Prevention of Early Readmission in Elderly Congestive Heart Failure Patients
Condition: Cardiovascular Diseases; Heart Diseases; Heart Failure, Congestive; Heart Failure
MeSH terms: Heart Failure; Cardiovascular Diseases; Heart Diseases
Study type: Interventional
Phase: Phase 2

Summary: 
      To assess the impact of a multidisciplinary treatment program on three-month readmission-free
      survival in elderly congestive heart failure patients.
    

Detailed description: 
      BACKGROUND:

      The prevalence of congestive heart failure increases progressively with advancing age, and
      congestive heart failure is a major cause of mortality, morbidity, and diminished quality of
      life in the elderly. Not only is congestive heart failure the most common cardiovascular
      indication for hospitalization in patients 65 years or older, but frequent repetitive
      hospitalizations, occurring in 30-50 percent of patients within three to six months of
      initial discharge, create an imposing cost burden in caring for these patients. A pilot study
      conducted at the grantee institution has shown that elderly congestive heart failure patients
      at risk for early readmission can be identified at the time of initial hospitalization, that
      up to 50 percent of readmissions are potentially preventable, and that a non-pharmacologic
      treatment strategy consisting of patient education, medication analysis, discharge planning,
      and enhanced follow-up is feasible and may reduce readmissions by 30 to 50 percent.

      DESIGN NARRATIVE:

      In the feasibility study, patients were randomly assigned to receive intervention or standard
      care over a four year period. Patients were stratified into readmission risk categories of
      high or moderate based on the presence of four independent risk factors for readmission
      defined in a prior study at Jewish Hospital in St. Louis. The risk factors included: four or
      more prior hospitalizations within the preceding five-year interval, previous history of
      congestive heart failure, hypocholesterolemia, and right bundle-branch block on the admitting
      electrocardiogram. The study intervention consisted of individualized patient education using
      teaching materials specifically designed for the study; a careful review of medications with
      specific recommendations designed to eliminate unnecessary drugs, decrease the number of
      dosing intervals, improve compliance, and minimize side effects; early discharge planning;
      and enhanced post-discharge follow-up. The primary endpoints were rehospitalization within 90
      days after initial hospital discharge and the cumulative number of days hospitalized during
      follow-up. Principal secondary endpoints included analyses of the effect of the study
      intervention on compliance with prescribed medications, dietary sodium intake, incidence of
      adverse drug reactions, patient knowledge and understanding of congestive heart failure,
      patient-assessed quality of life, and the overall cost of medical care.

      In the full-scale trial, 140 patients were assigned to the control group which received all
      standard treatments and services ordered by their physicians. A total of 142 patients were
      assigned to the treatment group which received intensive education about congestive heart
      failure and its treatment by an experienced cardiovascular research nurse, using a teaching
      booklet developed by study investigators for geriatric patients with heart failure. Treatment
      group patients also received individualized dietary assessment and instruction given by a
      registered dietitian; consultation with social-service personnel to facilitate discharge
      planning and care after discharge; an analysis of medications by a geriatric cardiologist who
      made specific recommendations to eliminate unnecessary medications and simplify the overall
      regimen; and intensive follow-up after discharge. The goals of follow-up were to reinforce
      the patient's education, ensure compliance with medications and diet, and identify recurrent
      symptoms amenable to treatment on an outpatient basis. The primary outcome measure was
      survival for 90 days without hospital readmission. Secondary endpoints included the number of
      readmissions for any cause, the number of readmissions for congestive heart failure, the
      cumulative number of days of hospitalization during follow-up, quality-of-life scores, and
      the overall cost of medical care.

      The study completion date listed in this record was obtained from the "End Date" entered in
      the Protocol Registration and Results System (PRS) record.
    

Intervention name(s): health education
Intervention type(s): Behavioral
Allocation: Randomized
Primary purpose: Prevention