Variations in Care: Comparing Heart Failure Care Transition Intervention Effects

Ong, Michael

Abstract

Recent studies by the Dartmouth Atlas of Health Care have identified geographic variation in hospital resource use and cost at the end of life among elderly Medicare beneficiaries with chronic illnesses. Reduction of variation in resource use and cost is a key focus for saving costs in the U.S. health care system. Readmission rates are a potential area of focus for reducing hospital resource use and cost variation, and interventions designed to improve the care transition period after hospital discharge have been shown to reduce readmissions and potentially improve morbidity and mortality at the patient level. However, studies have not demonstrated whether improving care transitions would result in reductions in variation between hospitals on resource use or health outcomes. In addition, interventions that improve care transitions may be cost-effective at a societal level, but have not been widely disseminated due to implementation costs at the hospital level. This comparative effectiveness project builds on our prior work since 2006 examining variation in resource use and mortality among the five University of California Medical Centers plus Cedars-Sinai Medical Center for elderly Medicare beneficiaries hospitalized with heart failure. This project compares two adaptations of existing care transition interventions, the Transition Coach and Re-Engineering Discharge Programs, designed to reduce the implementation costs for hospitals. One adaptation uses a centralized telephone post-discharge program instead of separate telephone post-discharge programs for each medical center. The other adaptation adds a telemedicine approach with remote sensors to minimize use of the centralized telephone post-discharge program. We propose a randomized, controlled trial with three arms to compare the effectiveness of implementing the two separate care transition interventions with concurrent controls on reducing variation in readmissions among elderly patients hospitalized with heart failure at the six medical centers over an 18-month period. This project also evaluates the historical trends among the six medical centers for readmissions, other resource use, and health outcomes to further control for secular trends that may affect trial findings, and evaluates the costs and benefits of these two care transition interventions. This work will begin to bridge the current gap between quality improvement research and studies of variation in care. Current studies of variation rarely have the clinical or organizational data to suggest ways to reduce variation between sites. This work also provides an opportunity to compare within a set of heterogeneous medical centers the effectiveness of two adaptations to existing care transition interventions on reducing readmissions, and their ability to reduce implementation costs that prevent wider dissemination of existing care transition interventions.

Public Health Relevance

Heart failure is a prevalent condition among the elderly that has high rates of potentially avoidable readmissions. Readmissions can be reduced through programs to improve the transition of care from inpatient to outpatient settings, but these programs are not currently widespread due to implementation costs at the hospital level. This research compares the costs and the effectiveness of two separate adaptations of care transition interventions on reducing readmissions for elderly heart failure patients, and their effectiveness on reducing the variation between six medical centers on readmission rates for elderly heart failure patients.