Article Figures & Data
Figures
- Figure 1
Trial selection flowchart.
- Figure 2
Forest plot for all-cause readmission (presented by weight).
Note: Percentage of patients with events: 45.9% in the incidence group and 47.8% in the control group.
aCluster randomization.
bTelephone and video telephone follow-up.
cTelecare.
dTelephone follow-up.
eIntervention guided by N-terminal pro-B-type natriuretic peptide.
fMultidisciplinary intervention.
gFollow-up in clinic.
hFollow-up in clinic and monthly contact with the nurse.
- Figure 3
Forest plot for all-cause emergency department visits (presented by weight).
Note: Percentage of patients with events: 34.3% in the intervention group and 45.4% in the control group.
M-H = Mantel-Haenszel
Tables
Intensity Component(s) Low Structured telephone follow-up without home visits or Periodic follow-up in an outpatient clinic without home visits Moderate Home visits only or
A combination of telephone follow-up with periodic follow-up in a clinic without home visits or
Telecare (a specific type of intervention involving the transfer of patient vital signs, such as electrocardiogram, blood pressure, weight, via digital cable22) without prearranged direct contact with patientsHigh A combination of home visits with other types of follow-up (telephone and/or clinic follow-up) or
Telecare combined with prearranged direct contact with patients (eg, home visits, telephone follow-up, video visits)Characteristics Number of Trials Continent and country Americas United States 19 Canada 3 Brazil 1 Europe Netherlands 3 Italy 3 Spain 2 Sweden 2 United Kingdom 2 Switzerland 1 Austria 1 Oceania New Zealand 1 Australia 1 Asia China 1 Hong Kong 1 Publication language: English 41 Number of arms 2 arms (intervention and usual care) 37 3 arms (2 arms in addition to usual care)a 4 Unit of randomization Patient 38 Clusterb 3 First follow-up contact after discharge Within 1 week 28 Within 2 weeks 9 Within 1 month 4 Within 2 months 1 Unclear 1 Assessment of congestive heart failure severity, No. of trials (patients) LVEF only 9 (1,321) NYHA only 8 (1,447) LVEF and NYHA 23 (8,172) Not reported 3 (420) Assessment of diastolic function, No. of trials (patients) 2 (285) Mean LVEF <40% 18 ≥40% 5 LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
a Telephone vs video telephone follow-up. Follow-up by the multidisciplinary team vs guided by N-terminal pro-B-type natriuretic peptide level. In-clinic follow-up vs in-clinic follow-up with monthly telephone/home visits. Telephone follow-up vs telecare.
↵b Clusters: primary care physicians or primary care clinics.
Intensity and Trial, Year Structured Home Visits Telephone Follow-up Clinic Follow-up Telecare Only Telecare + Other Types of Follow-up Details Low intensity Riegel et al,37 2006 X 11 RCTs had a prearranged telephone follow-up.37–44,53,56,62 Patients received 3 to 16 telephone calls (over a 2- to 12-month period). Domingues et al,56 2011 X DeBusk et al,38 2004 X Laramee et al,39 2003 X Wakefield et al,40 2008 X Dunagan et al,41 2005 X Rainville et al,42 1999 X Tsuyuki et al,53 2004 X Barth et al,43 2001 X Lopez Cabezas et al,62 2006 X Chaudhry et al,44 2010 X Doughty et al,70 2002 X In 2 RCTs, follow-up was provided in an outpatient clinic by the family physician or a cardiologist or multidisciplinary team.56,69 Patients visited the clinic7 to 10 times (over a 12- to 18-month period). Jaarsma et al,57 2008 X Moderate intensity Stewart et al,9 1998; Inglis et al,81 2004 X 4 RCTs used prearranged home visits9,34,70,71 with a total of 2 to 9 visits (over a 6- to 12-month period). Barker et al,71 2012 X Naylor et al,35 2004 X Kwok et al,72 2008 X Nucifora et al,59 2006 X X 8 RCTs combined a structured telephone call with follow-up in a clinic.44,45,53,57–59,62,63 They included 1 to 10 telephone calls and 1 to 8 visits to the clinic (over a 6- to 24-month period). Del Sindaco et al,60 2007 X X Cleland et al,58 2005 X X Ekman et al,64 1998 X X Atienza et al,63 2004 X X Kasper et al,45 2002 X X Angermann et al,46 2012 X X Ducharme et al,54 2005 X X Dar et al,66 2009 X 2 RCTs featured telecare without prearranged direct contact with patients.47,66 The vital signs transmit-ted daily consisted of weight,47,66 blood pressure, pulse, and oxygen saturation.66 Patients also answered questions on CHF symptoms via telephone (automated voice response).47,66 Goldberg et al,47 2002 X High intensity Harrison et al,55 2002 X X 6 RCTs used structured home visits combined with telephone follow-up.8,10,47,54,66,67 Patients had a total of 1 to 3 home visits (over a 3- to 12-month period). Rich et al,48 1993 X X Rich et al,8 1995 X X Blue et al,67 2001 X X Leventhal et al,68 2011 X X Jaarsma et al,10 1999 X X Cline et al,65 1998 X X 2 RCTs combined home visits with follow-up in a clinic.64,72 Patients received 1 home visit and 4 to 6 in-clinic follow-ups (over a 6- to 12-month period). Thompson et al,73 2005 X X Adlbrecht et al,69 2011; Berger et al,82 2010 X X X 3 RCTs combined home visits with telephone calls and a visit to a clinic.48,56,68 The total number of home visits ranged from 1 to 3 (over a 3- to 12-month period). Pugh et al,49 2001; Blaha et al,83 2000 X X X Jaarsma et al,57 2008 X X X Giordano et al,61 2009 X 5 RCTs combined telecare with prearranged direct contact with patients50–52,58,61 such as prearranged telephone calls,51,61 video calls and home visits,50,52 or visits to a clinic.58 Vital signs (weight, blood pressure, oxygen saturation, heart sounds, pulse, and electrocardiographic findings) were transmitted daily50,51,58 or at a scheduled time.52,61 Bowles et al,50 2011 X Kulshreshtha et al,51 2010 X Pekmezaris et al,52 2012 X Cleland et al,58 2005 X CHF = congestive heart failure; RCT = randomized controlled trial.
Intervention Intensity and Duration Number of Trials Relative Risk (95% CI) Low intensity ≤6 months39,44,53,56 5 1.121 (0.97–1.30) >6 months40–42,57,62,70 7 0.949 (0.86–1.10) Moderate intensity ≤6 months45–47,54,59,64,66,71,72 10 0.981 (0.86–1.30) >6 months58,60,63 4 0.788 (0.70–0.90) High intensity ≤6 months10,48–52,55,73 9 0.804 (0.69–0.93) >6 months58,61,65,67–69 7 0.885 (0.79–0.99) Note: Test for differences across 6 strata: P = .003
Supplemental Appendixes
Supplemental Appendix 1. Eligibility criteria; Appendix 2. Search strategy; Appendix 3. Characteristics of the included interventions; Appendix 4. Methodological quality of the included studies; Appendix 5. Additional analyses: exploratory subgroup analyses; Supplement 6. Additional analyses: sensitivity analyses; Appendix 7. Funnel plot for assessing publication bias.
Files in this Data Supplement:
- Supplemental data: Appendixes - PDF file
The Article in Brief
Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis
Isabelle Vedel , and colleagues
Background After hospital discharge, 25 percent of patients with congestive heart failure are readmitted within 30 days and 50 percent within six months. This analysis of existing research sets out to identify the most effective transitional care interventions (such as patient and caregiver education on self-management, discharge planning, and structured follow-up and coordination among health professionals) and determine their impact on the rate of all-cause readmission and emergency department visits by CHF patients.
What This Study Found Providing transitional care interventions to congestive heart failure patients reduces readmission and emergency department visits by 8 percent and 29 percent, respectively. Furthermore, high-intensity interventions that combine home visits with telephone follow up and/or clinic visits reduce readmission risk regardless of the length of follow-up. Moderate-intensity interventions are effective if implemented for a longer duration (at least six months) but low-intensity interventions, which only include follow-up in outpatient clinics or telephone follow-up, are not effective.
Implications
- Primary care clinicians and managers can incorporate these results to determine the most effective balance between intensity and duration of transitional care interventions.
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