Cardiac Transitional Care Effectiveness: Does Overall Comorbidity Burden Matter?



      Cardiovascular disease is the most common cause of mortality and hospitalization in the United States. Transitional care initiatives can improve outcomes for cardiac patients, but it is unclear whether patients with different baseline comorbidity burden benefit equally. We evaluated the effectiveness of the Bridging the Discharge Gap Effectively (BRIDGE) program, a nurse-practitioner-led transitional care clinic, in mitigating adverse clinical outcomes in cardiac patients with varying Charlson comorbidity index (CCI).


      We studied patients referred to BRIDGE between 2008 and 2017 postdischarge for a cardiac condition. Using proportional hazards regression models, we evaluated associations between attendance at BRIDGE and hospital readmission, emergency department (ED) visit, and a composite outcome consisting of readmission, ED visit, or mortality, and assessed interaction between BRIDGE attendance and CCI.


      Of 4559 patients, 3256 (71.4%) attended BRIDGE. In patients with low CCI, attendance at BRIDGE was inversely associated with hospital readmission (adjusted hazard ratio = 0.82, 95% confidence interval [CI]: 0.69, 0.97, P = .02) and the composite endpoint (adjusted hazard ratio = 0.84, 95% CI: 0.72, 0.98, P = .02). Associations of BRIDGE attendance with both readmission and ED visit were significantly weaker in patients with high CCI (adjusted P, interaction = .007 and .03, respectively). Overall, BRIDGE attendance was associated with an 11% lower hazard of developing the composite endpoint (95% CI: 2%, 19%, P = .01).


      Attendance at a transitional care clinic is inversely associated with risk of readmission and a composite endpoint in cardiac patients with low CCI. Future research should investigate modified transitional care programs in patients with varying comorbidity burden.


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      1. National Center for Health Statistics. Health, United States, 2017. 2018., accessed 8/7/2019.

        • Jencks SF
        • Williams MV
        • Coleman EA
        Rehospitalizations among patients in the Medicare fee-for-service program.
        N Engl J Med. 2009; 360: 1418-1428
        • Hernandez AF
        • Greiner MA
        • Fonarow GC
        • et al.
        Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure.
        JAMA. 2010; 303: 1716-1722
        • Donaho EK
        • Hall AC
        • Gass JA
        • et al.
        Protocol-driven allied health post-discharge transition clinic to reduce hospital readmissions in heart failure.
        J Am Heart Assoc. 2015; 4e002296
        • Feltner C
        • Jones CD
        • Cene CW
        • et al.
        Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.
        Ann Intern Med. 2014; 160: 774-784
        • Yu DS
        • Lee DT
        • Stewart S
        • Thompson DR
        • Choi KC
        • Yu CM
        Effect of nurse-implemented transitional care for Chinese individuals with chronic heart failure in Hong Kong: a randomized controlled trial.
        J Am Geriatr Soc. 2015; 63: 1583-1593
        • Liss DT
        • Ackermann RT
        • Cooper A
        • et al.
        Effects of a transitional care practice for a vulnerable population: a pragmatic, randomized comparative effectiveness trial.
        J Gen Intern Med. 2019; 34: 1758-1765
        • Le Berre M
        • Maimon G
        • Sourial N
        • Gueriton M
        • Vedel I
        Impact of transitional care services for chronically ill older patients: a systematic evidence review.
        J Am Geriatr Soc. 2017; 65: 1597-1608
        • Benjamin EJ
        • Virani SS
        • Callaway CW
        • et al.
        Heart disease and stroke statistics-2018 update: a report from the American Heart Association.
        Circulation. 2018; 137: e67-e492
        • Hirschman KB
        • Shaid E
        • McCauley K
        • Pauly MV
        • Naylor MD
        Continuity of care: the transitional care model.
        Online J Issues Nurs. 2015; 20: 1
        • Auerbach AD
        • Kripalani S
        • Vasilevskis EE
        • et al.
        Preventability and causes of readmissions in a national cohort of general medicine patients.
        JAMA Intern Med. 2016; 176: 484-493
        • Coleman EA
        Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.
        J Am Geriatr Soc. 2003; 51: 549-555
        • Greenwald JL
        • Jack BW
        Preventing the preventable: reducing rehospitalizations through coordinated, patient-centered discharge processes.
        Prof Case Manag. 2009; 14: 135-140
        • Krumholz HM
        Post-hospital syndrome–an acquired, transient condition of generalized risk.
        N Engl J Med. 2013; 368: 100-102
        • Bumpus SM
        • Krallman R
        • Kline-Rogers E
        • Montgomery D
        • Eagle KA
        • Rubenfire M
        Transitional care to reduce cardiac readmissions: 5-year results from the BRIDGE Clinic.
        J Fam Med Dis Prev. 2017; 3
        • Bumpus S
        • Brush BL
        • Pressler SJ
        • Wheeler J
        • Eagle KA
        • Rubenfire M
        A transitional care model for patients with acute coronary syndrome.
        Am J Accountable Care. 2014; 2 (Available at:) (Accessed August 7, 2019)
        • Charlson M
        • Szatrowski TP
        • Peterson J
        • Gold J
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47: 1245-1251
        • Baecker A
        • Meyers M
        • Koyama S
        • et al.
        Evaluation of a transitional care program after hospitalization for heart failure in an integrated health care system.
        JAMA Netw Open. 2020; 3e2027410
        • Soto GE
        • Huenefeldt EA
        • Hengst MN
        • et al.
        Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints.
        BMC Health Serv Res. 2018; 18: 672
        • Van Spall HGC
        • Lee SF
        • Xie F
        • et al.
        Effect of patient-centered transitional care services on clinical outcomes in patients hospitalized for heart failure: The PACT-HF Randomized Clinical Trial.
        JAMA. 2019; 321: 753-761
        • Stromberg A
        • Martensson J
        • Fridlund B
        • Levin LA
        • Karlsson JE
        • Dahlstrom U
        Nurse-led heart failure clinics improve survival and self-care behaviour in patients with heart failure: results from a prospective, randomised trial.
        Eur Heart J. 2003; 24: 1014-1023
        • Ekman I
        • Andersson B
        • Ehnfors M
        • Matejka G
        • Persson B
        • Fagerberg B
        Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure.
        Eur Heart J. 1998; 19: 1254-1260
        • Desai AS
        • Stevenson LW
        Rehospitalization for heart failure: predict or prevent?.
        Circulation. 2012; 126: 501-506
        • Zulman DM
        • Pal Chee C
        • Ezeji-Okoye SC
        • et al.
        Effect of an intensive outpatient program to augment primary care for high-need veterans affairs patients: a randomized clinical trial.
        JAMA Intern Med. 2017; 177: 166-175
        • Krumholz HM
        • Hsieh A
        • Dreyer RP
        • Welsh J
        • Desai NR
        • Dharmarajan K
        Trajectories of risk for specific readmission diagnoses after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        PLoS One. 2016; 11e0160492
        • Naylor MD
        • Shaid EC
        • Carpenter D
        • et al.
        Components of comprehensive and effective transitional care.
        J Am Geriatr Soc. 2017; 65: 1119-1125