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1997), Initial (index) Admission Stay Exceeding Seven Days (krumholz H M Et ...

1997), initial (index) admission stay exceeding seven days (Krumholz H M et al. 1997) increasing incidence or severity of comorbidities (Chin M H et al. 1997), both raised and abnormally low systolic blood pressure (Alexander M et al. 1999), under dosing with ACE inhibitors (either iatrogenic or lack of patient compliance) (Luzier A B et al. 1998) and significantly, physician lack of knowledge regarding appropriate heart failure treatment regimes (Vinson J M et al. 1990)

It is also very significant to note that although many papers have been able to identify and quantify those groups that are at increased and specific risk of readmission, no paper yet published has been able to identify a specific low risk group which requires less targeted attention.

Literature review of selected papers.
For list see appendix

This essay will specifically consider the six selected papers individually and then collectively and comparatively. Each of the papers selected covers an aspect of treatment and potential prevention of hospital readmission after an initial episode of heart failure.

The Jerant paper appears to be primarily concerned with reducing the cost of frequent hospital admissions... In overview this title is rather misleading since it implies that the paper is considering a number of different mechanisms designed to reduce readmission rates and thereby reduce costs. In reality, it is actually concerned with evaluating one specific intervention (telephony assessment) to see if it is effective in reducing the incidence of hospital readmission when compared to the usual treatment. As we shall discuss shortly the usual treatment is a phrase frequently used in papers reviewing heart failure and is an extremely imprecise term. The usual treatment is generally taken to mean treatment without the intervention specified in the paper rather than a specific universal regime common to all. Sadly it is this imprecision which makes comparisons between papers difficult and introduces a considerable element of potential error when analysing such comparisons. (Berlin J A et al. 1989)

In essence, the Jerant paper outlines a randomised trial which follows up 37 cases randomised into one of three groups over one year. The three study groups were:
1) home based telephony care including a 2 way video-conference link and integrated electronic stethoscope
2) nurse telephone calls
3) usual outpatient care

At this point we should note that the study is USA based. This should not detract from the results per se but is positive (as so many studies that consider cost elements) as the USA system of medicine is extremely cost orientated with virtually every item of service being costed. Determining the overall costs of an intervention is therefore considerably easier than in the NHS system where virtually all of the overheads are absorbed and not itemised.

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