According to published research, heart failure (HF) is a leading cause of hospitalization and healthcare costs in the United States. Current estimates show that up to 25% of patients hospitalized with HF are readmitted within 30 days. Early hospital readmissions following an initial hospitalization for HF are related to a variety of conditions. About one-third can be attributed to HF, whereas the rest are related to other conditions, such as renal disorders, pneumonia, and arrhythmias.

In an effort to reduce readmission rates for HF, CMS began decreasing reimbursements to hospitals with excessive risk-standardized readmissions in 2012. With this policy in place, hospitals have been incentivized to develop programs to reduce HF readmission rates. “Although significant advances have occurred with regard to the quality of how acute and chronic HF are managed, hospital readmissions in this population continue to be a problem,” says Cynthia Feltner, MD, MPH. She adds that there is uncertainty about the effectiveness of interventions to support the transition of care for people with HF.

Transitional care interventions are designed to prevent readmissions among patients transitioning from one care setting to another. Several models have been created, with the goal of avoiding poor outcomes caused by uncoordinated care. “These interventions focus on patient or caregiver education, medication reconciliation, and coordination among healthcare professionals involved in the transition,” Dr. Feltner says.

A Systematic Review

In a systematic review published in Annals of Internal Medicine, Dr. Feltner and colleagues examined transitional care interventions for people with HF as part of AHRQ’s Effective Health Care Program. The authors reviewed a broad range of intervention types that aimed to prevent readmissions in adults with HF transitioning from hospital to home (Table 1). The study team noted that 30-day readmissions are the focus of quality measures, but they also included readmissions measured over 3 to 6 months because these are common, costly, and potentially preventable.


For the analysis, Dr. Feltner and colleagues reviewed 47 trials, most of which enrolled adults with moderate to severe HF and who were 70 years of age, on average. Few trials assessed in the systematic review reported 30-day readmission rates. “Studies indicate that using a high-intensity, home-visiting program reduced all-cause readmissions and the risk of death among HF patients,” Dr. Feltner says. “Home-visiting programs also reduced HF-specific readmissions and correlated with a mortality benefit.” Over 3 to 6 months, home-visiting programs and multidisciplinary HF clinic interventions reduced all-cause readmission rates. These interventions should receive the greatest consideration by healthcare systems or providers seeking to implement transitional care interventions for HF.

Other transitional care interventions did not appear to be as effective, according to Dr. Feltner. “For example, structured telephone support interventions reduced HF-specific readmission rates, but not all-cause readmissions,” she says. “In addition, telemonitoring programs and primarily educational interventions were not as effective as other approaches at reducing readmission or mortality rates.” A summary of the key findings for the transitional care interventions assessed in the study is available in Table 2.

Quality Improvement

According to Dr. Feltner, current practices for the care of adults with HF after hospitalization vary greatly throughout the U.S. “Our findings can help physicians and policymakers by providing guidance to quality improvement efforts that aim to reduce readmission and mortality rates associated with HF,” she says. “The data are descriptive and informative for physicians interested in interventions that could be implemented during the transition from hospital to home.” She notes that the trials examined in the study were conducted in various inpatient settings, and more than half were performed in the U.S. As a result, the findings are generally applicable to many hospital settings throughout the country.

Future Research

The systematic review by Dr. Feltner and colleagues also identified important gaps in the evidence that future research should aim to address. For example, studies are needed to determine if interventions that reduce readmission rates over 3 to 6 months could also decrease 30-day readmission rates. It would also be helpful to directly compare specific interventions with others. For example, a comparison of home-visiting programs to multidisciplinary HF clinics could establish if one of these approaches should be preferred over another. “As we conduct more research on transitional care interventions for HF,” Dr. Feltner says, “it’s hoped that we can ensure that HF patients are receiving the supportive care they need early after their hospitalization. Doing so may improve outcomes and decrease the burden of HF in the future.”


Feltner C, Jones CD, Cene CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160:774-784. Available at:

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