Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Abstract

Purpose: We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration.

Results: We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious.

Conclusions: Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

Keywords: congestive heart failure; meta-analysis; outcomes research; systematic review; transitional care; utilization.

Figure 1

Trial selection flowchart.

Figure 2

Forest plot for all-cause readmission (presented by weight). Note: Percentage of patients with events: 45.9% in the incidence group and 47.8% in the control group. ^aCluster randomization. ^bTelephone and video telephone follow-up. ^cTelecare. ^dTelephone follow-up. ^eIntervention guided by N-terminal pro-B-type natriuretic peptide. ^fMultidisciplinary intervention. ^gFollow-up in clinic. ^hFollow-up in clinic and monthly contact with the nurse.

Figure 3

Forest plot for all-cause emergency department visits (presented by weight). Note: Percentage of patients with events: 34.3% in the intervention group and 45.4% in the control group. M-H = Mantel-Haenszel