Prevent Readmission Heartfailure

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OLDER PEOPLE

A randomized controlled trial of a community nurse-supported hospital

discharge programme in older patients with chronic heart failure

Timothy Kwok MD, FRCPDepartment of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China

Jenny Lee MSc, MRCPDepartment of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China

Jean Woo MD, MA, FRCPDepartment of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China

Diana TF Lee RN, PhD

The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China

Sian Griffith MA, FRCPSchool of Public Health, The Chinese University of Hong Kong, Hong Kong, China

Submitted for publication: 20 June 2006

Accepted for publication: 22 December 2006

Correspondence:

Professor Timothy Kwok

Department of Medicine & Therapeutics

Prince of Wales Hospital

Hong Kong

China

Telephone: (852)-26076900

E-mail: [email protected]

K W O K T , L E E J , W O O J , L E E T F D & G R I F F I T H S ( 2 0 0 8 )K W OK T , L E E J , W O O J , L E E T F D & G R IF F IT H S ( 2 00 8 ) Journal of Clinical

Nursing 17, 109117

A randomized controlled trial of a community nurse-supported hospital dischargeprogramme in older patients with chronic heart failure

Aims and objectives. To evaluate the effectiveness and cost-effectiveness of a

community nurse-supported hospital discharge programme in preventing hospital

re-admissions, improving functional status and handicap of older patients with

chronic heart failure.

Design. Randomized controlled trial; 105 hospitalized patients aged 60 years or

over with chronic heart failure and history of hospital admission(s) in previous year

were randomly assigned into intervention group (n 49) and control group

(n 56) for six months. Intervention group subjects received community nurse

visits before discharge, within seven days of discharge, weekly for four weeks, then

monthly. Community nurse liaised closely with a designated specialist in hospital

and were accessible to subjects during normal working hours. Control and inter-vention group subjects were followed up in the same specialist medical clinics.

Primary outcome was the rate of unplanned re-admission at six months. Secondary

outcomes were number of unplanned re-admissions, six-minute walking distance,

London Handicap Scale and public health care and personal care costs.

Results. At sixth months, the re-admission rates were not significantly different (46

vs. 57% in control subjects, p 0233, Chi-square test). But the median number of

re-admissions tended to lower in the intervention group (0 vs. 1 in control group,

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 109doi: 10.1111/j.1365-2702.2007.01978.x


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p 0057, Mann Whitney test). Intervention group subjects had less handicap in

independence (median change 0 vs. 05 in control subjects, p 0002, Mann

Whitney test), but there was no difference in six-minute walking distance. There was

no significant group difference in median total public health care and personal care

costs.

Conclusion. Community nurse-supported post-discharge programme was effective

in preserving independence and was probably effective in reducing the number of

unplanned re-admissions. The cost benefits to public health care were not signifi-

cant.

Relevance to clinical practice. Older chronic heart failure patients are likely to

benefit from post-discharge community nurse intervention programmes. More

comprehensive health economic evaluation needs to be undertaken.

Key words: cogestive, community health nursing, cost benefit analysis, heart failure,

older people

Introduction

Chronic heart failure (CHF) is a major health problem of

older people and is associated with recurrent hospital

admissions (Kwok et al. 1999). To account for this, several

factors have been identified. Lack of social support and

psychological maladjustment could contribute to symptoms

and health seeking behaviour. Under use of evidence-based

care for CHF, poor drug and dietary adherence, poor access

to medical care are additional potentially avoidable factors

(Williams & Fitton 1988, Ahmed 2003).

Post-hospital discharge home visits by nurses, with or

without medical or multidisciplinary support (Rich et al.

1995, Stewart et al. 1999, Blue et al. 2001, McAlister et al.

2004), have been shown to be effective in preventing re-

admission of high-risk patients with CHF. These programmes

have also been shown to be cost-effective (Williams & Fitton

1988, Naylor et al. 1994, Phillips et al. 2004). However,

these studies were performed in developed countries where

older people enjoyed comprehensive coverage of primary and

secondary health care either by insurance or by public

funding.

The publicly funded hospitals in Hong Kong are well

equipped and their charges are nominal. On the contrary,

primary health care is primarily private and not easilyaffordable to many older people. There is, therefore, a big

incentive for the chronic sick to rely on the Accident and

Emergency Departments (A&E) of public hospitals for the

relief of their symptoms. The communication between

hospital doctors and general practitioners is also poor.

For example, on hospital discharge, patients are only given a

summary of medical diagnoses and medication and the

summaries are not directly sent to the general practitioners.

It is, therefore, not surprising that older CHF patients in

Hong Kong have very high re-admission rates (at four weeksas high as 15%) (Kwok et al. 1999). In a local prospective

study of hospital-discharged older medical patients, major

problems in communication about medications and follow-

up arrangement, lack of community support and increase in

functional disabilities were identified (Woo & Cheung 1993).

In view of these problems, we envisaged that the post-

discharge community nursing programme for older CHF

patients had to be more intensive in Hong Kong. We,

therefore, performed a randomized controlled trial to exam-

ine its effectiveness and cost-effectiveness. The hypothesis

was that an intensive post-discharge community nursing

programme will reduce the chance of re-admission by

improving functional status and reducing handicap of older

CHF patients.

Methods

Subjects

Hospital patients with a principal diagnosis of CHF were

recruited from the medical wards in Prince of Wales Hospital

(PWH), a major teaching hospital in Hong Kong. A minority

of subjects were recruited in another acute district generalhospital, Alice Ho Miu Ling Nethersole Hospital (AHNH) in

the same health region. The two hospitals were publicly

funded and provided comprehensive specialist inpatient and

outpatient services for a regional population of one million.

The mean length of stay in the medical departments in these

hospitals was five days. Some frailer CHF patients, who

required a longer period of convalescent care, were dis-

charged to the two convalescent hospitals in the region

T Kwok et al.

110 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd


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Shatin and Taipo Hospitals. The inclusion criteria included

age older than 60, residing within the region and had at least

one hospital admission for CHF in the 12 months prior to the

index admission. The exclusion criteria included having

communication problems but without caregivers, residing in

a nursing home and terminal diseases with a life expectancy

of less than six months.

Procedure

Eligible subjects were identified and recruited by a research

nurse (RN) on the day or the day before hospital discharge.

After obtaining written consent from the subjects, the RN

recorded demographic data. Functional status was assessed

by six-minute walking test (Butland et al. 1982). Cognitive

function, psychological state and handicap were assessed by

Abbreviated Mental Test (AMT) (Chu 1999) General Health

Questionnaire (GHQ) (Chi & Boey 1993) and London

Handicap Scale (LHS) (Lo et al. 2001), respectively.General Health Questionnaire is a screening test aimed at

detecting psychological problems in people living in the

community. It has been translated into Chinese and validated

among older Chinese in Hong Kong (Chi et al. 1995). The

score ranges from 030, with scores of six or above indicating

psychological problems. The LHS was developed in the

United Kingdom and had been translated into Chinese and

validated in Hong Kong (Lo et al. 2001). It consisted of one

question for each of the six domains of handicap (mobility,

independence, occupation, social, orientation and economic).

For each domain, there were six progressive levels of

handicap. Higher score indicates higher level of handicap.

In subjects with AMT score less than 6/10, family caregivers

provided information for the handicap scale.

The ward nurses then phoned a second research assistant

who assigned trial grouping according to a random number

table. The group assignment was made known to the

patients.

All subjects were followed up by designated geriatricians or

cardiologists in their respective hospital medical clinics. The

interval of clinic appointment ranged from 612 weeks on

average. When the subjects were re-admitted, they were

assessed by either a geriatrician or a cardiologist for reasons ofre-admission. The primary and secondary causes of re-admis-

sion were categorized as follows: exacerbation of existing

disorder, new but related event, new unrelated event, elective,

admission with no deterioration, social/psychological prob-

lems, drug-related problems and dietary non-compliance.

After six months of trial, subjects had their functional and

psychosocial status re-assessed, as in the baseline, at the

follow-up clinics. The RN was not aware of the

randomization grouping of the subjects. All hospital admis-

sions, including attendance to the A&E, throughout Hong

Kong were traced by an electronic database maintained by

the Hospital Authority which operated all publicly funded

hospitals in Hong Kong.

Intervention group

The subjects were visited by a designated community nurse

(CN) before they were discharged from the hospital. The

objectives were to provide health counselling, such as drug

compliance, dietary advice and to encourage subjects to

contact CN via a telephone hotline during office hours when

they developed symptoms. The CN carried a pager and a

mobile phone. The trained clerk, who answered the hotline,

relayed the message from the subjects to the CN via the

pager.

The subjects were then visited by the CN at home within

seven days of discharge. During the home visits, the CN

checked vital signs and signs for poor control of CHF ankleswelling, dyspnoea and basal crepitation on auscultation.

Medications were checked and compliance encouraged.

Avoidance of salty and high fat foods and regular physical

exercise were promoted. Home care and day care services

were arranged if social support was found to be insufficient.

The CN thereafter performed home visits at weekly

intervals for another four weeks and monthly after that.

The CN liaised closely with either a geriatrician or a

cardiologist in their respective hospitals. After liaison, the

CN could alter medication regime, arrange urgent hospital

outpatient appointments and clinical admission. When sub-

jects were re-admitted, the CN visited the patients in the

hospital and provided background information to attending

doctors. Subjects who refused further home visits were

monitored by the CN by telephone.

Control group

The control subjects received usual medical and social care,

except that they were followed up in the hospital outpatient

clinics by the same group of designated geriatrician or car-

diologist.

Ethics approval

The study was approved by the Research Ethics Committee

of the Chinese University of Hong Kong.

Sample size calculation

According to the results from a pilot study of 49 older CHF

patients discharged from PWH, the re-admission rate at six

Older people Post-discharge program in heart failure

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 111


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months was 69%, a sample size of 50 per group was estimated

to have 80% chance of detecting a 40% relative reduction in

re-admission rate at a confidence interval of 0 95.

Statistical analysis

The primary outcome was the percentage of subjects who

ever had unplanned hospital re-admissions within six calen-

dar months of discharge. The secondary outcomes included

the following: number of unplanned hospital re-admissions,

changes in six-minute walking test and LHS domain scores.

Comparison of proportion of subjects with re-admissions

was made by Chi-square test. As the secondary outcome

variables were not normally distributed, Mann Whitney

U test was used for group comparison. Because LHS has six

domains, p-value has to be


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At the six-month follow-up, 44 in the intervention group

and 46 in the control group were available for re-assessment

for the six-minute walking test and LHS scores (Table 2).

When compared with the control subjects, the intervention

group subjects became significantly less limited in independ-

ence (median change in LHS independence domain score 0 vs.

05, p < 0005, Mann Whitney test). The change in

functional status of the subjects, as reflected by the six-

minute walking test, was not different between the groups.

The group comparison of costs to public health care system

was shown in Table 3. One intervention group subject andtwo control group subjects had missing records of outpatient

attendance and were therefore excluded. The median

community nursing costs in the intervention group was

HK$2 391 per subject. The median total public health costs

as a result of hospital stay and emergency care attendances

were significantly lower in intervention group than in control

group (HK$5 229 vs. HK$20 916, p 0048). However, the

total public health care costs were not significantly different.

Table 1 Baseline characteristics of

intervention (community nursing) and

control group subjects*

Intervention (n 49) Control (n 56)

Male 22 (45%) 25 (45%)

Age (years) 795 66 768 70

Live alone 15 (31%) 10 (18%)

CSSA 23 (47%) 14 (25%)

Six-minute walking test (m) 1207 620 1185 625

Abbr eviated Mental Test (max. 10) 86 14 87 13

General Health Questionnaire (max. 30) 56 37 61 33

London Handicap Scale (max. 6)

Mobility 3 (2, 3) 3 (3, 3)

Independence 3 (2, 3) 3 (2, 3)

Occupation 3 (3, 4) 3 (3, 4)

Social 2 (2, 2) 2 (2, 2)

Orientation 2 (2, 2) 2 (2, 2)

Economic 3 (3, 4) 3 (2, 3)

Left ventricular EF


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The medical and social costs paid by the subjects were

shown in Table 4. One intervention and two control group

subjects who attended the six month follow-up had missing

personal cost data. There was no significant group difference

in the total health and social care costs to the patients.

However, only 17 out of 49 intervention group subjects

(34%) paid for CN visits: 24 by CSSA, one by civil service

pension scheme, eight by research grant because of refusal topay. To exclude the confounding effect of waivers, the

personal cost analysis was repeated after excluding those

eligible for CSSA or civil service pension in both groups and

on the assumption that all those subjects who had to pay for

CN paid by themselves. The median cost of CN visits per

subject was HK$385 (quartile range 330, 578). The median

total personal costs (medical and social included) of the

intervention (n 21) and control (n 32) group subjects

Randomized

(n = 105)

Intervention(n = 49)

Control(n = 56)

Completed(n = 44)

Completed(n = 46)

Dropout(one moved )

Dropout(one moved,one cancer)

Six month

follow-up

Died

(n = 8)Died

(n = 4)

Readmitted

(n = 19)

Not readmitted

(n = 25)Readmitted

(n = 24)

Not readmitted

(n = 22) Figure 1 Flow diagram of major outcomes

of randomized subjects.

Table 3 Comparison of total public health

costs per person in six months between

intervention (community nursing) and

control groups*

Cost item Intervention (n 48) Control (n 54)

Hospital bed and emergency care 5 229 (0, 33 384) 20 916 (534, 72 312)

Outpatient clinic 1 365 (910, 1 544) 1 365 (533, 1 365)

Community nursing 2 391 (1 600, 3 050) 0 (0, 0)

Total 10 186 (3 785, 37 962) 21 599 (1 978, 73 449)

*HK$ presented as median (interquartile range).

Table 4 Medical and social care costs to subjects in six months*

Cost item

Intervention

(n 43) Control (n 44)

Outpatient clinic 0 (0, 132) 132 (0, 132)

Travel to clinics/hospital 100 (38, 150) 75 (33, 144)

Hospital stay 0 (0, 136) 0 (0, 527)

Community nurse 0 (0, 330) 0 (0, 0)

Private doctor 0 (0, 360) 0 (0, 608)Social services 0 (0, 10) 0 (0, 0)

Total 513 (213, 2 407) 775 (184, 2 107)

*HK$ presented as median (25th, 75th percentile); 12 control and 22

intervention group subjects had all charges waived because of com-

prehensive social security assistance or retired civil servant status;

seven intervention group subjects had community nurse visits paid by

research fund.Home help, meals on wheel, day care centre, escort for medical

follow-up.

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were HK$1 457 (589, 4 011) and 922 (193, 2 269), respect-

ively. The difference was not significant (P 0118, Mann

Whitney U test).

Discussion

Our results demonstrated that an intensive post-discharge

community nursing intervention programme for older CHF

patients could not reduce the chance of re-admissions in six

months, but was probably effective in reducing the number of

unplanned re-admissions. The latter is consistent with the

results of other similar trials overseas. The low drop out rate

in the intervention group reflects an overall good acceptance

of the intervention.

The subjects were well matched except that the interven-

tion group had more financial hardship. This might have had

a negative influence on the rate of public health care

utilization in the intervention group.

As expected for older CHF subjects, only a third of thesubjects had systolic heart failure. Consistent with clinical

practice at the time of the study, the great majority of CHF

patients were on diuretics and the use of angiotensin

converting inhibitor (ACEI) and beta blockers was limited.

It is noteworthy that the use of ACEI and beta blockers has

been associated with less re-admission in CHF patients

(Fowler et al. 2001, Abarca et al. 2004). The change of

medication after recruitment was unfortunately not docu-

mented in this study. However, as both groups were managed

by the same specialist outpatient clinics, significant differ-

ences in medication use were unlikely.

Although the intervention did not significantly reduce the

chance of admission within six months, it reduced the

number of unplanned admissions. The lower mortality rates

of the intervention group subjects (83 vs. 148% in control

subjects) suggested that the CN intervention did not delay

hospital admissions when they were needed. A meta-analysis

showed that post-discharge CN interventions, when com-

bined with specialist medical support, can reduce mortality of

CHF patients (McAlister et al. 2004).

Community nurse intervention did not improve functional

status of the CHF patients. However, relative to the control

group who showed deterioration in the independence domainof handicap, CN intervention helped to maintain the level of

independence. The educational and advisory role of the CN

had probably helped the patients and the family caregivers to

better manage the disease and its associated disabilities.

The CN might have been effective in preventing some

admissions by enhancing the interface between hospital

services and the medical needs of CHF patients and possibly

by improving the self-management of the disease by the

patients or the family members. There was still room for

improvement as a few intervention group subjects were still

re-admitted for dietary non-adherence and drug-related

problems.

The CN intervention can potentially be more effective if

they can have training in two important areas of self-

management of CHF, namely diet and exercise. There is good

evidence that regular physical exercise is beneficial to the

exercise tolerance of CHF patients (Smart & Marwick 2004),

even in advanced age and in the home setting (Corvera-Tindel

et al. 2004). CNs are in a good position to motivate older

patients to perform physical exercises that suit their lifestyle.

However, they require training in the prescription of physical

exercise and information about locally available exercise

programmes. Salty diet is a common problem in older people,

particularly in those with CHF. Simple advice to restrict salt

is usually not adequate to change behaviour in the long term

(Gonzalez et al. 2005). More training in dietetic approaches

in gradual salt restriction is needed.The high rate of re-admissions for reasons which may or

may not be related to CHF suggests that this group of

patients requires close medical supervision. Unfortunately,

most subjects in both groups relied primarily on specialist

outpatient clinics, but, the frequency of specialist outpatient

clinic is necessarily limited because of the workload in

hospitals and patients may not welcome that. The cost data

showed that the cost of transport to outpatient clinic

comprised a significant proportion of their health care costs.

Moreover, many older people have trouble finding their way

round the hospital clinics, therefore requiring family

members to escort them.

Primary health care clinics which are more locally access-

ible should play a major role in the follow-up of these high-

risk individuals in the community. This is indeed the case in

most Western countries, but our data confirmed that the use

of primary health care was minimal (data not shown). This

highlights the under use or inaccessibility of primary health

care for at risk older people. As in public hospitals, the

government general outpatient clinics (GOPD) had low

charges which were waived in those on CSSA, but to be seen

at the clinics, one had to queue for a consultation quota early

in the morning. This is not feasible for an ill older person. Inthe last two years, the Hospital Authority has taken over the

administration of the GOPD. This opens up the possibility of

arranging follow-up in GOPD upon hospital discharge and

the sharing of clinical data via the HA territory-wise

computerized client management system (CMS).

Private clinics are widely available in Hong Kong, but this

group of patients might have found them unaffordable. For

those who can afford it, the private doctors can potentially be




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more helpful if they can have access to clinical information

about the patients. At present, all hospital patients are

provided with a computer-generated discharge note showing

the diagnoses and medication. The detailed discharge sum-

mary is deliberately withheld from the patients because of

confidentiality issues. Patients can request medical reports

but, they are charged a significant fee and the procedures

normally take a few weeks. This administrative culture of

non-disclosure hinders the free flow of clinical information

which is critically important if doctors in the community are

expected to participate in chronic disease management. Pilot

programmes allowing selected private general practitioners to

gain access to their regular patients clinical information in

the CMS via the internet are under way.

The CN programme was probably effective in reducing

the costs of hospital stay and emergency care attendance,

but when the costs of CN were considered, the net gain in

public health care costs was not significant. In contrast,

most overseas post-discharge CN programmes were shownto be cost effective (McAlister et al. 2004). Admittedly, this

trial was under-powered to detect a small reduction in

health care costs. Nevertheless, this CN programme might

have been more cost effective if less home visits were made.

The number of home visits in this programme was greater

than in most previous trials which emphasized predischarge

face-to-face hospital visits and post-discharge phone follow-

ups more (Naylor et al. 1994, Krumholz et al. 2002). Apart

from the need to have an early home visit for an initial

assessment and formulation of management plan, the need

for further visits will largely depend on the resources and

physical condition of the patients. The greater use of

telephone follow-up and empowerment of patients and their

families in disease management may reduce the need for

home visits, therefore enhancing the cost-effectiveness of the

programme.

The costs to the patients were not overall increased by CN

intervention. However, a CN visit cost HK$55 in Hong Kong

at the time (the charge was increased to HK$80 in 2003).

After excluding those who were eligible for waived charges,

the cost of CN visits was a significant proportion of the total

health care costs paid by the patients. Further cost analysis

confirmed that the CN intervention tended to increase theoverall cost of care to the patients. It was, therefore, not

surprising that a significant proportion of subjects who had to

pay refused to do so. In Hong Kong, only those with net asset

of less than HK$30 000 were eligible for comprehensive

social security assistance which included waiving of all

charges from public services. However, there are many at

risk older people who are not eligible for CSSA, but have

meagre monthly incomes. This seriously questions the

rationale of charging for community health services which

can potentially reduce overall health care costs.

The strength of this trial is that it was the first randomized

controlled trial of CN intervention in CHF patients in Hong

Kong where the primary health care is not well organized.

The outcomes in functional status and handicap and cost

analysis were considered at the same time. The main

limitation was the small sample size which only allowed the

detection of a major effect of CN intervention. The subjects

had multiple medical problems and high mortality. In the cost

analysis, the hospital and clinic costs were all standardized.

The indirect costs to patients were not considered. More

comprehensive cost analysis is warranted.

Conclusion

We concluded that post-discharge visits by CNs in older

chronic cardiac failure patients were not effective in reducing

the chance of re-admission within a six month period. But,they were effective in preserving independence and were

probably effective in reducing the number of unplanned re-

admissions. More comprehensive health economic evaluation

needs to be undertaken.

Acknowledgements

We would like to express our gratitude to the participating

community nursing teams, Ms Eliza Lau, Dr Chan Chi Kin,

and Prof John Sanderson. The research was funded by the

Health Services Research Committee/Health Care & Promo-

tion Fund (HSRC/HCPF) of Hong Kong.

Statement of Competing Interests

None.

Contributions

Study design: KT, LTFD; data collection and analysis: KT,

WJ; manuscript preparation: KT, LJ, GS, WJ.

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