Are Transitional Care Services Worth Investing In for Heart Failure?

Worldwide, heart failure (HF) has been diagnosed in 26 million individuals, and this number is rising. It is one of the leading causes of hospitalization and rehospitalization for older adults, most with poor long-term prognoses, with annual costs amounting to between $39.2 billion and $60 billion each year.¹ The overall readmission rate is 20%.² Is there a way to reduce the readmission rate and improve patient outcomes?

Researchers from Stanford University published the results of their recent investigation for an answer to this question, in terms of lifetime cost-effectiveness, in Annals of Internal Medicine. Their study cohort consisted of patients with HF who were aged 75 at initial hospital discharge.¹

They believe that transitional care services—disease management clinics (DMCs), nurse home visits (NHVs), and nurse case management (NCM)—could replace the current standard of care for patients with HF recently discharged from the hospital.¹ This current standard comprises medication reconciliation, a close outpatient follow-up appointment, and some education,³ while the transitional care services consist of the following elements¹:

1. NHV: single home visit, or several, within 2 weeks of discharge
2. NCM: self-care education and telephone support
3. DMC: team-based, multidisciplinary, outpatient support

NHVs came out on top, as being the most cost-effective in terms of quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER). Whereas standard care presently increases QALYs by 2.25, NHVs brought this number up to 2.49, “driven by longer life expectancy and few subsequent hospitalizations,” for an ICER of $19,570. According to the authors, the ICER resulted from the longer life expectancy, which meant a higher total cost for healthcare. In addition, 4 months accrued to the average life expectancy for a patient with HF aged 75 years after hospital discharge, and the hospitalization rate fell by 10 readmissions per 100 patients. However, all 3 transitional care services were shown to reduce all-cause mortality and rehospitalization compared with the current standard of postdischarge care.

Limitations to these results include 2 major assumptions: (1) The conservative model used assumed the transitional care interventions reduced the mortality and rehospitalization rates only within the first year after the first hospital admission for HF but costs continually accrued,¹ and (2) the readmission risk remained the same through subsequent hospitalizations, even though it is usually higher compared with the index hospitalization.² Beyond this, the results may not be generalizable to younger patients because this study looked at outcomes among older patients.¹

So, why, if they are shown to be effective, are transitional care service programs not the current standard of care for patients with HF recently discharged from the hospital? In 2015 alone, only 7% of those eligible for the services received them.¹ First, there is a lack of high-quality studies showing both their short- and long-term effectiveness among a wide variety of patients. Second, getting these programs off the ground can be complicated,³ due to the costs that healthcare providers must lay out without guarantee of reimbursement from payers.² Third, there are concerns over the programs’ possible inadequate effectiveness compared with medications.³

“In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF,” the investigators concluded.

Proposed solutions include implementing standards for treatment protocols and training, offering incentives and insurance coverage specifically for transitional care, and building a foundation that consists of training programs and future reimbursement to grow the transitional care services.^1,2

References

1. Blum MR, Øien H, Carmichael HL, Heidenreich P, Owens DK, Goldhaber-Fiebert JG. Cost-effectiveness of transitional care services after hospitalization with heart failure [published online January 28,2020]. Ann Intern Med. doi: 10.7326/M19-1980.

2. Horwitz LJ. Taking care transitions programs to scale: is the evidence there yet ? [published online January 28,2020] Ann Intern Med. doi: 10.7326/M19-3872.

3. Nurse home visits after hospitalization for heart failure improve patient outcomes at a reasonable cost [press release]. Philadelphia, PA: EurekAlert; January 27, 2020. eurekalert.org/emb_releases/2020-01/acop-nhv012120.php. Accessed January 27, 2020.