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March 17, 2004

Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart FailureA Meta-analysis

Author Affiliations

Author Affiliations: Quality of Care Research and General Internal Medicine, Johns Hopkins University School of Medicine (Drs Phillips and Rubin), Division of General Internal Medicine, Johns Hopkins Bayview Medical Center (Drs Wright and Kern), Department of Medicine, Johns Hopkins University Bloomberg School of Public Health (Mr Singa and Dr Rubin), Baltimore, Md; and Institute of Health Sciences, University of Oxford, Oxford, England (Dr Shepperd).

JAMA. 2004;291(11):1358-1367. doi:10.1001/jama.291.11.1358

Context Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).

Objective To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs.

Data Sources We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field.

Study Selection We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age ≥55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome.

Data Extraction Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner.

Data Synthesis Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P = .60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P = .01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (−$359 [95% CI, −$763 to $45]; n = 4, P = .10 for non-US trials and −$536 [95% CI, −$956 to −$115]; n = 4, P = .03, for US trials).

Conclusion Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.