To conduct a systematic review and meta-analysis of the efficacy, comparative effectiveness, and harms of transitional care interventions that aim to reduce readmissions and mortality for adults hospitalized with heart failure (HF). We also sought to describe the components of interventions that showed efficacy.
MEDLINE, Cochrane Library, CINAHL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (January 1, 1990, to early May 2013).
Two investigators independently selected, extracted data from, and rated risk of bias of relevant randomized controlled trials. We conducted meta-analyses using random-effects models to estimate pooled effects. We graded strength of evidence (SOE) based on established guidance.
We included 47 trials. Most included patients with moderate to severe HF; mean ages of patients were in the 70s. Few trials reported 30-day readmission rates. A high-intensity home-visiting program reduced all-cause readmission and the composite endpoint (all-cause readmission or death) at 30 days (low SOE). Over 3 to 6 months, home-visiting programs reduced all-cause readmission (high SOE), HF-specific readmission (moderate SOE), and the composite endpoint (moderate SOE). Multidisciplinary (MDS)-HF clinic interventions reduced all-cause readmission (high SOE). Structured telephone support (STS) interventions reduced HF-specific readmission (high SOE) but not all-cause readmissions (moderate SOE). Home-visiting programs, MDS-HF clinics, and STS interventions produced a mortality benefit (moderate SOE). Neither telemonitoring nor nurse-led clinic interventions reduced readmissions or mortality. Components of interventions showing efficacy for reducing all-cause readmissions or mortality include: HF education, emphasizing self-care; HF pharmacotherapy, emphasizing promotion of adherence and evidence-based HF pharmacotherapy; and a streamlined mechanism to contact care delivery personnel (e.g., patient hotline). In general, categories of interventions that reduced all-cause readmissions or mortality were more likely to be of higher intensity, to be delivered face to face, and to be provided by MDS teams.
Home-visiting programs and MDS-HF clinic interventions reduced all-cause readmission and mortality; STS reduced HF-specific readmission and mortality but not all-cause readmission. These interventions should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for people with HF. We found no evidence assessing harms of transitional care interventions, such as increased caregiver burden.
