D-5L) for quality of life (range: 0 [dead] to 1 [full health]; and quality-adjusted-life-years (QALY) (range: 0 [dead] to 0.5 [healthy at 6 months]).
Disappointing that the effect of this intervention was so negligible. Great PRAGMATIC study and I commend the investigators! Keep at it! #transitionsofcare #patientsafety Effect of Transitional Care Services on Outcomes Among Inpatients With Heart Failure https://t.co/eexXQp8Ijy
— Joshua Denson MD (@jdensonMD) February 27, 2019
Care Model Fails to Move the Needle
The results suggested that for all 2,494 eligible trial participants, there was no discernible differences between the patient-care and usual care groups for the first primary composite outcome events (545 [49.4%] vs. 698 [50.2%], respectively, (HR=0.99; 95% CI, 0.83 to 1.19]) nor in the second primary events (304 [27.5%] vs. 408 [29.3%], respectively, (HR=0.93, 95% CI, 0.73 to 1.18]). Although results did indicate perceptible differences at six weeks in the average scores between the two groups in secondary outcomes of B-PREPARED (16.6 vs. 13.9; difference, 2.65, 95% CI, 1.37 to 3.92], CTM-3 (76.5 vs. 70.3; difference, 6.16 [95% CI: 0.90 to 11.43]) and EQ-5D-5L score (0.7 vs. 0.6; difference, 0.06, 95% CI: 0.01 to 0.12), the trial rendered no significant difference in the QALY between the two groups at a six-month interval (0.3 vs. 0.3).
While no effect of a HF care transitions model on primary outcome of utilization + death, @hvanspall found significant differences in many secondary #PatientCenteredOutcomes: discharge preparedness, post-discharge QOL, quality of transitions. Past time to #FlipTheOutcomes. https://t.co/vRubH3hdrn
— Anand S. Iyer, MD, MSPH (@anandiyermd) February 27, 2019
The researchers concluded that in these HF patients, the patient-centered program having no effect on clinical outcomes compared to a usual care model. In a cessation of their findings, researchers remarked that whether “this type of intervention could be effective in other health care systems of locations would require further research.”