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Canadian Journal of Cardiology

Comprehensive Strategies to Reduce Readmissions in Older Patients With Cardiovascular Disease

  • Kumar Dharmarajan
    Correspondence
    Corresponding author: Dr Kumar Dharmarajan, 1 Church St, Ste 200, New Haven, Connecticut 06510, USA. Tel.: +1-917-952-5162; fax: +1-203-764-5653.
    Affiliations
    Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT and Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
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Published:February 03, 2016DOI:https://doi.org/10.1016/j.cjca.2016.01.030

      Abstract

      Older adults are frequently readmitted to the hospital soon after hospitalization for common cardiovascular conditions. Yet there are few high-quality data on the best strategies to reduce short-term readmissions because most studies have involved small numbers of participants, single-centre design, and strong susceptibility to bias. Despite these limitations in the literature, a clear signal exists that most studies involving a singular type of intervention, a singular type of health provider, or a low intensity of intervention have failed to reduce readmissions. In contrast, interventions that are most likely to lower readmissions have used comprehensive approaches, including combined hospital and postacute care, multimodal interventions, multidisciplinary teams, or frequent longitudinal contact. Components of a comprehensive approach with the highest level of evidence include high-quality, disease-specific care; multiple transitional care interventions; involvement of multidisciplinary teams; early and frequent outpatient follow-up; and, when possible, home visits. These findings are consistent with data demonstrating that older adults have multiple sources of vulnerability and experience elevated readmission risk from a broad spectrum of medical conditions for an extended time after hospital discharge. Because readmission reduction is difficult and requires new ways of conceptualizing links between inpatient and postacute care, financial incentives may ultimately be required to motivate hospitals and health systems to redesign care processes, deploy new resources, and collaborate with out-of-hospital providers and organizations.

      Résumé

      Il arrive fréquemment que les adultes plus âgés soient réadmis à l’hôpital après un séjour pour une maladie cardiovasculaire courante. Il existe cependant peu de données de bonne qualité quant aux meilleures façons de réduire le taux de réadmission à court terme puisque la plupart des études effectuées jusqu’ici étaient unicentriques, ne portaient que sur un petit nombre de sujets et présentaient une forte vulnérabilité aux biais. Malgré cela, il en ressort clairement que dans la plupart des cas, le recours à une intervention unique, à un seul professionnel de la santé ou à une intervention de faible intensité n’est pas efficace pour réduire le taux de réadmission. En revanche, les interventions les plus susceptibles de réduire le taux de réadmission ont fait appel à des approches exhaustives, comprenant des soins hospitaliers et en phase postaiguë, des interventions multimodales, des équipes multidisciplinaires ou un suivi longitudinal régulier. Les composantes d’une approche exhaustive appuyées par les meilleures données probantes sont les suivantes : des soins de haute qualité et spécifiques à la maladie; de nombreuses interventions de soins transitoires; des soins offerts par des équipes multidisciplinaires; un suivi ambulatoire précoce et fréquent; et, lorsque c’est possible, des visites à domicile. Ces constatations cadrent avec les données indiquant que les adultes plus âgés présentent de nombreuses vulnérabilités et un risque élevé de réadmission à l’hôpital découlant d’un vaste éventail de problèmes médicaux, et ce, même longtemps après le séjour hospitalier initial. Étant donné qu’il est difficile de réduire les taux de réadmission et qu’il faut pour ce faire redéfinir l’ensemble des liens entre les soins hospitaliers et les soins en phase postaiguë, il se pourrait ultimement que des incitatifs financiers soient nécessaires pour motiver les systèmes de santé et les établissements à revoir leurs modalités de soins, à déployer de nouvelles ressources et à collaborer avec les prestataires de soins et les organismes qui œuvrent en dehors du réseau hospitalier.
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