Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.
BACKGROUND
Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).


OBJECTIVE
To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs.


METHODS
We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field.


METHODS
We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome.


METHODS
Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner.


RESULTS
Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials).


CONCLUSIONS
Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
Phillips
Christopher O
CO
Quality of Care Research and General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Md, USA.
Wright
Scott M
SM
Kern
David E
DE
Singa
Ramesh M
RM
Shepperd
Sasha
S
Rubin
Haya R
HR
D000368:Aged; D003266:Continuity of Patient Care; D017048:Health Care Costs; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D006801:Humans; D007902:Length of Stay; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge; D010359:Patient Readmission; D011788:Quality of Life