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Transitional Care Interventions for Heart Failure: What Are the Mechanisms?

Published:October 06, 2018DOI:https://doi.org/10.1016/j.amjmed.2018.09.028
      Two decades ago, heart failure clinics were proposed widely as an effective means of improving care.
      • Strömberg A
      Heart failure clinics.
      Despite dozens of trials over subsequent years, it has often been difficult to ascertain the true effectiveness of such programs due to poor descriptions of study populations, interventions, comparators, and outcomes. This is compounded by the use of terms such as “transitional care,” “integrated care,” “coordinated care,” “community care,” and “person-centred care.” These differences in terminology continue to make drawing conclusions about the effectiveness of interventions difficult. More recent studies refer to “transitional care interventions,” defined as “a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.”
      • Naylor MD
      • Aiken LH
      • Kutzman ET
      • Olds DM
      • Hirschman KB
      The care span: the importance of transitional care in achieving health reform.
      While this definition overlaps with other forms of established care (primary care, care coordination, discharge planning, disease management, case management), and there is no clear consensus on when the transition period ends, at least this definition is inclusive.
      Recent systematic reviews of transitional care provide some supporting, though imprecise, evidence. There is consensus as to what interventions should focus on: patient/caregiver education, medication reconciliation, coordination with outpatient providers, arrangements for future care, symptom monitoring, home visits, telephone support. Of 2 recent systematic reviews and meta-analyses
      • Feltner C
      • Jones CD
      • Cené CW
      • et al.
      Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.
      • Van Spall HGC
      • Rahman T
      • Mytton O
      • et al.
      Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis.
      of transitional interventions, one found that home-visiting programs and multidisciplinary heart failure clinics reduced all-cause readmission (relative risk [RR] 0.75; 95% confidence interval [CI], 0.68-0.86; RR 0.70; 95% CI, 0.55-0.89, respectively) and mortality (RR 0.77; 95% CI, 0.60-0.997; RR 0.56; 95% CI, 0.34-0.92, respectively) at 3-6 months, and structured telephone support reduced heart failure-specific readmission (RR 0.74; 95% CI, 0.61-0.90) and mortality (RR 0.74; 95% CI, 0.56-0.97) at 3-6 months.
      • Feltner C
      • Jones CD
      • Cené CW
      • et al.
      Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.
      This review concluded that these interventions should receive the greatest consideration by health care providers.
      • Feltner C
      • Jones CD
      • Cené CW
      • et al.
      Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.
      The other systematic review and network meta-analysis testing the efficacy of transitional care provided beyond 1 month of follow-up found that nurse home visits and nurse case management reduced all-cause readmission (incident rate ratio [IRR] 0.65; 95% CI, 0.49-0.86; IRR 0.77; 95% CI, 0.63-0.55, respectively) and nurse home visits and disease management clinics reduced all-cause mortality (RR 0.78; 95% CI, 0.62-0.98; RR 0.80; 95% CI, 0.67-0.97, respectively).
      • Van Spall HGC
      • Rahman T
      • Mytton O
      • et al.
      Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis.
      Interestingly, nurse home visits and nurse case management had greater pooled cost savings (US$3810 and US$3435, respectively) than disease management clinics (US$245).
      • Van Spall HGC
      • Rahman T
      • Mytton O
      • et al.
      Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis.
      These analyses incorporated trials which, though categorized under the broad heading of “transitional care,” reported a wide range of heterogeneous interventions. Consequently, the key characteristics of effective interventions cannot be discerned. These components were identified in a systematic review of transitional care strategies and heart failure readmission that identified 8 characteristics integral to improving long-term outcomes: discharge planning; multiprofessional teamwork, communication and collaboration; timely, clear and organized information; medication reconciliation and adherence; engaging social and community support groups; monitoring/managing signs and symptoms after discharge and delivering patient education; outpatient follow-up; and advanced-care planning and palliative and end-of-life care.
      • Albert NM
      A systematic review of transitional-care strategies to reduce rehospitalisation in patients with heart failure.
      Finally, a systematic review of the impact of heart failure care systems found that access to a specialist heart failure team/service reduced hospital readmissions and mortality, and that, in the transitional care phase, disease management programs and nurse-led clinics reduced hospital readmissions.
      • Driscoll A
      • Meagher S
      • Kennedy R
      • et al.
      What is the impact of systems of care for heart failure on patients diagnosed with heart failure: a systematic review.
      Nurses are invariably and inextricably linked with driving all of these activities; consequently, they play a key role, directly and indirectly, in reducing readmission.
      This evidence, taken as a whole, provides compelling evidence attesting to the value and effectiveness of transitional care interventions in reducing all-cause readmission and mortality and costs. In order to ensure the evidence is stronger, there is a need for better defined and described, sufficiently powered head-to-head trials to show efficacy. The evidence base would be enhanced by including measures of caregiver burden and analysis of costs, clearly distinguished intervention components and outcomes, including process evaluations and follow-up beyond 2 years.

      Moving from Measuring Outcomes to Understanding Outcomes

      The need for deeper and more useful knowledge from trials must be recognized. These are complex interventions, and simplistic approaches to evaluation focused on “headline effect sizes” don't identify the key characteristics of these heterogeneous interventions and are unlikely to persuade skeptics wary of excessively simplistic evidence.
      • Clark AM
      • Thompson DR
      The future of management programmes for heart failure.
      • Clark AM
      • Savard L
      • Thompson DR
      What is the strength of evidence for heart failure disease management programs?.
      • Clark AM
      • Thompson DR
      What heart failure programmes work best? Wrong question, wrong assumptions.
      • Savard L
      • Thompson DR
      • Clark AM
      A meta-review of evidence on heart failure disease management programs: the challenges of describing and synthesizing evidence on complex interventions.
      • Clark AM
      • Thompson DR
      Heart failure disease management programmes: a new paradigm for research.
      Indeed, we recommend that evidence continues to move from establishing whether interventions work to establishing why they work and in what context—in short, to understand the main mechanisms of interventions and how context moderates this.
      • Clark AM
      • Thompson DR
      What heart failure programmes work best? Wrong question, wrong assumptions.
      However, although research into intervention mechanisms has been prominent for some decades—for example, in a large and growing volume of research,
      • Astbury B.
      • Leeuw FL
      Unpacking black boxes: mechanisms and theory building in evaluation.
      review approaches,
      • Pawson R
      Realist review – a new method of systematic review designed for complex policy interventions.
      frameworks,
      • Craig C
      • Dieppe P
      • Macintyre S
      • Michie S
      • Nazareth I
      • Petticrew M
      Developing and Evaluating Complex Interventions: New Guidance.
      and methods,
      • Pawson R
      • Tilley N
      Realistic Evaluation.
      there have been no detailed primary studies of the mechanisms of these complex and common interventions. A primary reason for this may be the challenge of researching mechanisms—a concept which, like the complexity of the interventions described, is often poorly defined and theorized. Mechanisms in social and health sciences research are often wrongly defined or handled as statistical associations—rather than what “explains” outcomes. Rather, mechanisms should be considered to be that which are “responsible, subject to circumstances, for the observable degree of regularity.
      • Elder-Vass D
      The Causal Power of Social Structures.
      Accordingly, mechanisms constitute the “black box” between an intervention's inputs and its outputs
      • Broadbent A
      Inferring causation in epidemiology: mechanisms, black boxes, and contrasts.
      —they are causal in nature, often unobservable, and may be associated with benefits, harms, and costs of an intervention. Finally, instead of just being singular factors, mechanisms can be seen themselves as complex systems that affect outcomes via the interaction of a number of intervention parts.
      • Datta J
      • Petticrew M
      Challenges to evaluating complex interventions: a content analysis of published papers.
      No dedicated primary studies have been done of the mechanisms of heart failure disease management interventions. This is curious but understandable because, while theories and approaches invoking mechanisms of complex interventions conceptually are prominent,
      • Pawson R
      • Tilley N
      Realistic Evaluation.
      • Elder-Vass D
      The Causal Power of Social Structures.
      mechanisms have received less attention in recent complex intervention research and methods.
      • Clark AM
      • Wiens KS
      • Banner D
      • et al.
      A systematic review of the main mechanisms of heart failure disease management interventions.
      Consequently, practical guidance on how to identify, disentangle, and verify mechanisms in complex interventions research has remained scant. Yet, a review of studies containing data pertaining to mechanisms identified that successful interventions for heart failure patients mobilize mechanisms that increase patient understanding of their condition and its links to self-care, promote the involvement of other people in this self-care, improve psychosocial well-being, and attain support from health professionals to use technology.
      • Clark AM
      • Wiens KS
      • Banner D
      • et al.
      A systematic review of the main mechanisms of heart failure disease management interventions.
      Again, these roles are all potentially central to transitional care. This suggests that mechanisms offer an influential, but as yet relatively untapped, source of insight into the influence of transitional care interventions for heart failure.

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