Effectiveness of transitional-care heart failure programmes in multimorbid patiens: a population-based study with longitudinal real-world data in 77,554 patients
Authors: Alcoberro L , Jimenez-Marrero S , Basalo M , Vela E , Cleries M , Monterde D , Alcober L , Calero E , Hidalgo E , Jose N , Yun S , Corbella M , Enjuanes C , Capdevila C , Comin-Colet J 
Published: November 2023

Abstract

Background
High comorbidity burden has a negative impact in terms of outcomes and medical resource use despite access to integrated care in universal health-care systems in patients with heart failure (HF). Whether the breach in outcomes determined by comorbidity burden can be mitigated by intensive HF management in integrated care programs is not known.

Purpose
To analyse the effectiveness across morbidity groups on health outcomes of integrated care before and after a pragmatic implementation of an intensive transitional care nurse-based HF management program in a healthcare area of 209,255 inhabitants.

Methods
We included all individuals discharged alive in Catalonia with HF as the primary diagnosis between 2015 and 2019. Morbidity and clinical complexity were evaluated using the Adjusted Morbidity Group (GMA) index. The GMA is an instrument developed and validated in Catalonia for grouping morbidity that identifies populations with multimorbidity and higher use of healthcare resources and has been shown better discrimination power than Charlson’s Index. For this study we classified patients into 3 morbidity groups: low or intermediate risk GMA, high risk GMA and very high-risk GMA. To evaluate the efficacy of the programme according to GMA strata, we compared outcomes between HF patients of the implementation area and HF patients of the remaining healthcare areas of Catalonia stratified in morbidity groups according to levels of GMA and across implementation periods (years 2015-2016 (pre-implementation), 2017 (transition) and 2018-2019 (consolidation).

Results
We included 77,554 patients: 3,396 exposed to the implementation area and 74,158 exposed to the rest of healthcare areas. 13,981 had a low or intermediate risk GMA 32,138 high risk and 31,435 very high risk. During the period of the study, 55,886 patients (72.1%) experienced at least one major adverse event. As shown in Table 1, multivariate adjusted Cox proportional hazards models stratified according to GMA groups showed that implementation of the program resulted in an improvement of all studied outcomes in the consolidation period compared to the pre-implementation period across all risk-group according to GMA. As shown in Figure 1, the implementation of the program resulted in a significant reduction of the risk adverse events compared to the rest of Catalonia during the consolidation period (left column) and this improvement was observed across all morbidity-group strata (Figure 1, central and right columns). Interestingly, the size effect of the improvement was particularly noticeable in patients in the high-risk and very high-risk group strata.

Conclusions
Transitional-care nurse-based HF programmes improve clinical outcomes in patients with HF and are effective regardless the comorbidity burden of patients. Individuals with a very high comorbidity index obtain even a greater reduction of readmissions when exposed to those programs than less comorbid patients.