Transitional Care Interventions to Prevent Readmissions for People With Heart Failure ― Comparative Effectiveness Review Number 133

Heart failure (HF) is a major public health problem and a leading cause of hospitalization and health care costs in the United States. It is the most common principal discharge diagnosis among Medicare beneficiaries and the third highest for hospital reimbursements. Up to 25 percent of patients hospitalized with HF are readmitted within 30 days. In an effort to reduce the frequency of rehospitalization of Medicare patients, in October 2012 CMS began lowering reimbursements to hospitals with excessive risk-standardized readmission rates as part of the Hospital Readmissions Reduction Program authorized by the Affordable Care Act. This policy provides incentives for hospitals to develop effective transition programs to reduce readmission rates for people with HF. In 2010, nearly 7 million Americans 18 years of age and older had an HF diagnosis; by 2030, an additional 3 million Americans will have the condition. The incidence of HF increases with age; it affects 1 of every 100 people 65 years of age and older. Coronary disease and uncontrolled hypertension are the two highest population-attributable risks for HF. Survival after HF diagnosis has improved over time. However, the death rate remains high: 50 percent of people diagnosed with HF die within 5 years after diagnosis. Among Medicare beneficiaries, more than 30 percent of patients with HF die within 1 year after hospitalization. National data show no evidence that readmission rates for HF patients have fallen during the past two decades, despite the observation that HF hospitalizations in the United States have declined by almost 30 percent during the past decade. Readmission rates vary by both geographic location and insurance coverage. The relationship between readmission rates and other important outcomes (e.g., mortality, emergency room [ER] visits) is unclear. Some data suggest that hospitals with the lowest mortality rates among patients with HF tend to have higher readmission rates. Some predict that interventions aimed at reducing readmissions may increase use of other health care services, such as ER observational visits. An assessment of the efficacy, comparative effectiveness, and harms of transitional care interventions is needed to support evidence-based policy and clinical decisionmaking. Despite advances in the quality of acute and chronic HF disease management, gaps remain in knowledge about effective interventions to support the transition of care for patients with HF.Our report focuses mainly on transitional care interventions that aim to reduce 30-day readmission and mortality rates for patients hospitalized with HF. We also include readmissions measured over 3 to 6 months because these are common, costly, and potentially preventable. We examine several related issues, including other health care use (e.g., ER visits), quality of life, and potential harms such as increased caregiver burden. We include these outcomes because they may provide information on the unintended consequences of interventions aimed at preventing readmissions.