Advanced practice nurse directed transitional care reduced readmission or death in elderly patients admitted to hospital with heart failure

摘要

The trial by Naylor et al provides evidence of the benefit of comprehensive discharge planning and post-discharge support for older patients with HF, a highly prevalent condition with substantial associated morbidity and mortality. The study is of good quality, and although follow up falls slightly below the generally accepted criterion of 80%, use of intention to treat analysis and equal attrition from the study groups increases our confidence in the findings.A recent systematic review had comparable results for a range of similar interventions in this patient group,1 although Naylor et al found improved outcomes for comorbid conditions specifically. Other studies have been unable to demonstrate such an effect, although similar trends have been found.Extended post-discharge support for patients with HF should be implemented as a routine. Services should be established as a multidisciplinary endeavour, with consideration of the detail of implementation, in light of evidence that post-discharge support given in the form of increased clinic visits or telephone follow up may not be as effective.' Although cost savings, as shown by Naylor et al, are possible, fragmented healthcare systems may impede the development of these services by not reimbursing providers. Such disincentives will exist in any system where the focus for outcomes and resource allocation is on individual services rather than the effect of all services.