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Original Investigation
February 26, 2019

Effect of Patient-Centered Transitional Care Services on Clinical Outcomes in Patients Hospitalized for Heart Failure: The PACT-HF Randomized Clinical Trial

Author Affiliations
  • 1Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  • 2Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  • 3Population Health Research Institute, Hamilton, Ontario, Canada
  • 4Centre for Health Economics and Policy Analysis, Program for Health Economics and Outcome Measures, Hamilton, Ontario, Canada
  • 5Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  • 6Department of Medicine, University of Toronto, Ontario, Canada
  • 7Department of Medicine, St Joseph’s Health Centre, Toronto, Ontario, Canada
  • 8Cardiac Health Program, Trillium Health Partners, Mississauga, Ontario, Canada
  • 9Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
  • 10Department of Medicine, Halton Health Care Services, Oakville, Ontario, Canada
  • 11Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
  • 12Department of Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
  • 13School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
  • 14Hamilton Niagara Haldimand Brant Community Care Access Centre, Hamilton, Ontario, Canada
JAMA. 2019;321(8):753-761. doi:10.1001/jama.2019.0710
Key Points

Question  Can implementing a group of evidence-informed transitional care services in a publicly funded health care system improve outcomes among patients discharged after hospitalization for heart failure?

Findings  In this pragmatic stepped-wedge cluster randomized trial that included 2494 patients in 10 hospitals in Ontario, Canada, there were no significant differences between patients who were randomized to receive a care transition program vs usual care in the primary composite outcome of time to all-cause readmission, emergency department visit, or death at 3 months (hazard ratio, 0.99) or the co–primary composite outcome of all-cause readmission or emergency department visit at 30 days (hazard ratio, 0.92).

Meaning  This patient-centered transitional care service model did not improve a composite of clinical outcomes in patients hospitalized for heart failure.

Abstract

Importance  Health care services that support the hospital-to-home transition can improve outcomes in patients with heart failure (HF).

Objective  To test the effectiveness of the Patient-Centered Care Transitions in HF transitional care model in patients hospitalized for HF.

Design, Setting, and Participants  Stepped-wedge cluster randomized trial of 2494 adults hospitalized for HF across 10 hospitals in Ontario, Canada, from February 2015 to March 2016, with follow-up until November 2016.

Interventions  Hospitals were randomized to receive the intervention (n = 1104 patients), in which nurse-led self-care education, a structured hospital discharge summary, a family physician follow-up appointment less than 1 week after discharge, and, for high-risk patients, structured nurse homevisits and heart function clinic care were provided to patients, or usual care (n = 1390 patients), in which transitional care was left to the discretion of clinicians.

Main Outcomes and Measures  Primary outcomes were hierarchically ordered as composite all-cause readmission, emergency department (ED) visit, or death at 3 months; and composite all-cause readmission or ED visit at 30 days. Secondary outcomes were B-PREPARED score for discharge preparedness (range: 0 [most prepared] to 22 [least prepared]); the 3-Item Care Transitions Measure (CTM-3) for quality of transition (range: 0 [worst transition] to 100 [best transition]); the 5-level EQ-5D version (EQ-5D-5L) for quality of life (range: 0 [dead] to 1 [full health]); and quality-adjusted life-years (QALY; range: 0 [dead] to 0.5 [full health at 6 months]).

Results  Among eligible patients, all 2494 (mean age, 77.7 years; 1258 [50.4%] women) completed the trial. There was no significant difference between the intervention and usual care groups in the first primary composite outcome (545 [49.4%] vs 698 [50.2%] events, respectively; hazard ratio [HR], 0.99 [95% CI, 0.83-1.19]) or in the second primary composite outcome (304 [27.5%] vs 408 [29.3%] events, respectively; HR, 0.93 [95% CI, 0.73-1.18]). There were significant differences between the intervention and usual care groups in the secondary outcomes of mean B-PREPARED score at 6 weeks (16.6 vs 13.9; difference, 2.65 [95% CI, 1.37-3.92]; P < .001); mean CTM-3 score at 6 weeks (76.5 vs 70.3; difference, 6.16 [95% CI, 0.90-11.43]; P = .02); and mean EQ-5D-5L score at 6 weeks (0.7 vs 0.7; difference, 0.06 [95% CI, 0.01 to 0.11]; P = .02) and 6 months (0.7 vs 0.6; difference, 0.06 [95% CI, 0.01-0.12]; P = .02). There was no significant difference in mean QALY between groups at 6 months (0.3 vs 0.3; difference, 0.00 [95% CI, −0.02 to 0.02]; P = .98).

Conclusions and Relevance  Among patients with HF in Ontario, Canada, implementation of a patient-centered transitional care model compared with usual care did not improve a composite of clinical outcomes. Whether this type of intervention could be effective in other health care systems or locations would require further research.

Trial Registration  ClinicalTrials.gov Identifier: NCT02112227

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