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Therapeutics

A home-based intervention reduced out-of-hospital deaths and hospitalizations in CHF

ACP J Club. 1999 July-Aug;131:6. doi:10.7326/ACPJC-1999-131-1-006

Related Content in the Archives
• Letter: A home-based intervention reduced out-of-hospital deaths and hospitalizations in CHF


Source Citation

Stewart S, Vandenbroek AJ, Pearson S, Horowitz JD. Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Arch Intern Med. 1999 Feb 8;159:257-61.


Abstract

Question

In patients with congestive heart failure (CHF) who have been discharged from the hospital, can a home-based intervention (HBI) reduce the frequency of hospital readmissions and out-of-hospital deaths?

Design

Subgroup analysis of a randomized controlled trial with 18-month follow-up (n = 762 patients).

Setting

A tertiary care referral hospital in Adelaide, South Australia, Australia.

Patients

97 patients (mean age 75 y, 52% women) with CHF, impaired systolic function, functional impairment (New York Heart Association class II, III, or IV), and ≥ 1 previous hospital admission for CHF. Follow-up was 100%.

Intervention

All patients received discharge planning. 49 patients were allocated to HBI (a single home visit by a nurse and a pharmacist to assess the need for further intervention and to ensure optimal compliance). 48 patients were allocated to usual care (a visit to the patient's family physician within 2 wk of discharge).

Main outcome measures

Proportion of patients with the combined end point of unplanned readmission or out-of-hospital death. Secondary outcomes were number of unplanned admissions, total days of hospitalization, number of emergency department visits, death, and cost of hospital-based health care.

Main results

The 2 groups did not differ for the proportion of patients with combined readmissions or out-of-hospital deaths (Table) (P = 0.12). However, patients in the HBI group had fewer out-of-hospital deaths (Table) (P = 0.02) and unplanned readmissions (64 vs 125 admissions, P = 0.02), spent fewer days in the hospital (10.5 vs 21.1 d, P = 0.02), made fewer visits to the emergency department (2.5 vs 4.5 visits, P = 0.004), and accrued lower hospital costs (Aust. $5100 vs $13 000, P = 0.02). Death was predicted by non-English speaking background (adjusted odds ratio [OR] 4.9, 95% CI 1.5 to 15.4), unplanned admission in the previous 6 months (OR 4.9, CI 1.6 to 15.2), and left ventricular ejection fraction ≤ 40% (OR 3.0, CI 1.1 to 8.6).

Conclusion

A home-based intervention after hospitalization for congestive heart failure reduced out-of-hospital deaths and unplanned readmissions.

Source of funding: Commonwealth Department of Health and Family Services of Australia.

For correspondence: Dr. J.D. Horowitz, Cardiology Unit, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia 5011, Australia. FAX 61-88-222-6030.


Table. Home-based intervention (HBI) vs usual care after discharge for patients with congestive heart failure*

Outcomes at 18 mo HBI Usual care RRR (95% CI) NNT (CI)
Combined end point† 67.3% 81.3% 17% (-5 to 36) Not significant
Out-of-hospital death 4.1% 18.8% 78% (17 to 95) 7 (3 to 44)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.
†Unplanned hospital readmission or out-of-hospital death.


Commentary

A few persons who had several hospital readmissions may account for the difference between the 2 groups in this study. Other studies of domiciliary interventions after hospital discharge have shown no differences in outcomes between groups, especially when patients are evaluated after 1 or more years (1).

It is surprising that 1 visit after hospital discharge resulted in a continuing difference in all-cause mortality between the 2 groups. Stewart and colleagues list possible reasons for this effect, such as not adhering to the medication regimen and requiring early review of medication. However, the reduction of total time spent in the hospital and the decreased number of emergency department visits support the delivery of more organized care. A measurement of patient satisfaction with the intervention would have provided further evidence.

The intervention described here was an outreach study in which specific skills relevant to CHF were developed in a hospital setting and applied in the community. It is unclear whether these skills can be transferred to community-based personnel. Community-based care programs that provide generic nursing and rehabilitation services have outcomes similar to those of hospital care for a range of selected conditions. However, these programs may be more expensive than hospital care and may shift costs from hospital to community budgets (2). The program reported by Stewart and colleagues seems inexpensive and cost-effective, but a full economic analysis was not provided. Replication of the study would be desirable.

Andrew Farmer, MD
The Health CentreThame, Oxfordshire, England, UK


References

1. Gladman JR, Lincoln NB. Follow-up of a controlled trial of domiciliary stroke rehabilitation (DOMINO Study). Age Ageing. 1994;23:9-13.

2. Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis. BMJ. 1998;316:1791-6.