Home Telemonitoring to Reduce Readmission of High-Risk Patients: a Modified Intention-to-Treat Randomized Clinical Trial

Unlocking Continuous Improvement in Heart Failure Remote Monitoring: A Participatory Approach to Unveil Value Dimensions and Performance Indicators

Introduction: Heart failure (HF) constitutes a public health concern affecting quality of life, survival, and costs. Remote patient monitoring (RPM) can enhance HF management, involving patients actively and improving follow-up. While current HF RPM assessments emphasise cost-effectiveness analysis, there is a need to consider wider RPM impacts and integrate stakeholders' perspectives into assessments for better comprehensiveness. Methods: We developed a four-stage participatory approach to select value dimensions and indicators for continuous HF RPM assessment: Stage 1 involved building a literature-informed initial list; Stage 2 utilized expert interviews for validation and list expansion; Stage 3 involved a web-Delphi process with Portuguese stakeholders and experts for agreement assessment; and Stage 4 included a conclusive expert interview. Results: A literature review identified fourteen studies on telehealth, RPM, and HF, informing an initial list of four value dimensions (Access, Clinical aspects, Acceptability, and Costs) and 22 indicators. Seven semistructured interviews validated and further adjusted the list to 38 indicators. Subsequently, the web-Delphi process engaged 29 stakeholders, giving their opinions regarding assessment aspects' relevance and proposing additional elements - 1 dimension and 12 indicators. Five value dimensions and 38 indicators (76.0%) reached group agreement for selection, while 12 did not reach an agreement. Upon expert appreciation, 5 dimensions, 43 indicators, and 6 case-mix parameters were considered relevant. Discussion: This comprehensive social approach captured diverse stakeholder perspectives, achieving agreement on pertinent HF RPM monitoring and evaluation indicators. Findings can inform visualization and management tool development, aiding day-to-day RPM evaluation and identification of improvement opportunities.

Home Heart Hospital Associated With Reduced Hospitalizations and Costs Among High-Cost Patients With Cardiovascular Disease

BACKGROUND

There is no widely accepted care model for managing high-need, high-cost (HNHC) patients. We hypothesized that a Home Heart Hospital (H3), which provides longitudinal, hospital-level at-home care, would improve care quality and reduce costs for HNHC patients with cardiovascular disease (CVD).

OBJECTIVE

To evaluate associations between enrollment in H3, which provides longitudinal, hospital-level at-home care, care quality, and costs for HNHC patients with CVD.

METHODS

This retrospective within-subject cohort study used insurance claims and electronic health records data to evaluate unadjusted and adjusted annualized hospitalization rates, total costs of care, part A costs, and mortality rates before, during, and following H3.

RESULTS

Ninety-four patients were enrolled in H3 between February 2019 and October 2021. Patients' mean age was 75 years and 50% were female. Common comorbidities included congestive heart failure (50%), atrial fibrillation (37%), coronary artery disease (44%). Relative to pre-enrollment, enrollment in H3 was associated with significant reductions in annualized hospitalization rates (absolute reduction (AR): 2.4 hospitalizations/year, 95% confidence interval [95% CI]: -0.8, -4.0; p < 0.001; total costs of care (AR: -$56 990, 95% CI: -$105 170, -$8810; p < 0.05; and part A costs (AR: -$78 210, 95% CI: -$114 770, -$41 640; p < 0.001). Annualized post-H3 total costs and part A costs were significantly lower than pre-enrollment costs (total costs of care: -$113 510, 95% CI: -$151 340, -$65 320; p < 0.001; part A costs: -$84 480, 95% CI: -$121 040, -$47 920; p < 0.001).

CONCLUSIONS

Longitudinal home-based care models hold promise for improving quality and reducing healthcare spending for HNHC patients with CVD.

Using Machine Learning Models to Identify Factors Associated With 30-Day Readmissions After Posterior Cervical Fusions: A Longitudinal Cohort Study

OBJECTIVE

Readmission rates after posterior cervical fusion (PCF) significantly impact patients and healthcare, with complication rates at 15%-25% and up to 12% 90-day readmission rates. In this study, we aim to test whether machine learning (ML) models that capture interfactorial interactions outperform traditional logistic regression (LR) in identifying readmission-associated factors.

METHODS

The Optum Clinformatics Data Mart database was used to identify patients who underwent PCF between 2004-2017. To determine factors associated with 30-day readmissions, 5 ML models were generated and evaluated, including a multivariate LR (MLR) model. Then, the best-performing model, Gradient Boosting Machine (GBM), was compared to the LACE (Length patient stay in the hospital, Acuity of admission of patient in the hospital, Comorbidity, and Emergency visit) index regarding potential cost savings from algorithm implementation.

RESULTS

This study included 4,130 patients, 874 of which were readmitted within 30 days. When analyzed and scaled, we found that patient discharge status, comorbidities, and number of procedure codes were factors that influenced MLR, while patient discharge status, billed admission charge, and length of stay influenced the GBM model. The GBM model significantly outperformed MLR in predicting unplanned readmissions (mean area under the receiver operating characteristic curve, 0.846 vs. 0.829; p < 0.001), while also projecting an average cost savings of 50% more than the LACE index.

CONCLUSION

Five models (GBM, XGBoost [extreme gradient boosting], RF [random forest], LASSO [least absolute shrinkage and selection operator], and MLR) were evaluated, among which, the GBM model exhibited superior predictive performance, robustness, and accuracy. Factors associated with readmissions impact LR and GBM models differently, suggesting that these models can be used complementarily. When analyzing PCF procedures, the GBM model resulted in greater predictive performance and was associated with higher theoretical cost savings for readmissions associated with PCF complications.

Digitally Enabled Transitional Care Management in Oncology

PURPOSE

Improving care transitions for patients with cancer discharged from the hospital is considered an important component of quality care. Digital monitoring has the potential to better the delivery of transitional care through improved patient-provider communication and enhanced symptom management. However, remote patient monitoring (RPM) interventions have not been widely implemented for oncology patients after discharge, an innovative setting in which to apply this technology.

METHODS

We implemented a RPM intervention which identifies medical oncology patients at discharge, monitors their symptoms for 10 days, and intervenes as necessary to manage symptoms. We evaluated the feasibility (>50% patient engagement with symptom assessment), appropriateness (symptom alerts), and acceptability (net promoter score >0.7) of the intervention and the initial effect on acute care visits and return on investment.

RESULTS

During the study period, January 1, 2021, to December 31, 2022, we evaluated 2,257 medical oncology discharges representing 1,857 unique patients. We found that 65.9% of patients discharged (N = 1,489) completed at least one symptom assessment postdischarge and of them, 45.5% (n = 678) generated a severe symptom alert that we helped to manage. Patients expressed high satisfaction with the intervention with a net promoter score of 84%. In preliminary analysis of patients with GI malignancies (n = 449), we found a nonsignificant decrease in 30-day readmissions for the intervention cohort (n = 269) by 5.8% as compared with the control (n = 180; from 33.3% to 27.5%; P = .22).

CONCLUSION

Digital transitional care management was feasible and demonstrated that patients transitioning from the hospital to home have a substantial symptom burden. The intervention was associated with high patient satisfaction but will require further refinement and evaluation to increase its impact on 30-day readmission.

Effectiveness of nurse-led electronic health interventions on illness management in patients with chronic heart failure: A systematic review and meta-analysis

BACKGROUND

Chronic heart failure (CHF) is a global health concern, and nurse-led electronic health is an effective management strategy for this condition.

OBJECTIVE

This systematic review and meta-analysis aimed to identify current patterns and strategies for nurse-led electronic health interventions and examine the effects of nurse-led electronic health interventions for illness management in patients with chronic heart failure.

DESIGN

This study combined a systematic review and meta-analyses.

PARTICIPANTS

Twenty-four articles, involving a total of 3660 patients, met the inclusion criteria.

METHODS

We conducted a large amount of literature review using seven English databases: namely PubMed, Embase, Web of Science, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and SCOPUS, along with three Chinese databases: China National Knowledge Infrastructure(CNKI), WanFang, and the VIP Database. Databases were searched from inception until September 2022. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies were independently screened by two reviewers who extracted of the details of those meeting the inclusion criteria study. The Joanna Briggs Institute randomized controlled trial checklist was used to evaluate the methodological value of each incorporation study. Meta-analysis was performed by the use of Manager 5.3.

RESULTS

The main patterns of electronic health intervention involve smartphone, Internet and specialized (portable) electronic monitoring devices that are used for the illness management of patients with chronic heart failure, mainly including providing self-management guidance for chronic heart failure, and tracking of the patient's health information, providing peer support, and facilizing medical and health resources. The collective findings of 9 studies reported that electronic health interventions improved self-care (MD: 15.30, 95 % CI: 1.59 to 29.02, p < 0.05). Regarding psychosocial well-being outcomes, the incorporative conclusions indicated that electronic health interventions effectively increased quality of life, reduced depression and anxiety, and improved patient satisfaction. Regarding disease-related examinations, electronic health interventions significantly increased cardiac function during the 6-minute walk test. Regarding healthy economic outcomes, electronic health interventions significantly decreased the rehospitalization rate and the cost of medical care services.

CONCLUSIONS

The findings of this review suggest that nurse-led electronic health interventions involving multiple patterns have an active influence on managing patients with chronic heart failure, including enhancing self-care, and medication adherence; increasing quality of life; reducing depression, anxiety, and improved patient satisfaction; increasing cardiac function, and reducing rehospitalization rate and hospitalization costs. Thus, it could be a promising alternative in the clinical settings.

REGISTRATION

CRD42023389450.

Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis

Importance

Discharge from the hospital to the community has been associated with serious patient risks and excess service costs.

Objective

To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community.

Data Sources

CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022.

Study Selection

Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified.

Data Extraction and Synthesis

At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Main Outcomes and Measures

The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake.

Results

Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits.

Conclusions and Relevance

These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.

Digital Transformation in the Diagnostics and Therapy of Cardiovascular Diseases: Comprehensive Literature Review

BACKGROUND

The digital transformation of our health care system has experienced a clear shift in the last few years due to political, medical, and technical innovations and reorganization. In particular, the cardiovascular field has undergone a significant change, with new broad perspectives in terms of optimized treatment strategies for patients nowadays.

OBJECTIVE

After a short historical introduction, this comprehensive literature review aimed to provide a detailed overview of the scientific evidence regarding digitalization in the diagnostics and therapy of cardiovascular diseases (CVDs).

METHODS

We performed an extensive literature search of the PubMed database and included all related articles that were published as of March 2022. Of the 3021 studies identified, 1639 (54.25%) studies were selected for a structured analysis and presentation (original articles: n=1273, 77.67%; reviews or comments: n=366, 22.33%). In addition to studies on CVDs in general, 829 studies could be assigned to a specific CVD with a diagnostic and therapeutic approach. For data presentation, all 829 publications were grouped into 6 categories of CVDs.

RESULTS

Evidence-based innovations in the cardiovascular field cover a wide medical spectrum, starting from the diagnosis of congenital heart diseases or arrhythmias and overoptimized workflows in the emergency care setting of acute myocardial infarction to telemedical care for patients having chronic diseases such as heart failure, coronary artery disease, or hypertension. The use of smartphones and wearables as well as the integration of artificial intelligence provides important tools for location-independent medical care and the prevention of adverse events.

CONCLUSIONS

Digital transformation has opened up multiple new perspectives in the cardiovascular field, with rapidly expanding scientific evidence. Beyond important improvements in terms of patient care, these innovations are also capable of reducing costs for our health care system. In the next few years, digital transformation will continue to revolutionize the field of cardiovascular medicine and broaden our medical and scientific horizons.

Patient Satisfaction With a Multisite, Multiregional Remote Patient Monitoring Program for Acute and Chronic Condition Management: Survey-Based Analysis

BACKGROUND

Remote patient monitoring (RPM) is an option for continuously managing the care of patients in the comfort of their homes or locations outside hospitals and clinics. Patient engagement with RPM programs is essential for achieving successful outcomes and high quality of care. When relying on technology to facilitate monitoring and shifting disease management to the home environment, it is important to understand the patients' experiences to enable quality improvement.

OBJECTIVE

This study aimed to describe patients' experiences and overall satisfaction with an RPM program for acute and chronic conditions in a multisite, multiregional health care system.

METHODS

Between January 1, 2021, and August 31, 2022, a patient experience survey was delivered via email to all patients enrolled in the RPM program. The survey encompassed 19 questions across 4 categories regarding comfort, equipment, communication, and overall experience, as well as 2 open-ended questions. Descriptive analysis of the survey response data was performed using frequency distribution and percentages.

RESULTS

Surveys were sent to 8535 patients. The survey response rate was 37.16% (3172/8535) and the completion rate was 95.23% (3172/3331). Survey results indicated that 88.97% (2783/3128) of participants agreed or strongly agreed that the program helped them feel comfortable managing their health from home. Furthermore, 93.58% (2873/3070) were satisfied with the RPM program and ready to graduate when meeting the program goals. In addition, patient confidence in this model of care was confirmed by 92.76% (2846/3068) of the participants who would recommend RPM to people with similar conditions. There were no differences in ease of technology use according to age. Those with high school or less education were more likely to agree that the equipment and educational materials helped them feel more informed about their care plans than those with higher education levels.

CONCLUSIONS

This multisite, multiregional RPM program has become a reliable health care delivery model for the management of acute and chronic conditions outside hospitals and clinics. Program participants reported an excellent overall experience and a high level of satisfaction in managing their health from the comfort of their home environment.

Structured handoff to improve communication from inpatient to outpatient dialysis units: A quality improvement project

BACKGROUND

Patients with end-stage kidney disease requiring dialysis encounter high hospital readmission rates. One contributor is poor communication between hospitals and outpatient dialysis facilities. We hypothesized that improved communication may reduce 30-day hospital readmissions for patients on dialysis at an urban, safety net hospital.

METHODS

We created a standardized discharge handoff tool that is easy to use and provides concise data for dialysis centers. The handoff tool is a novel, electronic MACRO template (called a "dot-phrase") to be included in discharge documentation. Instructions for the dot-phrase and electronic facsimile (e-faxing) were sent to Internal Medicine residents immediately prior to their rotation on an inpatient Renal service. We then measured the intervention implementation rate and its impact on hospital readmission metrics.

RESULTS

We compared 3 months of preintervention and 6 months of postintervention data, identifying 82 and 135 index discharges in each respective study period. Patients were predominantly male (56.2%) and receiving hemodialysis (89.8%); a minority (9.2%) were undomiciled at the time of discharge. Mean age was 60.5 years (SD 14.0). Renal discharges followed by 30-day Renal readmission were not statistically lower in the postintervention group for the index discharge alone (26.8% vs. 20.0%, p = 0.12), but were for overall discharges (51.2% vs. 25.7%, p < 0.0001). The dot-phrase was used in 95.4% of discharge summaries, and 74.7% of discharge summaries were e-faxed within 24 h of discharge.

CONCLUSION

There was high uptake of a standardized discharge handoff tool among Internal Medicine residents on a Renal inpatient service. Using a handoff tool and e-faxing may improve communication with outpatient dialysis centers and may reduce readmissions among some patients but is likely insufficient to fully address high readmission rates. Subsequent intervention iterations would benefit from further collaboration with outpatient dialysis units for customization of the handoff tool to meet local communication needs.

Digital Health Technologies for Post-Discharge Care after Heart Failure Hospitalisation to Relieve Symptoms and Improve Clinical Outcomes

The prevention of recurrent heart failure (HF) hospitalisations is of particular importance, as each such successive event may increase the risk of death. Effective care planning during the vulnerable phase after discharge is crucial for symptom control and improving patient prognosis. Many clinical trials have focused on telemedicine interventions in HF, with varying effects on the primary endpoints. However, the evidence of the effectiveness of telemedicine solutions in cardiology is growing. The scope of this review is to present complementary telemedicine modalities that can support outpatient care of patients recently hospitalised due to worsening HF. Remote disease management models, such as video (tele) consultations, structured telephone support, and remote monitoring of vital signs, were presented as core components of telecare. Invasive and non-invasive monitoring of volume status was described as an important step forward to prevent congestion-the main cause of clinical decompensation. The idea of virtual wards, combining these facilities with in-person visits, strengthens the opportunity for education and enhancement to promote more intensive self-care. Electronic platforms provide coordination of tasks within multidisciplinary teams and structured data that can be effectively used to develop predictive algorithms based on advanced digital science, such as artificial intelligence. The rapid progress in informatics, telematics, and device technologies provides a wide range of possibilities for further development in this area. However, there are still existing gaps regarding the use of telemedicine solutions in HF patients, and future randomised telemedicine trials and real-life registries are still definitely needed.

Telemonitoring in heart failure patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Home telemonitoring has been used as a modality to prevent readmission and improve outcomes for patients with heart failure. However, studies have produced conflicting outcomes over the years.

AIM

To determine the aggregate effect of telemonitoring on all-cause mortality, heart failure-related mortality, all-cause hospitalization, and heart failure-related hospitalization in heart failure patients.

METHODS

We conducted a systematic review and meta-analysis of 38 home telemonitoring randomized controlled trials involving 14993 patients. We also conducted a sensitivity analysis to examine the effect of telemonitoring duration, recent heart failure hospitalization, and age on telemonitoring outcomes.

RESULTS

Our study demonstrated that home telemonitoring in heart failure patients was associated with reduced all-cause [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.75-0.92, P = 0.001] and cardiovascular mortality (RR = 0.66, 95%CI: 0.54-0.81, P < 0.001). Additionally, telemonitoring decreased the all-cause hospitalization (RR = 0.87, 95%CI: 0.80-0.94, P = 0.002) but did not decrease heart failure-related hospitalization (RR = 0.88, 95%CI: 0.77-1.01, P = 0.066). However, prolonged home telemonitoring (12 mo or more) was associated with both decreased all-cause and heart failure hospitalization, unlike shorter duration (6 mo or less) telemonitoring.

CONCLUSION

Home telemonitoring using digital/broadband/satellite/wireless or blue-tooth transmission of physiological data reduces all-cause and cardiovascular mortality in heart failure patients. In addition, prolonged telemonitoring (≥ 12 mo) reduces all-cause and heart failure-related hospitalization. The implication for practice is that hospitals considering telemonitoring to reduce heart failure readmission rates may need to plan for prolonged telemonitoring to see the effect they are looking for.

Development and implementation of a nurse-based remote patient monitoring program for ambulatory disease management

Introduction

Numerous factors are intersecting in healthcare resulting in an increased focus on new tools and methods for managing care in patients' homes. Remote patient monitoring (RPM) is an option to provide care at home and maintain a connection between patients and providers to address ongoing medical issues.

Methods

Mayo Clinic developed a nurse-led RPM program for disease and post-procedural management to improve patient experience, clinical outcomes, and reduce health care utilization by more directly engaging patients in their health care. Enrolled patients are sent a technology package that includes a digital tablet and peripheral devices for the collection of symptoms and vital signs. The data are transmitted from to a hub integrated within the electronic health record. Care team members coordinate patient needs, respond to vital sign alerts, and utilize the data to inform and provide individualized patient assessment, patient education, medication management, goal setting, and clinical care planning.

Results

Since its inception, the RPM program has supported nearly 22,000 patients across 17 programs. Patients who engaged in the COVID-19 RPM program experienced a significantly lower rate of 30-day, all-cause hospitalization (13.7% vs. 18.0%, P = 0.01), prolonged hospitalization >7 days (3.5% vs. 6.7%, P = 0.001), intensive care unit (ICU) admission (2.3% vs. 4.2%, P = 0.01), and mortality (0.5% vs. 1.7%, P = 0.01) when compared with those enrolled and unengaged with the technology. Patients with chronic conditions who were monitored with RPM upon hospital discharge were significantly less likely to experience 30-day readmissions (18.2% vs. 23.7%, P = 0.03) compared with those unmonitored. Ninety-five percent of patients strongly agreed or agreed they were likely to recommend RPM to a friend or family member.

Conclusions

The Mayo Clinic RPM program has generated positive clinical outcomes and is satisfying for patients. As technology advances, there are greater opportunities to enhance this clinical care model and it should be extended and expanded to support patients across a broader spectrum of needs. This report can serve as a framework for health care organizations to implement and enhance their RPM programs in addition to identifying areas for further evolution and exploration in developing RPM programs of the future.

Colectomy Complicated by High-Output Ileostomy Managed in a Virtual Hybrid Hospital-at-Home Program

Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic's HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.

Influence of Neighborhood Conditions on Recurrent Hospital Readmissions in Patients with Heart Failure: A Cohort Study

PURPOSE

This study examined how certain aspects of residential neighborhood conditions (ie, observed built environment, census-based area-level poverty, and perceived disorder) affect readmission in urban patients with heart failure.

METHODS

A total of 400 patients with heart failure who were discharged alive from an urban-university teaching hospital were enrolled. Data were collected about readmissions during a 2-year follow-up. The impact of residential neighborhood conditions on readmissions was examined with adjustment for 7 blocks of covariates: 1) patient demographic characteristics; 2) comorbidities; 3) clinical characteristics; 4) depression; 5) perceived stress; 6) health behaviors; and 7) hospitalization characteristics.

RESULTS

A total of 83.3% of participants were readmitted. Participants from high-poverty census tracts (≥20%) were at increased risk of readmission compared with those from census tracts with <10% poverty (hazard ratio [HR]: 1.53; 95% confidence interval: 1.03-2.27; P < .05) when adjusted for demographic characteristics. None of the built environmental or perceived neighborhood conditions were associated with the risk of readmission. The poverty-related risk of readmission was reduced to nonsignificance after including diabetes (HR: 1.33) and hypertension (HR: 1.35) in the models.

CONCLUSIONS

The effect of high poverty is partly explained by high rates of hypertension and diabetes in these areas. Improving diabetes and blood pressure control or structural aspects of impoverished areas may help reduce hospital readmissions.

Effectiveness of Transitional Care Interventions for Heart Failure Patients: A Systematic Review With Meta-Analysis

Heart failure is a leading cause of hospitalizations. Heart failure patients were found to have a high incidence of re-admission after discharge. This highlights a care gap during the transition from hospital to home environment and interventions were utilized to cover this care gap. The aim of this review was to evaluate the effectiveness of these interventions. This was investigated in terms of re-admissions, mortality, emergency department (ED) visits, and quality of life. An exhaustive systematic search was conducted in electronic databases, which include MEDLINE, CINAHL, AMED, Cochrane library, and PubMed. Databases were explored for literature published in English between April 2012 and April 2022. The review included 13 randomized controlled trials and comprised a total of 7,693 heart failure patients with 3,835 receiving transitional care interventions (TCIs) and 3,858 receiving standard care. It was found that implementing TCIs resulted in a reduction of all-cause re-admission and all-cause mortality. Although it is controversial if TCIs improve quality of life, TCIs were noted to decrease the frequency of ED visits. Telephone support interventions proved most efficacious among other interventions in reducing hospital readmissions, and were found effective in reducing mortality in combination with other interventions, i.e. clinic visits. Additionally, telemonitoring is found beneficial in supporting patients just after discharge, the most vulnerable period, for medically optimizing and monitoring patients during the care gap.

Improving heart failure care and guideline-directed medical therapy through proactive remote patient monitoring-home telehealth and pharmacy integration

To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of remote patient monitoring-home telehealth (RPM-HT) and pharmacist consultations. Each enrolled patient (n=38) was assigned an RPM-HT registered nurse (RN), cardiology licensed independent provider (provider), and, if referred, a clinical pharmacy specialist (pharmacist). The RN called patients weekly and for changes detected by RPM-HT, while the pharmacist worked to optimise GDMT. The RN and pharmacist communicated clinical status changes to the provider for expedited management. Process measures were the percentage of outbound RN weekly calls missed per enrolled patient; the weekly percentage of provider interventions missed; and the number of initiative-driven diuretic changes. Outcome measures included eligible GDMT medications prescribed, optimisation of those medications, and the pre–post difference in emergency department (ED) visits/hospitalisations. After a 4-week run-in period, RN weekly calls missed per enrolled patient decreased from a mean of 21.4% (weeks 5–15) to 10.2% (weeks 16–23). Weekly missed provider interventions decreased from a mean of 15.1% (weeks 1–15) to 3.4% (weeks 16–23), with special cause variation detected. The initiative resulted in 43 diuretic changes in 21 patients. Among 34 active patients, 65 ED visits (0.16 per person-month) occurred in 12 months pre intervention compared with 8 ED visits (0.04 per person-month) for 6 intervention months (p<0.001). Among 16 patients referred to pharmacist, the per cent of eligible GDMT medications prescribed increased by 17.1% (p<0.001); the number of patients receiving all eligible medications increased from 3 to 11 (p=0.008). Similarly, the per cent optimisation of GDMT doses increased by 25.3% (p<0.001), with the number of patients maximally optimised on GDMT increasing from 1 to 6 (p=0.06). We concluded that a cardiology, RPM-HT RN and pharmacist team improved prescription of GDMT and may have reduced HF admissions.

ANMCO POSITION PAPER: The reorganization of cardiology in times of the SARS-CoV-2 pandemic

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic,new models, paradigms, interventional approaches, values and priorities should be suggested and implemented.