Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Multidisciplinary approach reduced readmissions in patients with CHF

ACP J Club. 1996 Mar-April;124:31. doi:10.7326/ACPJC-1996-124-2-031

Related Content in this Issue
• Companion Abstract and Commentary: Annual comprehensive geriatric assessments improved community living


Source Citation

Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995 Nov 2;333:1190-5. [PubMed ID: 7565975]


Abstract

Objective

To determine the effect of a multidisciplinary approach to heart failure care in elderly patients who were recently hospitalized for congestive heart failure (CHF).

Design

Randomized controlled trial with 90-day follow-up.

Setting

University medical center in Missouri, USA.

Patients

282 patients ≥ 70 years of age (mean age 79 y, 63% women, 55% black) who were hospitalized for CHF between July 1990 and June 1994. Exclusion criteria were plans to enter a long-term care facility, dementia or psychiatric illness, terminal illness, expected survival < 3 months, or refusal to participate. Follow-up was complete.

Intervention

Patients were allocated to a multidisciplinary intervention (n = 142) or to conventional care (n = 140). The intervention consisted of intensive in-hospital educational sessions about CHF given by a cardiovascular nurse, individualized dietary assessment and instruction by a dietitian, social services consultation to facilitate discharge, medication recommendations by a geriatric cardiologist, and follow-up after discharge with home visits and telephone calls. Patients in the conventional care group received standard treatments and services ordered by their primary physician.

Main Outcome Measures

The primary outcome was survival for 90 days without readmission. Secondary outcomes were number of readmissions for any cause, number of readmissions for CHF, number of days spent in the hospital during follow-up, quality-of-life scores, and overall cost of care.

Main Results

Analysis was by intention to treat. 91 patients (64.1%) in the multidisciplinary care group survived for 90 days without readmission compared with 75 patients (53.6%) in the conventional care group (P = 0.09). The multidisciplinary approach to care led to fewer readmissions for any reason at 90 days than did conventional care (53 vs 94 readmissions, P = 0.02) and fewer readmissions for CHF (24 vs 54 readmissions, P = 0.04). Patients in the multidisciplinary care group spent fewer mean days per patient in the hospital than did patients in the conventional care group (3.9 vs 6.2 days, P = 0.04). For 126 patients who were given the Chronic Heart Failure Questionnaire, quality-of-life scores improved more in patients in the multidisciplinary care group than in patients in the conventional care group (mean change in score 22.1 vs 11.3, P = 0.001). The overall cost of care per patient-month of follow-up was $153 less in the multidisciplinary care group.

Conclusion

A multidisciplinary approach to care for elderly patients recently hospitalized for congestive heart failure reduced the number of hospital readmissions and the number of days spent in the hospital and improved quality of life but did not affect 90-day readmission-free survival.

Source of funding: National Heart, Lung, and Blood Institute.

For article reprint: Dr. M.W. Rich, Jewish Hospital of St. Louis, 216 South Kingshighway, St. Louis, MO 63110, USA. FAX 314-454-5265.


Commentary

The optimal management of elderly persons after hospital discharge as well as those living independently in the community has generated intense interest. The extensive literature on this subject is complemented by these 2 well-designed studies: 1 tested the hypothesis that intensive follow-up after hospital discharge in patients with CHF will reduce costs and hospitalizations; the other tested the hypothesis that in-home comprehensive geriatric assessments will help prevent disability among elderly persons.

Several points made by the 2 studies invite comment. In both studies, the intervention increased quality of life and functional outcomes, which were primary outcomes of the study by Stuck and colleagues. In this study, however, the rates of admission to acute care hospitals and short-stay nursing homes were not reduced. In addition, organizing a full-scale geriatric outreach program with geriatrician-supervised, specially trained nurse practitioners to visit healthy elderly persons in the community might not be feasible in many locations; it is, however, a novel approach for decreasing the demand for long-term care services. The study by Rich and colleagues, by including elderly persons admitted to the hospital with a serious diagnosis (CHF), showed a substantial decline in the rate of hospital readmissions.

The cost calculations made in both studies are complex and, I believe, fail to make a convincing case that the interventions actually save money. For example, Rich and colleagues base their calculation on a rate of $20/h for nursing care. This is considerably less than the $78/h that Medicare allows in my part of the United States and probably in the area where this study was done. The charge for a routine office visit to a primary care physician is usually less than a home visit by a nurse.

The challenge in interpreting any study that deals with home visits is that many patients, caregivers, and policymakers have already decided that this is a good way to take care of the frail elderly and the disabled. The intuitive belief that home care is beneficial warrants further research that examines the spectrum of home care services available for chronically ill patients while considering the costs that the health care system can absorb (1). In the present health care "market," new systems of care are being created that are supposedly cost-effective—systems that are expensive to operate but are not being evaluated to confirm their intended efficiencies. These authors should be congratulated for rigorously evaluating their interventions, but I would be reluctant to say that the application of these 2 studies would lead to a decrease in total health care cost; rather, it might shift some of the cost to other providers.

Elderly persons use many support services. One study (2) showed that as many as 88% of elderly patients discharged from the hospital required some form of home care. Bull (3) suggests that 2 readily available variables—age and functional ability before discharge—predict whether home care will be beneficial. Solomon and colleagues (4) add educational level, social support, impairment of ADL, and previous home care use as major predictors.

Key to the success of home care or outreach preventive services is the availability of programs that are acceptable to the patient and suited to the environment in which the patient lives. An important goal of any program is to reduce the use of health care services, which includes not only hospital and nursing home admissions but also home care visits. Most elderly persons want to be independent. To the extent that our services allow that to happen, the patient will have a valuable outcome. Simply calling the patient after discharge has been shown to reduce the use of health care services (5). Future research that helps to determine the proper balance of services for each patient will be welcomed.

Dennis L. DeSilvey, MD
University of VirginiaCharlottesville, Virginia, USA

Dennis L. DeSilvey, MD
University of Virginia
Charlottesville, Virginia, USA


References

1. Cummings JE, Weaver FM. Cost-effectiveness of home care. Clin Geriatr Med. 1991;7:865-74.

2. Hanger HC, Conway C, Sainsbury R. The costs of returning home. N Z Med J. 1993;106:397-9.

3. Bull MJ. Use of formal community services by elders and their family caregivers 2 weeks following hospital discharge. J Adv Nurs. 1994;19:503-8.

4. Solomon DH, Wagner DR, Marenberg ME, et al. Predictors of formal home health care use in elderly patients after hospitalization. J Am Geriatr Soc. 1993;41:961-6.

5. Wasson J, Gaudette C, Whaley F, et al. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788-93.