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Background: Heart failure (HF) has a 2% prevalence in the population and is a major cause of morbidity and mortality. Multiple efforts have been made worldwide to improve quality of care and decrease unplanned readmissions for HF patients, one of which has been the introduction of specialist HF nurses (HFN) in primary health care. The present evidence on the benefits of HFN is contradicting. This study aims to evaluate the impact of a quality improvement intervention, availability of a HFN in Swedish primary care, on hospital readmissions.

Methods: All patients over the age of 65 with a HF diagnosis and with complete information on availability of a HFN were included in this retrospective register-based study. Using propensity score matching (PSM) techniques, two comparable groups of 128 patients each were created according to the exposure status, availability or no availability of a HFN. The rate of readmission was compared between the groups.

Results: Using PSM, 256 patients were matched, 128 in the HFN group and 128 in the no-HFN group. A total of 50% and 46.09% of patients in the HFN and no-HFN groups were readmitted, respectively. Mean number of readmissions per patient was 1.19 (SD 0.61) in the HFN group and 1.10 (SD 0.44) in the no-HFN group. Patients in the HFN had 17.6% higher odds of being readmitted during the study period, OR: 1.176 (CI: 0.716-1.932), and 3.8% lower odds of being readmitted within 30 days, OR: 0.962 (CI: 0.528-1.750).

Conclusions: Availability of a HFN in primary care was not significantly associated with reduced readmissions for the patients included in this study. Further investigations are warranted looking at the impacts of availability and access to a HFN in primary care on readmissions and other patient outcomes.

Background

Heart failure patients tend to experience higher rates of hospital readmissions compared to other ambulatory care-sensitive conditions. In Sweden, the nationwide Care Coordination Act (CCA) was introduced in January 2018 with the goal of improving care coordination resulting in a reduction of readmissions and length of stay. There is insufficient knowledge regarding the effect of this reform on heart failure patients.

Methods

We studied the association of implementing CCA on all cause 30-day readmissions and length of stay for patients over 65 years of age with ICD-50 heart failure. The dataset included all admissions with a primary diagnosis of heart failure among elderly, multimorbid patients between 2015 and 2019. An interrupted time series analysis using hierarchical mixed models with random effects clustered at the hospital ward level was conducted.

Results

A total of 111 414 admissions were included. The average readmission rate for heart failure patients was 26.8 % before and 26.7 % after the CCA. The average length of stay (LOS) was 8.4 days before the CCA and 8.1 days after. Mortality within 30 days was 7.3 % before the CCA and 7.5 % after. There were no significant differences between the periods before and after. In an analysis assessing the overall linear time trend 2 of 21 regions showed a reduction in readmissions and 10 in length of stay.

Conclusions

After the introducing the CCA, no detectable impact was found on readmissions or mortality for heart failure patients, which is in line with previous studies such as those studying the US Hospital Readmission Reduction Program. While no overall association on length of stay could be identified, it was reduced in a number of the Swedish regions. The heterogeneity between regions could be used to understand the specific components needed to achieve reduction of readmissions in future studies.

Background

The hospital discharge process entails substantial challenges, particularly among older multimorbid patients with a high risk of subsequent readmission and/or death. Discharging hospitals often face a decision regarding whether such patients should be discharged to a short- or long-term stay at a nursing home, or sent home with community-based support services. Our aim is to investigate whether and how these forms of post-inpatient care impact readmission and mortality rates.

Methods

We used data from nationally comprehensive Swedish health- and social care registries during 2015 to 2019 to perform a retrospective analysis using a target trial emulation design. The study included multimorbid patients over 65, who lived at home prior to hospitalization, and were subsequently discharged to either a nursing home or to their own residence with formal home care interventions. To estimate the average treatment effect of nursing home vs in-home care, each patient discharged to a nursing home was matched to a patient discharged home using a propensity score generated by a machine-learning model based on the patients previous medical and social care history. Outcomes were assessed using survival analysis.

Results

Patients discharged to nursing homes had a substantially lower risk of hospital readmission across 7-, 30- and 90-day endpoints, with Hazard Ratios of 0.53, 0.69, and 0.83 respectively. Short term (7 day) mortality was lower for nursing home patients (HR 0.59), but was by 30 days similar (HR 1.02), and higher by 90 days (HR 1.37).

Discussion

Our findings suggest substantial short-term benefits of nursing home care in terms of reduced readmission and mortality rates. The causal effect of nursing home care on longer term outcomes is more uncertain, and may be influenced by residual confounding not captured by the propensity score. In practice, factors such as availability of care placements, patient preferences, and the clinical team's assessment influence discharge decisions. Based on our findings, an additional advantage of nursing home placement may be considered: A reduced risk of readmission and short-term mortality, benefiting both patients and the healthcare system.

Introduction

30-day readmission is an indicator of integrated care between health care providers including primary care. While some studies have demonstrated effective models for improvement, most countries, including Sweden, have not shown significant progress. This study aims to understand what health care leaders suggest can be done to reduce readmissions, as well as how they value the indicator itself.

Method

Semi-structured interviews of fifteen primary care and internal medicine leaders in general practice and internal medicine, qualitatively analyzed by a framework model.

Results

Four main themes, with altogether nine subthemes were identified. The leaders pointed out that readmissions is a widely used indicator. They identify multiple areas for reducing readmissions like involving the patients more and improve system-level thinking.

Discussion

30-day readmission is analyzed, but seldom together with other providers. Key for improving readmissions is to create a safe and secure atmosphere for patients and relatives and to develop a better system thinking, the latter which is outside the interviewed leaders’ own jurisdiction. 

Conclusion

The leaders have a clear view of what is needed to reduce readmissions, however the top leadership has to set specific goals and follow up on all levels in the system.