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Transitional Care Interventions To Prevent Readmissions for People With Heart Failure

Comparative Effectiveness Reviews, No. 133

Investigators: , MD, MPH, , MD, MS, , MD, MPH, , MD, MPH, PhD, , MD, PhD, , MPH, , MD, , PhD, MPhil, MA, , PhD, and , MD, MPH.

Author Information
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 14-EHC021-EF

Structured Abstract


To conduct a systematic review and meta-analysis of the efficacy, comparative effectiveness, and harms of transitional care interventions that aim to reduce readmissions and mortality for adults hospitalized with heart failure (HF). We also sought to describe the components of interventions that showed efficacy.

Data sources:

MEDLINE®, Cochrane Library, CINAHL®,, and World Health Organization International Clinical Trials Registry Platform (January 1, 1990, to early May 2013).

Review methods:

Two investigators independently selected, extracted data from, and rated risk of bias of relevant randomized controlled trials. We conducted meta-analyses using random-effects models to estimate pooled effects. We graded strength of evidence (SOE) based on established guidance.


We included 47 trials. Most included patients with moderate to severe HF; mean ages of patients were in the 70s. Few trials reported 30-day readmission rates. A high-intensity home-visiting program reduced all-cause readmission and the composite endpoint (all-cause readmission or death) at 30 days (low SOE). Over 3 to 6 months, home-visiting programs reduced all-cause readmission (high SOE), HF-specific readmission (moderate SOE), and the composite endpoint (moderate SOE). Multidisciplinary (MDS)-HF clinic interventions reduced all-cause readmission (high SOE). Structured telephone support (STS) interventions reduced HF-specific readmission (high SOE) but not all-cause readmissions (moderate SOE). Home-visiting programs, MDS-HF clinics, and STS interventions produced a mortality benefit (moderate SOE). Neither telemonitoring nor nurse-led clinic interventions reduced readmissions or mortality.

Components of interventions showing efficacy for reducing all-cause readmissions or mortality include: HF education, emphasizing self-care; HF pharmacotherapy, emphasizing promotion of adherence and evidence-based HF pharmacotherapy; and a streamlined mechanism to contact care delivery personnel (e.g., patient hotline). In general, categories of interventions that reduced all-cause readmissions or mortality were more likely to be of higher intensity, to be delivered face to face, and to be provided by MDS teams.


Home-visiting programs and MDS-HF clinic interventions reduced all-cause readmission and mortality; STS reduced HF-specific readmission and mortality but not all-cause readmission. These interventions should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for people with HF. We found no evidence assessing harms of transitional care interventions, such as increased caregiver burden.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00008-I. Prepared by: Research Triangle Institute–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC

Suggested citation:

Feltner C, Jones CD, Cené CW, Zheng Z-J, Sueta CA, Coker-Schwimmer EJL, Arvanitis M, Lohr KN, Middleton JC, Jonas DE. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure. Comparative Effectiveness Review No. 133. (Prepared by the Research Triangle Institute–University of North Carolina Evidence-based Practice Center under Contract No. 290-2012-00008-I). AHRQ Publication No. 14-EHC021-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2014.

This report is based on research conducted by the Research Triangle Institute–University of North Carolina Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00008-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This report may periodically be assessed for the urgency to update. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at Search on the title of the report.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.


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Bookshelf ID: NBK209241PMID: 24967474


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