Effect of Early Follow-Up After Hospital Discharge on Outcomes in Patients With Heart Failure or Chronic Obstructive Pulmonary Disease: A Systematic Review.

Abstract

Background: Transitions in care can increase patients' vulnerability to adverse events. In particular, patients admitted for heart failure or chronic obstructive pulmonary disorder (COPD) have high rates of readmission and return emergency department visits. Heart failure patients have the highest 30-day readmission rates in Canada, and COPD patients comprise the highest volume of readmissions. Combined, these two conditions account for the largest number of emergency department returns. Prompt follow-up of discharged patients has been linked with reduced rates of readmission, emergency department use, and death. This systematic review evaluated the clinical effectiveness of early follow-up, within either 7 days or 30 days after hospital discharge, compared with usual care or a different time to follow-up, in reducing readmissions, emergency department visits, and mortality in patients with heart failure or COPD.

Methods: We performed a literature search to identify studies published in English up to May 25, 2016, on early follow-up after discharge from hospital in patients with heart failure or COPD. A single reviewer screened the titles and abstracts and obtained full-text articles for studies meeting the eligibility criteria. The risk of bias in the studies was evaluated according to ROBINS-I and EPOC criteria, and the quality of the body of evidence for each outcome was examined according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.

Results: From a total of 3,228 unique citations, we identified 10 eligible studies: one randomized controlled trial, two nonrandomized controlled trials, and seven observational studies. Four studies were specifically on 7-day follow-up and 30-day health outcomes. The other six studies were on 30-day follow-up and more variable time to health outcomes. Follow-up was conducted by general and specialist physicians, nurses, and pharmacists in clinics, by telephone, and by home visit. Risk of bias was moderate for most of the studies. Having follow-up within either 7 days or 30 days after hospitalization for heart failure or COPD was associated with lower all-cause readmissions, emergency department visits, and mortality, even after accounting for confounders such as age, sex, socioeconomic status, and disease severity (GRADE: Very low to low). However, the evidence was inconsistent. We did not find a difference in effectiveness between studies using a 7-day versus a 30-day follow-up.

Conclusions: Based on low- and very low-quality evidence, follow-up within 7 days and within 30 days of discharge from hospitalization for heart failure or COPD-compared with usual care or no follow-up-were both associated with a reduced risk of all-cause readmission, emergency department visits, and mortality. Overall, there is a lack of large, methodologically robust studies specifically focusing on the effectiveness of 7-day follow-up after discharge in improving patient outcomes.