Breaking the 30-day barrier: Long-term effectiveness of a nurse-led 7-step transitional intervention program in heart failure

• DOI: 10.1371/journal.pone.0279815
• Publication Date: 2023-02-07T18:28:35Z
• Authors: Lidia Alcoberro; Pedro Moliner; Joan Vime; Santiago Jiménez-...; Alberto Garay; Sergi Yun; Alexandra Pons-Ri...; Raúl Ramos-Polo; Mar Ras-Jiménez; Marta Tajes; Encarna Hidalgo; Esther Calero; Marta Ruiz; Nuria José-Bazán; Carles Ferre; Cristina Delso; Laia Alcober; Cristina Enjuanes; Josep Comin-Colet
• Keywords: Transitional care

Background and aims Heart failure (HF) programs successfully reduce 30-day readmissions. However, conflicting data exist about its sustained effects afterwards impact on mortality. We evaluated whether the of a new nurse-led coordinated transitional HF program extends to longer periods time, including 90 180 days after discharge. Methods results designed natural experiment undertake pragmatical evaluation implementation program. compared outcomes between patients discharged with as primary diagnosis in Period #1 (pre-program; Jan 2017—Aug 2017) those during #2 (HF program; Sept 2017—Jan 2019). Primary endpoint was composite all-cause death or hospitalization 440 were enrolled: 123 317 #2. Mean age 75±9 years. There more females (p = 0.025), no other significant differences periods. The significantly reduced group, at [adjusted OR 0.31 (0.18–0.53), p <0.001] 0.18 (CI 0.11–0.32), <0.001]. Such decrease due reduction cardiovascular (CV) hospitalization. All-cause when double check discharge planning implanted usual care [0 (0%) vs. 7 (3.8%), 0.022]. Conclusion A bundle interventions model reduces both for HF, also high-risk populations. is driven by CV Reduction mortality observed full exhaustive process implemented.