Heart Failure
Conditions
Keywords
Heart Failure, Transitional Care, Knowledge Translation, Outcomes
Brief summary
Heart failure (HF) is the most common cause of hospitalization in older adults. The month after hospital discharge represents a vulnerable period, when patients are at increased risk of death and readmission to hospital. Research has shown that certain discharge-planning services can reduce death and readmissions, but these have not been widely implemented. In this study, we will group evidence-informed discharge-planning services into 'Patient-centered Care Transitions in HF' (PACT-HF), a model of care that will prepare patients for their transition from hospital to home. Through PACT-HF, patients will benefit from a comprehensive assessment of their health care needs, learn to recognize and manage symptoms of HF, and receive the information and follow-up care needed to optimize their health. We will introduce PACT-HF to 10 Ontario hospitals over a number of time periods using a stepped wedge cluster trial design. We will compare the outcomes (hierarchically ordered) of patients in hospitals with PACT-HF to those in hospitals without PACT-HF. We anticipate that patients hospitalized at the sites with PACT-HF will have fewer readmissions, emergency visits, and deaths after discharge; report a better quality of life; and feel more prepared for discharge. We also anticipate that overall, PACT-HF will reduce health system costs.
Interventions
OTHERPACT-HF Model
PACT-HF Model includes the following 1) comprehensive patient assessment 2) self-care education 3) patient-centered discharge summary 4) early follow up with FP 5) referral of high-risk patients to regional multidisciplinary HF clinic and to nurse-led home care
Sponsors
Hamilton Health Sciences Corporation
McMaster University
Population Health Research Institute
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
16 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* In participating hospitals, all patients hospitalized with the most responsible diagnosis of Heart Failure
Exclusion criteria
* Patients who die during hospitalization or are transferred to another hospital
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Time to composite all-cause readmissions/emergency department (ED) visits/death at 3 months | Within 3 months of hospital discharge |
| Time to composite all-cause readmissions/emergency department (ED) visits/death at 30 days | Within 30 days of hospital discharge |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Preparedness for discharge | On admission, at 6 weeks and 6 months post discharge | Patient-centered outcome, as measured by a validated survey instrument |
| Quality of life, as measured by the EQ5D5L scale | Administered on admission for HF and also 6 weeks and 6 months post discharge | Health-related quality of life, as measured by the validated EQ5D5L scale. This will be administered on admission and within 6 weeks and 6 months of the patient's discharge. |
| Health Care Costs | 6 months post discharge | Total health care system costs per patient, using the viewpoint of the Ministry of Health. This will be measured using administrative databases. |
Countries
Canada
Outcome results
None listed