Crystal W. Cené

Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.

Heart failure (HF) is a leading cause of hospitalization and health care costs in the United States (1). Up to 25% of patients hospitalized with HF are readmitted within 30 days (25). Readmissions after an index hospitalization for HF are related to various conditions. An analysis of Medicare claims data from 2007 to 2009 found that 35% of readmissions within 30 days were for HF; the remainder were for diverse indications (for example, renal disorders, pneumonia, and arrhythmias) (2). To reduce rehospitalization of Medicare patients, in October 2012, the Centers for Medicare & Medicaid Services began decreasing reimbursements to hospitals with excessive risk-standardized readmission (6). This policy incentivizes hospitals to develop programs to reduce readmission rates for persons with HF. Despite advances in the quality of acute and chronic HF disease management, knowledge gaps remain about effective interventions to support the transition of care for persons with HF. Interventions designed to prevent readmissions among populations transitioning from one care setting to another are often called transitional care interventions (7, 8). They aim to avoid poor outcomes caused by uncoordinated care, such as preventable readmissions (9). Although no clear set of components defines transitional care interventions, they focus on patient or caregiver education, medication reconciliation, and coordination among health professionals involved in the transition. We conducted a systematic review of transitional care interventions for persons with HF for the Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) (10). We included a broad range of intervention types (Table 1) applicable to adults transitioning from hospital to home that aimed to prevent readmissions. Although 30-day readmissions are the focus of quality measures, we also included readmissions measured over 3 to 6 months because these are common, costly, and potentially preventable (5). The full technical report addressed 5 questions (Appendix Table 1). For this article, we focused on readmission and mortality outcomes. Table 1. Transitional Care Interventions Appendix Table 1. Scope and Key Questions* Methods We developed and followed a standard protocol. A technical report that details methods and includes complete search strategies and additional evidence tables is available at www.effectivehealthcare.ahrq.gov/reports/final.cfm. Data Sources and Searches We searched MEDLINE, the Cochrane Library, and CINAHL for English-language and human-only studies published from 1 July 2007 to late October 2013, and we used a previous technology assessment on a similar topic to identify randomized, controlled trials (RCTs) published before 1 July 2007 (11). An experienced Evidence-based Practice Center librarian conducted the searches, and a second librarian reviewed them. We manually searched reference lists of pertinent reviews, included trials, and background articles on this topic to look for relevant citations our searches might have missed. We searched for relevant unpublished studies using ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. Study Selection We developed inclusion and exclusion criteria with respect to populations, interventions, comparators, outcomes, timing, settings, and study designs (Appendix Table 2). We included studies of adults recruited during or within 1 week of an index hospitalization for HF that compared a transitional care intervention with another eligible intervention or with usual care (that is, routine or standard care, as defined by the primary studies). We required that interventions include 1 or more of the following components: education of patient or caregiver delivered before or after discharge, planned or scheduled outpatient clinic visits (primary care or multidisciplinary heart failure [MDS-HF] clinic), home visits, telemonitoring, structured telephone support (STS), transition coach or case management, or interventions to increase provider continuity. We required studies to report a readmission rate, mortality rate, or the composite outcome (all-cause readmission or mortality). In the full report, we also assessed emergency department visits, acute care visits, hospital days of subsequent readmissions, quality of life, functional status, and caregiver or self-care burden (10). Appendix Table 2. Inclusion and Exclusion Criteria for Studies of Transitional Care Interventions for Patients Hospitalized for HF Data Extraction and Risk-of-Bias Assessment One team member extracted relevant data from each article, and a second team member reviewed all data extractions for completeness and accuracy. We used predefined criteria based on the AHRQ Methods Guide for Comparative Effectiveness Reviews (12) to rate studies as having low, medium, high, or unclear risk of bias. Two reviewers independently assessed risk of bias for each study, and disagreements were resolved by consensus. Data Synthesis and Analysis We categorized intervention types primarily on the basis of the method and environment of delivery, as defined in Table 1. One investigator categorized the intervention, and a second team member reviewed the categorization. Disagreements were resolved by consensus. Given heterogeneity of the clinic-based interventions, we subcategorized these by clinic setting: MDS-HF, nurse-led HF, or primary care. We used DerSimonianLaird random-effects models (13) for meta-analyses of outcomes reported by multiple studies that were sufficiently similar to justify combining results. We ran meta-analyses of trials that reported the number of deaths or number of persons readmitted in each group (and not total readmissions per group). When only the total number of readmissions per group was available, we contacted authors for additional data. When we could not obtain the number of persons readmitted, we did not include the results in meta-analyses; instead, we included the results in qualitative syntheses and considered them when grading the strength of evidence (SOE). For readmission and mortality rates, we calculated risk ratios (RRs). We stratified analyses for each intervention category by outcome timing and separated rates reported at 30 days from those after 30 days (that is, rates reported over 3 to 6 months were combined). We did not include studies rated as high or unclear risk of bias in our main analyses but included them in sensitivity analyses, which are available in the technical report (10); we describe them here only when they differed from primary analyses. We assessed statistical heterogeneity using the chi-square and I 2 statistics (14, 15). We calculated the number needed to treat (NNT) for readmission and mortality outcomes when we had statistically significant findings based on our primary analyses of trials rated as low or medium risk of bias, and we found at least low SOE for benefit. The NNT was derived from the RR and median usual care event rate using methods described in the Cochrane Handbook (16). We conducted meta-analyses using Stata, version 11.1 (StataCorp, College Station, Texas). We did meta-analysis stratified by intensity in each intervention category when variation existed. The results of these subgroup analyses are available in the main report (10); we describe them here only when we found a difference in efficacy based on level of intensity. Given the heterogeneity of included interventions, we could not develop a single measure of intensity that could be applied to all intervention categories. For most interventions, we defined intensity as the duration, frequency, or periodicity of patient contact and categorized each intervention as low-, medium-, or high-intensity. We reserved the low-intensity category for interventions that included 1 episode of patient contact or few resources. We graded SOE as high, moderate, low, or insufficient based on guidance established for the Evidence-based Practice Center program (17). The approach incorporates 4 key domains: risk of bias, consistency, directness, and precision. When only 1 study reported an outcome of interest, we usually graded the SOE as insufficient (primarily due to unknown consistency and imprecision); however, when similar interventions had consistent results at other time points, we graded the SOE as low. Two reviewers assessed each domain for each outcome, and differences were resolved by consensus. Role of the Funding Source The AHRQ funded this review, and AHRQ staff participated in the development of the scope of the work and reviewed draft manuscripts. Approval from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for publication. Results Searches of all sources identified 2419 potentially relevant citations. We included 47 RCTs (Appendix Figure 1). Trial characteristics are shown in Appendix Table 3. Most trials compared a transitional care intervention with usual care; 2 directly compared more than 1 intervention (both rated high risk of bias) (18, 19). In general, trials included adults with a mean age of 70 years who were hospitalized with a primary diagnosis of HF. Most reported HF disease severity based on the New York Heart Association classification and included persons with moderate to severe HF. Twenty-nine trials reported mean ejection fraction. Of these, 27 enrolled persons with a mean ejection fraction less than 0.50 and 7 trials specified a reduced ejection fraction as an inclusion criterion. Across most trials, the majority of patients were prescribed an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. The percentages of patients who were prescribed -blockers at discharge varied widely across trials. Trials were conducted in a range of settings: academic medical centers, Department of Veterans Affairs hospitals,

Multisite Randomized Trial of a Single-Session Versus Multisession Literacy-Sensitive Self-Care Intervention for Patients With Heart Failure

Background— Self-care training can reduce hospitalization for heart failure (HF), and more intensive intervention may benefit more vulnerable patients, including those with low literacy. Methods and Results— A 1-year, multisite, randomized, controlled comparative effectiveness trial with 605 patients with HF was conducted. Those randomized to a single session received a 40-minute in-person, literacy-sensitive training; the multisession group received the same initial training and then ongoing telephone-based support. The primary outcome was combined incidence of all-cause hospitalization or death; secondary outcomes included HF-related hospitalization and HF-related quality of life, with prespecified stratification by literacy. Overall, the incidence of all-cause hospitalization and death did not differ between intervention groups (incidence rate ratio, 1.01; 95% confidence interval, 0.83–1.22). The effect of multisession training compared with single-session training differed by literacy group: Among those with low literacy, the multisession training yielded a lower incidence of all-cause hospitalization and death (incidence rate ratio, 0.75; 95% confidence interval, 0.45–1.25), and among those with higher literacy, the multisession intervention yielded a higher incidence (incidence rate ratio, 1.22; 95% confidence interval, 0.99–1.50; interaction P=0.048). For HF-related hospitalization, among those with low literacy, multisession training yielded a lower incidence (incidence rate ratio, 0.53; 95% confidence interval, 0.25–1.12), and among those with higher literacy, it yielded a higher incidence (incidence rate ratio, 1.32; 95% confidence interval, 0.92–1.88; interaction P=0.005). HF-related quality of life improved more for patients receiving multisession than for those receiving single-session interventions at 1 and 6 months, but the difference at 12 months was smaller. Effects on HF-related quality of life did not differ by literacy. Conclusions— Overall, an intensive multisession intervention did not change clinical outcomes compared with a single-session intervention. People with low literacy appear to benefit more from multisession interventions than people with higher literacy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00378950.

Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health

The opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. We review scientific evidence from promising interventions focused on the social determinants of health and discuss how such interventions can improve population health and reduce health disparities. We found sufficient evidence of successful outcomes to support disparity-reducing policy interventions targeted at education and early childhood; urban planning and community development; housing; income enhancements and supplements; and employment. Cost-effectiveness evaluations show that these interventions lead to long-term societal savings, but the interventions require more routine attention to cost considerations. We discuss challenges to implementation, including the need for long-term financing to scale up effective interventions for implementation at the local, state, and national levels.

Self-Care Confidence Mediates the Relationship Between Perceived Social Support and Self-Care Maintenance in Adults With Heart Failure

BACKGROUND Social support may be associated with heart failure (HF) self-care; however, the mechanisms are not well understood. We examined the association between perceived support and self-care behaviors and whether self-care confidence mediates these relationships. METHODS Cross-sectional survey of HF patients seen in outpatient clinic settings. Our outcome (HF self-care maintenance and self-care management) and mediator (HF self-care confidence) variables were assessed with the Self-Care of Heart Failure Index. Perceived emotional/informational support was assessed with the Medical Outcomes Study social support survey. We performed regression analyses to examine associations between perceived support and HF self-care behaviors. Mediation analysis was performed according to the Baron and Kenny method. RESULTS We surveyed 150 HF patients (mean age 61 y; 51% female; 43% black). More emotional/informational support was associated with better self-care maintenance (β = 0.13; P = .04). More emotional/information support was associated with better self-care management in unadjusted (β = 0.23; P = .04), but not adjusted (β = 0.20, P = .10), analysis. Self-care confidence mediates the association between perceived support and self-care maintenance (percent change in β coefficient was 32%) and management (percent change in β coefficient was 20%). CONCLUSION Perceived emotional/informational support is associated with better self-care maintenance and possibly better self-care management. Greater self-care confidence is one mediating mechanism.

Is adherence to weight monitoring or weight-based diuretic self-adjustment associated with fewer heart failure-related emergency department visits or hospitalizations?

BACKGROUND Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. METHODS AND RESULTS We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23-0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19-0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. CONCLUSIONS Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity.

Community-based Teaching about Health Disparities: Combining Education, Scholarship, and Community Service

The Institute of Medicine recommends that clinicians receive training to better understand and address disparities. While disparities in health status are primarily due to inequities in social determinants of health, current curricula largely focus on how to teach about disparities within the health care setting. Learners may more fully understand and appreciate how social contextual factors contribute to disparities through instruction about disparities in community settings. Community-based teaching about health disparities may be advantageous for learners, medical institutions, and participating communities. This manuscript aims to guide medical educators in teaching students and residents about health disparities through community-based activities, including service learning and research.The Institute of Medicine recommends that clinicians receive training to better understand and address disparities. While disparities in health status are primarily due to inequities in social determinants of health, current curricula largely focus on how to teach about disparities within the health care setting. Learners may more fully understand and appreciate how social contextual factors contribute to disparities through instruction about disparities in community settings. Community-based teaching about health disparities may be advantageous for learners, medical institutions, and participating communities. This manuscript aims to guide medical educators in teaching students and residents about health disparities through community-based activities, including service learning and research.

Social isolation, vital exhaustion, and incident heart failure: Findings from the Atherosclerosis Risk in Communities Study

Prospective studies have shown that social isolation (i.e. lack of social contacts) predicts incident coronary heart disease (CHD), but it is unclear whether it predicts incident heart failure (HF) and what factors might mediate this association. HF patients may be more susceptible to social isolation as they tend to be older and may have disrupted social relationships due to life course factors (e.g. retirement or bereavement). We prospectively examined whether individuals with higher vs. low social isolation have a higher incidence of HF and determined whether this association is mediated by vital exhaustion.

The heart healthy lenoir project-an intervention to reduce disparities in hypertension control: study protocol

BackgroundRacial disparities in blood pressure control are well established; however the impact of low health literacy (LHL) on blood pressure has garnered less attention. Office based interventions that are created with iterative patient, practice and community stakeholder input and are rolled out incrementally, may help address these disparities in hypertension control. This paper describes our study protocol.Methods/designUsing a community based participatory research (CBPR) approach, we designed and implemented a cohort study that includes both a practice level and patient level intervention to enhance the care and support of patients with hypertension in primary care practices in a rural region of eastern North Carolina. The study is divided into a formative phase and an ongoing 2.5 year implementation phase. Our main care enhancement activities include the integration of a community health coach, using home blood pressure monitoring in clinical decision making, standardizing care delivery processes, and working to improve medication adherence. Main outcomes include overall blood pressure change, the differential change in blood pressure by race (African American vs. White) and health literacy level (low vs. higher health literacy).DiscussionUsing a community based participatory approach in primary care practice settings has helped to engage patients and practice staff and providers in the research effort and in making practice changes to support hypertension care. Practices have engaged at varying levels, but progress has been made in implementing and iteratively improving upon the interventions to date.Trial registrationClinicalTrials.gov NCT01425515.

Implementation of the power to prevent diabetes prevention educational curriculum into rural African American communities: a feasibility study.

Purpose The purpose of this study was to describe the feasibility of using a community-based participatory research (CBPR) approach to implement the Power to Prevent (P2P) diabetes prevention education curriculum in rural African American (AA) settings. Methods Trained community health workers facilitated the 12-session P2P curriculum across 3 community settings. Quantitative (based on the pre- and post-curriculum questionnaires and changes in blood glucose, blood pressure [BP], and weight at baseline and 6 months) and qualitative data (based on semi-structured interviews with facilitators) were collected. Indicators of feasibility included: demand, acceptability, implementation fidelity, and limited efficacy testing. Results Across 3 counties, 104 AA participants were recruited; 43% completed ≥ 75% of the sessions. There was great demand for the program. Fifteen community health ambassadors (CHAs) were trained, and 4 served as curriculum facilitators. Content and structure of the intervention was acceptable to facilitators but there were challenges to implementing the program as designed. Improvements were seen in diabetes knowledge and the impact of healthy eating and physical activity on diabetes prevention, but there were no significant changes in blood glucose, BP, or weight. Conclusion While it is feasible to use a CBPR approach to recruit participants and implement the P2P curriculum in AA community settings, there are significant challenges that must be overcome.

Comparing effects of tobacco use prevention modalities: need for complex system models

Many modalities of tobacco use prevention programming have been implemented including various policy regulations (tax increases, warning labels, limits on access, smoke-free policies, and restrictions on marketing), mass media programming, school-based classroom education, family involvement, and involvement of community agents (i.e., medical, social, political). The present manuscript provides a glance at these modalities to compare relative and combined impact of them on youth tobacco use. In a majority of trials, community-wide programming, which includes multiple modalities, has not been found to achieve impacts greater than single modality programming. Possibly, the most effective means of prevention involves a careful selection of program type combinations. Also, it is likely that a mechanism for coordinating maximally across program types (e.g., staging of programming) is needed to encourage a synergistic impact. Studying tobacco use prevention as a complex system is considered as a means to maximize effects from combinations of prevention types. Future studies will need to more systematically consider the role of combined programming.