Major Finding: One intervention to facilitate the transition from hospitalization to home care cut the 30-day readmission rate by 48%; the other cut the rate by 36%.
Data Source: A prospective pilot study of readmission in 56 heart failure patients participating in a 3-month intervention, and a prospective cohort study of readmission in 257 patients with a variety of disorders who participated in a different, 1-month intervention.
Disclosures: Dr. Stauffer's study was supported by the Baylor Health Care System, Dallas. Ms. Voss's study was funded by the Centers for Medicare & Medicaid Services. Both research groups reported no financial conflicts of interest.
Two interventions to improve the transition from hospital discharge to home care, and to thereby reduce readmissions, were effective in the first attempts to implement them in real-world settings.
Both interventions had been effective in the comparatively controlled conditions of several randomized controlled trials, but until now it wasn't known whether that success would translate into real-world practice.
The first report was a pilot study at a single medical center involving patients with heart failure. The 3-month intervention was a traditional care program in which advanced practice nurses educated patients and families about symptoms and self-management strategies, improved communication patterns with care providers, and marshaled caregiver and community resources to facilitate adherence to treatment and improve quality of life. It included at least eight home visits, beginning within 72 hours of hospital admission, as well as 24-hour phone availability.
A total of 140 Medicare fee-for-service patients with heart failure were eligible, and 56 enrolled in the study.
The 30-day readmission rate was 48% lower after the intervention was implemented than it had been before. No such reduction in readmissions was noted at other medical centers in the same area during the study period, said Dr. Brett D. Stauffer of the Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, and his associates.
Total direct costs were lower for patients who participated in the intervention than for those who did not; however, the cost of the intervention itself was not recovered by the hospital.
In the second report, a Medicare demonstration project following the Care Transitions Intervention (CTI) model was assessed in 257 adults in the Medicare fee-for-service program who were hospitalized for a variety of diagnoses at six Rhode Island medical centers during an 18-month period. The facilities included community hospitals, teaching hospitals, and a tertiary care center, and their size ranged from 129 to 719 beds, said Rachel Voss of Quality Partners of Rhode Island, the Medicare Quality Improvement Organization for Rhode Island, and her associates.
The CTI is a 1-month program designed to help patients on the verge of discharge and their families to manage their health more actively and to communicate more effectively with their providers. Nurses or social workers act as “coaches” who conduct a hospital visit, a home visit within 3 days of discharge, a phone visit within 7-10 days, and a final phone visit within 30 days.
At these visits, the coaches review a booklet in which patients record their health problems, medications, and questions for providers; troubleshoot problems with outpatient care; ensure patients understand the signs and symptoms of any worsening of their condition; and help patients locate other sources of continued support.
Before implementation of the CTI program, the average 30-day readmission rate at the six participating hospitals was 21%. In comparison, the rate was only 12.8% in patients who participated in the intervention.
The primary outcome measure was the difference between the readmission rate among the study participants (12.8%) and a control group of similar patients who did not participate (20%). This represents a 36% reduction in readmissions with intervention, a significant decrease, Ms. Voss and her colleagues said (Arch. Intern. Med. 2011;171:1232-7).
Only 55% of eligible patients who were approached agreed to participate in the intervention, and the attrition rate among those who initially agreed to a home visit was 75%.
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It is comforting to read about “two successful real-world translations of interventions shown to be effective in reducing hospitalizations in randomized controlled trials.” But other aspects of these real-world successes are sobering, said Dr. Mitchell H. Katz.
Both studies had low participation rates. And in the study by Voss et al, only 14% of the patients who were approached would agree to a home visit. With such a small proportion of patients willing to try such interventions, these programs cannot have a major impact on readmission rates, he noted.