The Value of Hospital Transition Interventions

And another one bites the dust, and another one, and another one.  (Queen is hot right now, right?)  A study in the Journal of the American Medical Association looks at the impact of a transactional care model for patients hospitalized with heart failure.  (JAMA Article)   Helping with the transition from hospital to usual sources of care has been widely promoted as having a substantial impact on outcomes.  Spoiler alert, oops, there wasn’t any in this trial.  The study was conducted in Ontario, Canada in ten hospitals and included about 2500 patients, around 1100 of which were treated at hospitals randomized to receive the intervention.  The intervention consisted of a hospital nurse who helped the patient “navigate” the transition to home, including a needs assessment, multidisciplinary referrals for follow-up care, self-care education, a patient-centered discharge summary with a symptom-driven action plan, which certainly sounds impressive, family physician follow-up visit arranged within one week of discharge and referrals to nurse home visits and phone calls.  Primary outcomes were time to all-cause hospital readmission or ER visit, death at 3 months or readmission or ER visit rate at 30 days post-discharge.  Surveys and scores for post-discharge readiness and quality of care transition and quality of life were also collected. The intervention and normal care groups filled prescriptions at the same rate.  No difference in the rate of 3 month composite all-cause readmission, ER visits or death rates between the groups.  No difference in time to first readmission, ER visit or death.  This despite the fact that the intervention group reported higher preparedness for discharge scores, quality of care transition and quality of life.  Was the quality of care transition really any better if meaningful clinical outcomes didn’t improve?  This is a tough group of patients, very expensive ones, so it might be hard to make a difference for them, but it is also hard to see the value to a health system in implementing these kinds of interventions if they don’t appear to make any real impact.