Transitions of care, readmissions, and more

Summaries from ACP Hospitalist Weekly.

Transitional interventions cost-effective for elderly heart failure patients, model shows

For recently hospitalized elderly patients with heart failure, transitional care inventions are more cost-effective than standard care, according to a recent study.

The study used data from randomized controlled trials, clinical registries, cohort studies, the CDC, CMS, and the National Inpatient Sample to model the effects of three transitional care interventions—disease management clinics, nurse home visits, and nurse case management—on patients with heart failure who were 75 years old at the time of hospital discharge. Results were published by Annals of Internal Medicine on Jan. 28 and appeared in the Feb. 18 issue.

The model showed that all three transitional care interventions were more costly but also more cost-effective than standard care. Nurse home visits performed the best of the three, with an increase of 2.49 quality-adjusted life-years (compared to 2.25 with usual care) and a decrease in rehospitalizations. Costs under the nurse visit model were $81,327 (compared to $76,705 with standard care), resulting in an incremental cost-effectiveness ratio of $19,570.

The results show that transitional care services are “economically attractive,” the authors said, with nurse home visits appearing the most cost-effective. “However, each of the interventions resulted in important improvements in health outcomes, and the differences among the interventions were modest. Furthermore, it is highly unlikely that standard care postdischarge management is more cost-effective than any of the transitional care services we studied,” they added.

The authors recommended that transitional care services should become the standard of care after hospitalization for older patients with heart failure, with the choice among the three interventions made according to setting-specific factors. They noted that research indicates relatively few patients currently receive such services. Limitations of the study include heterogeneity in design and cost of the studied transitional care services. The results may also not be generalizable to younger or healthier patients with heart failure, the authors said.

An accompanying editorial advised caution before drawing broad conclusions from the study's findings. “There is reason to doubt that benefits from these mostly small trials would be similar when deployed to scale,” the editorialist wrote. For example, the largest published trial of chronic disease management to date did not find any reduction in hospitalizations, the editorial reported. Still, the results are promising and support wider adoption of transitional care interventions, it said. “Now, it is up to policymakers, insurers, and health care organizations to create the enabling structures, training programs, and reimbursement systems to take the programs to scale.”

Use of observation, ED in place of readmission not responsible for heart failure mortality

Increases in heart failure mortality under the Hospital Readmissions Reduction Program (HRRP) were not caused by increased use of ED and observation care after discharge, a recent study found.

The retrospective cohort study used Medicare claims data for 2008 to 2016 on patients ages 65 years or older who were admitted with heart failure (n=3,772,924), acute myocardial infarction (n=1,570,113), or pneumonia (n=3,131,162) to look at the effects of the HRRP, which was announced in 2010 and implemented in 2012. The main outcomes were 30-day mortality and admissions, ED visits, or observation care within 30 or 90 days of discharge. Results were published by The BMJ on Jan. 15.

Image by Getty Images
Image by Getty Images

Average mortality rates in the 30 days after discharge were 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. In annual comparisons over the studied period, risk-adjusted mortality did not change for pneumonia, decreased by 0.06% (95% CI, −0.09% to −0.04%) for myocardial infarction, and increased by 0.05% (95% CI, 0.02% to 0.08%) for heart failure. The study found that the increase in heart failure mortality could be attributed to patients who did not utilize any of the studied types of postdischarge care, as their mortality increased at a rate of 0.08% (95% CI, 0.05% to 0.12%) per year, while patients who returned to observation units or the ED did not have any increase in mortality over time. The trend of rising mortality also predated the HRRP, the study found.

For all three conditions, there was a reduction in readmissions over the study period and an accompanying increase in observation stays and ED visits, both within 30 days of discharge and in the following 60 days. The overall rate of postdischarge acute care utilization (readmissions, observation stays, ED visits) within 30 days of discharge did not change significantly. The finding that use of observation and the ED increased across the full 90 days after discharge means “we cannot be sure whether the changing patterns of post-discharge acute care was part of a strategy to reduce readmissions or whether they were related to other concurrent policy changes such as the wider implementation of criteria for inpatient hospital admissions that discouraged inclusion of short hospital stays,” the authors said.

The findings offer reassurance about the effects of readmission reduction efforts on heart failure patients, according to the authors. “The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern,” they wrote. It's still uncertain whether the increase in mortality after discharge indicates underuse of acute care for these patients or more expected deaths under comfort-centered care, they added.

Program targeting superutilizers did not reduce readmission rates in randomized trial

An intervention targeting patients with very high use of health care services, or “superutilizers,” had no significant effect on readmission rates compared to usual care in a recent randomized controlled trial.

The superutilizer program, created by the Camden Coalition of Healthcare Providers, enrolled eligible patients while in the hospital. Once patients returned home, they worked with a team of nurses, social workers, community health workers, and health coaches in the months after discharge. The team conducted home visits, scheduled and accompanied patients to initial primary and specialty care visits, coordinated follow-up care and medication management, measured blood pressure and blood glucose levels, coached patients in disease-specific self-care, and helped patients apply for social services and appropriate behavioral health programs.

To test the program's effect on readmissions, researchers randomly assigned 800 hospitalized patients with medically and socially complex conditions and at least one additional hospitalization in the prior six months to receive either the program (n=399) or usual care (n=401). They collected hospital discharge data through March 31, 2018, from the four Camden, N.J., hospital systems. The primary outcome was hospital readmission within 180 days after discharge. Results were published Jan. 9 by the New England Journal of Medicine.

Overall, 782 (98%) patients had complete outcomes data and were included in the analysis sample. The trial population was 50% male, with about 17% who were younger than age 44 years, 55% who were between ages 45 and 64 years, and 28% who were age 65 years or older. About 55% were non-Hispanic black, 30% were Hispanic, and 15% were non-Hispanic white. Nearly all (94%) were not employed, and 44% received a diagnosis of substance use disorder during the index admission. Medicare and Medicaid were the primary payers for 48% and 45% of participants, respectively.

The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group, for an adjusted between-group difference of 0.82 percentage point (95% CI, −5.97 to 7.61 percentage points; P=0.81). The intervention also had no significant effect on any of the secondary outcomes (number of readmissions, proportion of patients with at least two readmissions, hospital days, hospital charges, hospital payments received, mortality) or within any of the prespecified subgroups (number of admissions in the previous year, two or at least three; preferred language, English or other). In contrast with these results, a comparison of admission rates for the intervention group in the six months before and after enrollment misleadingly suggested a substantial decline in admissions in response to the intervention because it did not account for a similar decline in the control group.

The authors noted that the trial was not powered to detect smaller differences that could be clinically meaningful or to analyze effects within specific subgroups. In addition, usual care evolved during the trial period, as the Coalition was leading a citywide campaign to connect Medicaid patients with primary care within seven days after discharge, they said.

Approaches to care management that are designed to connect patients with existing resources may be insufficient for those with complex needs, the authors said. “The results suggest both the challenges of reducing readmissions in a medically and socially complex superutilizer population and the importance of conducting randomized evaluation of interventions such as this one, which, because they target high-cost patients, are likely to show substantial regression to the mean in observational studies,” they concluded.

Hospital-based palliative care may reduce ICU use

Implementation of a hospital-based palliative care program appeared to modestly decrease intensive care unit (ICU) use during terminal hospitalizations.

Researchers performed a cohort study using data from 51 hospitals in New York State that did or did not start a palliative care program between 2008 and 2014. Study participants were adult patients who died during hospitalization. The study's main outcome measure was ICU use, and a difference-in-differences analysis was used to assess the association between implementation of a palliative care program and ICU use during terminal hospitalizations. Data were adjusted for patient and hospital characteristics and for time trends. Results were published Jan. 8 by JAMA Network Open.

Of the 51 included hospitals, 24 implemented a palliative care program during the study period and 27 had no program. Eighty-three hospitals that had palliative care programs during the entire study period were excluded. A total of 73,370 patients died during hospitalization. The mean age was 76.5 years, and 52.4% were women. Of these 73,370 patients, 37,628 (51.3%) were cared for at hospitals that started palliative care services and 35,742 (48.7%) were cared for at hospitals that did not. In the implementing hospitals, 17,146 study patients (45.6%) received care before the palliative care program began and 20,482 (54.5%) received care afterward.

Patients who received care after a hospital implemented palliative care services were less likely to receive intensive care than those cared for at the same hospital before palliative care services were started (49.3% vs. 52.8%; difference, 3.5% [95% CI, 2.5% to 4.5%]; P<0.001). Implementing palliative care services was associated with a 10% reduction in ICU use during terminal hospitalizations versus no implementation of palliative care (adjusted relative risk, 0.90; 95% CI, 0.85 to 0.95; P<0.001). Implementation of palliative care was not associated with significant differences in length of stay or use of dialysis or with differences in ICU days or use of mechanical ventilation among patients admitted to the ICU.

The authors noted that their data could be affected by residual confounding and that most hospitals were excluded from the study because they already had palliative care programs in place, among other limitations. They concluded that their findings indicate a modest decrease in ICU use during terminal hospitalizations at hospitals that have implemented palliative care programs and that this association could differ according to hospital characteristics.

“Future work should focus on identifying characteristics associated with the effectiveness of palliative care programs in decreasing treatment intensity,” the authors wrote.