Taking Care Transitions Programs to Scale: Is the Evidence There Yet?
Authors: Leora I. Horwitz
Journal: Annals of Internal Medicine (2020)

Editorials18 February 2020Taking Care Transitions Programs to Scale: Is the Evidence There Yet?Leora I. Horwitz, MD, MHSLeora I. Horwitz, MD, MHSNew York University Grossman School of Medicine and New York University Langone Health, New York, New York (L.I.H.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3872 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Heart failure affects 26 million people globally and is a leading cause of hospitalization and rehospitalization among older adults (1). In 2011, 18 in 1000 persons older than 64 years in the United States were hospitalized for heart failure (2), and the readmission rate for heart failure is 20% (3). Yet despite dozens of studies on methods for reducing rehospitalizations in this cohort, the great majority of patients still receive “usual care”—at best, careful medication reconciliation, a close outpatient follow-up appointment, and some education.In an elegant and well-conducted microsimulation study published in Annals, Blum and colleagues (4) estimate that ...References1. Ambrosy AP, Fonarow GC, Butler J, et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol. 2014;63:1123-1133. [PMID: 24491689] doi:10.1016/j.jacc.2013.11.053 CrossrefMedlineGoogle Scholar2. Krumholz HM, Normand SL, Wang Y. Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Circulation. 2014;130:966-75. [PMID: 25135276] doi:10.1161/CIRCULATIONAHA.113.007787 CrossrefMedlineGoogle Scholar3. Dharmarajan K, Qin L, Lin Z, et al. Declining admission rates and thirty-day readmission rates positively associated even though patients grew sicker over time. Health Aff (Millwood). 2016;35:1294-302. [PMID: 27385247] doi:10.1377/hlthaff.2015.1614 CrossrefMedlineGoogle Scholar4. Blum MR, Øien H, Carmichael HL, et al. Cost-effectiveness of transitional care services after hospitalization with heart failure. Ann Intern Med. 2020;172:248-57. doi:10.7326/M19-1980 LinkGoogle Scholar5. McCall N, Cromwell J. Results of the Medicare Health Support disease-management pilot program. N Engl J Med. 2011;365:1704-12. [PMID: 22047561] doi:10.1056/NEJMsa1011785 CrossrefMedlineGoogle Scholar6. Chen AJ, Hu X, Conti RM, et al. Trends in the price per median and mean life-year gained among newly approved cancer therapies 1995 to 2017. Value Health. 2019;22:1387-1395. [PMID: 31806195] doi:10.1016/j.jval.2019.08.005 CrossrefMedlineGoogle Scholar7. Bauer MS, Damschroder L, Hagedorn H, et al. An introduction to implementation science for the non-specialist. BMC Psychol. 2015;3:32. [PMID: 26376626] doi:10.1186/s40359-015-0089-9 CrossrefMedlineGoogle Scholar8. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. HCUPnet. Hospital Inpatient National Statistics. Accessed at https://hcupnet.ahrq.gov/#setup on 10 December 2019. Google Scholar9. American College of Cardiology. Quality Improvement for Institutions. Hospital to Home. Accessed at https://cvquality.acc.org/initiatives/hospital-to-home on 10 December 2019. Google Scholar10. Alliance for Home Health Quality and Innovation. Care Transitions. Accessed at http://ahhqi.org/quality-initiatives/care-transitions on 10 December 2019. Google Scholar Author, Article, and Disclosure InformationAffiliations: New York University Grossman School of Medicine and New York University Langone Health, New York, New York (L.I.H.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3872.Corresponding Author: Leora I. Horwitz, MD, MHS, Department of Population Health, NYU Grossman School of Medicine, 550 First Avenue, TRB, Room 633, New York, NY 10016; e-mail, leora.[email protected]org.This article was published at Annals.org on 28 January 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure Manuel R. Blum , Henning Øien , Harris L. Carmichael , Paul Heidenreich , Douglas K. Owens , and Jeremy D. Goldhaber-Fiebert Metrics Cited byTransitional care services cost effective after hospitalisation for HF 18 February 2020Volume 172, Issue 4Page: 285-286KeywordsDisclosureHealth careHeart failureHospitalizationsLongitudinal studiesMedicareMotivationNursesQuality adjusted life yearsScientists ePublished: 28 January 2020 Issue Published: 18 February 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...