Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Strategies to reduce hospitalizations in patients with heart failure

Leora Horwitz, MD, MHS
Harlan Krumholz, MD
Section Editor
Sharon A Hunt, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Heart failure (HF) is one of the most common causes of hospitalization and readmission. Approximately six million Americans and 15 million Europeans are living with HF [1,2]. In 2011, the HF hospitalization rate in the United States was 18 per 1000 for those over age 64 [3], making HF among the leading causes of hospitalization in this age group [4]. Furthermore, about a quarter of those who are hospitalized with HF are readmitted within 30 days [4] and 30 percent within 60 to 90 days post-discharge [5]. A marked decrease in admission rates between 1999 and 2011 (30.5 percent reduction, 95% CI, 29.3-31.6) has not been matched by a comparable reduction in readmission rates, which declined 9.7 percent (95% CI, 8.5-10.8) over the same period [6,7]. Data for Medicare patients show that risk-standardized rehospitalization rates and mortality rates were correlated only weakly [8]. A majority of readmissions after HF hospitalization are not for HF, as shown in a separate study of Medicare patients [9].

Strategies to reduce hospitalizations in patients with HF include optimization of evidence-based drug and device therapies, addressing causes of HF, treating comorbidities, and improved management of care [10]. It has been suggested that reducing disruption during the hospitalization might lower readmission risk as well [11]. Evidence from randomized controlled trials has established the efficacy of certain drug and device therapies in reducing hospitalizations as well as mortality in patients with systolic HF, but treatment in patients with diastolic HF remains empiric since trial data are limited. (See "Overview of the therapy of heart failure with reduced ejection fraction", section on 'General management' and "Treatment and prognosis of heart failure with preserved ejection fraction".)

Patients with HF are typically older adults with complex drug regimens for HF, multiple concurrent diagnoses, and resulting polypharmacy [12]. They are often cared for by many clinicians. Because of these complexities, the care of HF involves more than straightforward medical management of a solitary disease. Moreover, HF patients may have trouble with balance, eyesight, hearing, and/or executive function that makes self-management difficult. Decreased cognitive function has been associated with readmission risk [13]. The clinician, working with others in a care team, must provide appropriate coordination of care, manage the patient between office visits, ensure adequate patient education to support the acquisition of self-care skills, and create safe transitions of care between settings.

This topic will review outpatient- and inpatient-based management strategies aimed at reducing the risk of hospitalization and rehospitalization for patients with HF. Patient self-management of HF is discussed separately. (See "Heart failure self management".) The medical management of heart failure and treatment of acute decompensation are also discussed separately. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction" and "Treatment of acute decompensated heart failure in acute coronary syndromes" and "Treatment of acute decompensated heart failure: Components of therapy".)


Disease management — Disease management programs are designed to provide a multidisciplinary, integrated approach to care for patients with a chronic condition. Disease management programs facilitate the development of an individualized care plan, provide patient education and support, and coordinate care among healthcare providers, patients and patients’ support systems. A clinician acting as a solo caregiver typically has neither the expertise nor time to address all these components of a patient’s healthcare needs.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 19, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010; 121:e46.
  2. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29:2388.
  3. Krumholz HM, Normand SL, Wang Y. Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Circulation 2014; 130:966.
  4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.
  5. Gheorghiade M, Peterson ED. Improving postdischarge outcomes in patients hospitalized for acute heart failure syndromes. JAMA 2011; 305:2456.
  6. Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008. JAMA 2011; 306:1669.
  7. Bueno H, Ross JS, Wang Y, et al. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006. JAMA 2010; 303:2141.
  8. Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA 2013; 309:587.
  9. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA 2013; 309:355.
  10. Gheorghiade M, Braunwald E. Hospitalizations for heart failure in the United States--a sign of hope. JAMA 2011; 306:1705.
  11. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med 2013; 368:100.
  12. Wong CY, Chaudhry SI, Desai MM, Krumholz HM. Trends in comorbidity, disability, and polypharmacy in heart failure. Am J Med 2011; 124:136.
  13. Patel A, Parikh R, Howell EH, et al. Mini-cog performance: novel marker of post discharge risk among patients hospitalized for heart failure. Circ Heart Fail 2015; 8:8.
  14. Krumholz HM, Currie PM, Riegel B, et al. A taxonomy for disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group. Circulation 2006; 114:1432.
  15. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  16. Multidisciplinary Care for Patients with Chronic Heart Failure: Priniciples and Recommendations for Best Practice. National Heart Foundation of Australia. 2010.
  17. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008; 337:a1655.
  18. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 2004; 44:810.
  19. Gonseth J, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J 2004; 25:1570.
  20. Clark RA, Inglis SC, McAlister FA, et al. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. BMJ 2007; 334:942.
  21. Gwadry-Sridhar FH, Flintoft V, Lee DS, et al. A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure. Arch Intern Med 2004; 164:2315.
  22. Roccaforte R, Demers C, Baldassarre F, et al. Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail 2005; 7:1133.
  23. Holland R, Battersby J, Harvey I, et al. Systematic review of multidisciplinary interventions in heart failure. Heart 2005; 91:899.
  24. Inglis SC, Clark RA, McAlister FA, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev 2010; :CD007228.
  25. Jovicic A, Holroyd-Leduc JM, Straus SE. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovasc Disord 2006; 6:43.
  26. Mezger J. [Comments on the contribution by R. Niehues et al]. Internist (Berl) 1992; 33:848.
  27. Clark AM, Savard LA, Thompson DR. What is the strength of evidence for heart failure disease-management programs? J Am Coll Cardiol 2009; 54:397.
  28. Takeda A, Taylor SJ, Taylor RS, et al. Clinical service organisation for heart failure. Cochrane Database Syst Rev 2012; :CD002752.
  29. GESICA Investigators. Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ 2005; 331:425.
  30. Galbreath AD, Krasuski RA, Smith B, et al. Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure. Circulation 2004; 110:3518.
  31. McCall N, Cromwell J. Results of the Medicare Health Support disease-management pilot program. N Engl J Med 2011; 365:1704.
  32. Jaarsma T, van der Wal MH, Lesman-Leegte I, et al. Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Arch Intern Med 2008; 168:316.
  33. Wennberg DE, Marr A, Lang L, et al. A randomized trial of a telephone care-management strategy. N Engl J Med 2010; 363:1245.
  34. Ferrante D, Varini S, Macchia A, et al. Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up. J Am Coll Cardiol 2010; 56:372.
  35. Ditewig JB, Blok H, Havers J, van Veenendaal H. Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Educ Couns 2010; 78:297.
  36. Grady KL. Self-care and quality of life outcomes in heart failure patients. J Cardiovasc Nurs 2008; 23:285.
  37. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation 2005; 111:179.
  38. Ross SE, Moore LA, Earnest MA, et al. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res 2004; 6:e12.
  39. Polisena J, Tran K, Cimon K, et al. Home telemonitoring for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare 2010; 16:68.
  40. Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med 2010; 363:2301.
  41. Koehler F, Winkler S, Schieber M, et al. Telemedical Interventional Monitoring in Heart Failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design. Eur J Heart Fail 2010; 12:1354.
  42. Ong MK, Romano PS, Edgington S, et al. Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial. JAMA Intern Med 2016; 176:310.
  43. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240.
  44. Abraham WT. Disease management: remote monitoring in heart failure patients with implantable defibrillators, resynchronization devices, and haemodynamic monitors. Europace 2013; 15 Suppl 1:i40.
  45. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm400550.htm (Accessed on February 13, 2015).
  46. Dhruva SS, Krumholz HM. Championing Effectiveness Before Cost-Effectiveness. JACC Heart Fail 2016; 4:376.
  47. Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011; 377:658.
  48. Adamson PB, Abraham WT, Bourge RC, et al. Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction. Circ Heart Fail 2014; 7:935.
  49. Krahnke JS, Abraham WT, Adamson PB, et al. Heart failure and respiratory hospitalizations are reduced in patients with heart failure and chronic obstructive pulmonary disease with the use of an implantable pulmonary artery pressure monitoring device. J Card Fail 2015; 21:240.
  50. Abraham WT, Stevenson LW, Bourge RC, et al. Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial. Lancet 2016; 387:453.
  51. Loh JP, Barbash IM, Waksman R. Overview of the 2011 Food and Drug Administration Circulatory System Devices Panel of the Medical Devices Advisory Committee Meeting on the CardioMEMS Champion Heart Failure Monitoring System. J Am Coll Cardiol 2013; 61:1571.
  52. Packer M, Abraham WT, Mehra MR, et al. Utility of impedance cardiography for the identification of short-term risk of clinical decompensation in stable patients with chronic heart failure. J Am Coll Cardiol 2006; 47:2245.
  53. Sharma V, Rathman LD, Small RS, et al. Stratifying patients at the risk of heart failure hospitalization using existing device diagnostic thresholds. Heart Lung 2015; 44:129.
  54. Small RS, Whellan DJ, Boyle A, et al. Implantable device diagnostics on day of discharge identify heart failure patients at increased risk for early readmission for heart failure. Eur J Heart Fail 2014; 16:419.
  55. Whellan DJ, Ousdigian KT, Al-Khatib SM, et al. Combined heart failure device diagnostics identify patients at higher risk of subsequent heart failure hospitalizations: results from PARTNERS HF (Program to Access and Review Trending Information and Evaluate Correlation to Symptoms in Patients With Heart Failure) study. J Am Coll Cardiol 2010; 55:1803.
  56. Cowie MR, Sarkar S, Koehler J, et al. Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in an ambulatory setting. Eur Heart J 2013; 34:2472.
  57. van Veldhuisen DJ, Braunschweig F, Conraads V, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation 2011; 124:1719.
  58. Boriani G, Da Costa A, Ricci RP, et al. The MOnitoring Resynchronization dEvices and CARdiac patiEnts (MORE-CARE) randomized controlled trial: phase 1 results on dynamics of early intervention with remote monitoring. J Med Internet Res 2013; 15:e167.
  59. Tibaldi V, Isaia G, Scarafiotti C, et al. Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial. Arch Intern Med 2009; 169:1569.
  60. Mendoza Ruiz de Zuazu H, Regalado de los Cobos J, Altuna Basurto E, et al. [Treatment of congestive heart failure in the setting of hospital at home. Study of 158 patients]. Med Clin (Barc) 2003; 120:405.
  61. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005; 143:798.
  62. Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol 2003; 41:62.
  63. Indridason OS, Coffman CJ, Oddone EZ. Is specialty care associated with improved survival of patients with congestive heart failure? Am Heart J 2003; 145:300.
  64. Lee DS, Stukel TA, Austin PC, et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation 2010; 122:1806.
  65. Chin MH, Friedmann PD, Cassel CK, Lang RM. Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med 1997; 12:523.
  66. Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997; 30:518.
  67. Go AS, Rao RK, Dauterman KW, Massie BM. A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. Am J Med 2000; 108:216.
  68. Foody JM, Rathore SS, Wang Y, et al. Physician specialty and mortality among elderly patients hospitalized with heart failure. Am J Med 2005; 118:1120.
  69. Jong P, Gong Y, Liu PP, et al. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003; 108:184.
  70. Reis SE, Holubkov R, Edmundowicz D, et al. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol 1997; 30:733.
  71. Lazkani M, Ota KS. The role of outpatient intravenous diuretic therapy in a transitional care program for patients with heart failure: a case series. J Clin Med Res 2012; 4:434.
  72. Hebert K, Dias A, Franco E, et al. Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program. Congest Heart Fail 2011; 17:309.
  73. Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med 2014; 160:774.
  74. Yancy CW, Krum H, Massie BM, et al. Safety and efficacy of outpatient nesiritide in patients with advanced heart failure: results of the Second Follow-Up Serial Infusions of Nesiritide (FUSION II) trial. Circ Heart Fail 2008; 1:9.
  75. Tacon CL, McCaffrey J, Delaney A. Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensive Care Med 2012; 38:359.
  76. Kfoury AG, French TK, Horne BD, et al. Incremental survival benefit with adherence to standardized heart failure core measures: a performance evaluation study of 2958 patients. J Card Fail 2008; 14:95.
  77. Patterson ME, Hernandez AF, Hammill BG, et al. Process of care performance measures and long-term outcomes in patients hospitalized with heart failure. Med Care 2010; 48:210.
  78. Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA 2007; 297:61.
  79. Werner RM, Bradlow ET. Public reporting on hospital process improvements is linked to better patient outcomes. Health Aff (Millwood) 2010; 29:1319.
  80. Phillips CO, Wright SM, Kern DE, et al. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004; 291:1358.
  81. Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med 1994; 120:999.
  82. Stauffer BD, Fullerton C, Fleming N, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med 2011; 171:1238.
  83. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006; 166:1822.
  84. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150:178.
  85. Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med 2009; 361:2637.
  86. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 2010; 303:1716.
  87. Metra M, Gheorghiade M, Bonow RO, Dei Cas L. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation 2010; 122:1782.
  88. Al-Damluji MS, Dzara K, Hodshon B, et al. Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 2015; 8:77.
  89. Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med 2009; 24:381.
  90. Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation. BMJ Qual Saf 2011; 20:773.