Risk-guided Intervention to Reduce Heart Failure Readmission

2019 Vanguard Grant

Years funded: 2020-2021

Around 500,000 Australians are affected by heart failure (HF). As HF patients form a large proportion of hospital readmissions, reducing HF readmission rates would benefit both hospital expenditure and quality of care. Our planned study arises from four preparatory observations. First, we demonstrated significant regional variations in HF readmission in Australia. These were linked to the availability of nurse-led disease management programs (DMP) and were independent of disease severity and comorbidity. Second, we developed and validated a HF risk score based on our observations that psychosocial determinants, such as living alone, cognitive decline and carer stress, are important drivers of HF readmission.

Unlike existing scores (which predict death), our HF risk score effectively predicts the chance of readmission with the best discrimination to date. Third, we developed a nurse-led “DMP-Plus” multidisciplinary intervention through a recently completed randomised controlled trial – which effectively reduced HF readmission and was best at reducing HF readmissions in patients with the highest risk.

Finally, we have recently collaborated to develop a smartphone app, as a digital health coach, to educate and prompt appropriate behaviours in HF patients. In this proposed study, we plan to apply the risk-guided DMP-Plus intervention in two geographically and socially diverse hospitals. We will investigate the effectiveness of DMP-Plus in high-risk HF patients, and test the additional potential of the digital health coach to reduce readmission rates. Given the high numbers of people experiencing HF, calibrating DMP to those most likely to benefit will have wide-reaching implications for medical service delivery both nationally and internationally.