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Annotated Bibliographies on Chf Readmissions

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Annotated Bibliographies
Lisa Stevens
Kaplan University

Annotated Bibliographies
Au, A., McAlister, F., Bakal, J., Ezekowitz, J., Kaul, P., & vanWalraven, C. (2012). Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization. American Heart Journal, 164(3). 365-372. Retrieved from:
This article sought to find an appropriate model to predict the risk of unplanned heart failure readmissions. The primary outcome from chart reviews also included death of heart failure patients within 30 days of discharge. The study looked at Centers for Medicaid and Medicare Services (CMS) models and the LACE+ index, to mention two of many that looked at prediction ability. The LACE+ index is a model that looks at length of stay, acuity, the Charlson comorbidity score and age, to predict readmissions. They found that no one model was appropriate in predicting the 30-day readmission rates, although using a combination of the models was an improvement to that predictor.
The authors are all physicians, PhDs, or have a Master’s degree- helping to establish credibility. The authors also make a statement as to the funding of the project and that they (the authors) were solely responsible for all data collection, design and submission approval writing for the project, also lending credibility to the study. The references used for this study were appropriate in age, of the 28; 13 were within the last five years. Statistical data was gathered by experts and calculations made through third party experts, lending validity to the study. This article does not use the words ‘Evidence-Based Practice’ (EBP), but the CMC model is an EBP model, and many of the newer references make note to EBP.
Although this was an interesting article, I may not use this in my final project. I believe the process of being able to predict the target patients who are at risk for death and readmissions are very important, but if every patient with this diagnosis is put into a high risk category and treated the same—why would one need to find a ‘target’ population. I speak for the CHF clients only; maybe I will use this after all, as a point in showing why every patient needs follow-up care after discharge, and how a CHF clinic can make this a reality.

Case, R., Haynes, D., Holaday, B. & Parker, V. (2010). Evidence Based Nursing: The role of the advanced practice registered nurse in the management of heart failure patients in the outpatient setting. Dimensions of Critical Care Nursing, 29(2). 57-62. Doi: 10.1097/DCC.0b013e3181c92efb. Retrieved from:
This article was a systematic review specifically aimed at finding evidence-based practice (EBP) in the care of heart failure patients in the outpatient setting. An intense literature review ensued and found many items included in this systematic review. Studies included randomized trials and quasi-experimental trials. Two of the studies found patients in the intervention groups with nursing management had fewer hospitalizations than those in the control group. The authors conclude the importance of nursing managed care for follow-up, medication readjustment and symptom management. This article also supports the need for team assessment and collaborative efforts. Advanced practice nurses also were shown as a needed adjunct in creating a cost-effective alternative when managing outpatient Congestive Heart Failure clinic programs.

The authors’ credentials are that of registered nurses and a PhD, lending to the validity of the article. The article is published in a peer-reviewed, scholarly and evidence-based journal. The sources are valid and five of the seven references are current within five years of the date of the article. The fact that the article is looking for EBP, also lends to validity, in that the authors were seeking best practice and what is appropriate care available to the CHF patient.
I liked this article, it did give me some new information, like the improvement of adherence to dietary restrictions and appropriate use of pharmacological therapy. The fact that all the literature points to CHF patients benefitting from advanced care and outpatient follow-up, seals my notions of the need for a CHF clinic. Increasing quality of life was also another important finding gained from this study.

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal Of The American Geriatrics Society, 57(3), 395-402. doi:
This article was a randomized controlled study that looked at exercise and a 24-week telephone follow-up to decrease readmissions and increase quality of life. The study was conducted in Australia, at a single tertiary hospital. The intervention group received a specialized discharge including home follow-up to 6 months, and an in-hospital exercise program. The control group received the normal discharge and education. Findings included a decrease in readmissions and a quality of life increase. Evidenced-based models were utilized in the study.
Credit worthiness begins with the authors as they are all PhD’s or hold Master’s degrees. The academic credentials of the authors lends to the study’s validity. The statistical data was collected and evaluated appropriately. 14/32 references were within five years of the study date. The study was funded and outside sources revealed no bias of information and no association to the collection of data, design or evaluation mechanisms were used. A multivariable logistic regression model was used when looking at demographics. A 95% confidence interval was shown. Other appropriate statistics used were: SPSS version 13.0, chi-square tests, Mann-Whitney U tests and t-tests.

This article gave me new information that will be used in my health promotion proposal. The information gleaned from this article has to do with the exercise program and the involvement before discharge. Medication information, social support, community services and adherence to exercise programs were also helpful and added information I will use.
Fonarow, G., Albert, N., Curtis, A., Stough, W., Gheorghiade, M… & Yancy, C. (2010).
Improving evidence-based care for heart failure in outpatient cardiology practices: primary results of the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF). Circulation, 122(6):585-96. doi: 10.1161/CIRCULATIONAHA.109.934471. Retrieved from:
This article used a prospective study to evaluate and make recommendations on the treatment of Congestive Heart Failure (CHF) patients. The name of the study was IMPROVE-HF and wanted to provide evidence-based guideline-recommended therapies to patients with CHF. The facilitation of more EBP facilitated care therapies was another of the study’s goals. The authors note that although there are many obstacles to overcome, 5 out of 7 quality measures were met by cardiology practices that participated in the IMPROVE-HF study. The study concluded with favorable outcomes in CHF therapies including: performance profiling in cardiology settings, educational outreach, collaborative support, and establishing a model and framework for future programs.
The authors showed credibility in their professional credentials, all were MDs and RNs. This EBP study was found on a credible website – the National Institute for Health, also lending to reliability. The references were mostly current within five years of the date of the article. 16 of 18 fell into this category. Statistical data and evaluation of the data was performed by external experts, which gave further credibility in the area of validity.
I really enjoyed the information gained from this article. The references each have a direct web- to- article connector which made it very easy to look at the supporting data. The new information gained was through the use of collaboration of cardiology offices and how they can be an integral part of the process and project. I will use the article and the IMPROVE-HF project as reference in my health proposal.

Hines, P., Yu, K., & Randall, M. (2010). Preventing heart failure readmissions: Is your organization prepared? Nursing Economic$, 28(2). 74-86. Retrieved from: This article intended to be informative only. There was no study performed by the authors. The article compares and gives information available on testing your facility’s readiness for heart failure readmissions. They talk about strategies to reduce the risk of readmissions, new reform and payment changes on the horizon and a process to execute the decrease of heart failure readmissions. They go into great detail on changes coming within the Centers for Medicare & Medicaid Services (CMS) including; changes in readmission payments, bundled payments and care management models. They discuss in detail the importance of a proper transition home with four specific areas noted: Enhanced admission assessing, enhanced education, patient and family centered ‘hand-off’ communication and follow-up.
The authors, although noted, do not give information about themselves. Credibility then needs established in other areas. The article is published in a review boarded journal – NurseEconomic$. This helps with reliability, also there does not appear to be a hidden agenda, lending a little more reliability. The references are many; 27 of the 44 are new and within five years old. The authors also make reference to additional reading sites. This article does not specifically refer to Evidence-Based Practice, although they use EBP models in their strategies as evidenced by the EBP in their references.
I loved this article; I will most definitely use it in my health proposal project. The information as referenced, I felt was accurate and appropriate. With the adoption of some of this article’s strategies, I hope to make readmissions less. This has added benefits of increased CMS reimbursements along with high-quality and continuous care for the heart failure patients.
Jacob, L., & Poletick, E. (2008). Systematic review: predictors of successful transition to community-based care for adults with chronic care needs. Care Management Journals,
9(4), 154-165. Doi: 10.1891/1521-0987.9.4.154
This article is a qualitative systematic review on transition of care for patients with chronic care needs. The authors performed an extensive review of the literature and restricted the count from over 3000 to 129 useful articles. The bulk of the article wanted to find whether or not an enhanced discharge for those patients that are at higher risk for death or 30-day readmissions was appropriate. They looked at designs such as grounded theory, phenomenology and ethnography to interpret some of the data. Heart failure proved to be an area where with enhanced discharge criteria; facilities could see a reduction in those readmissions. The review found patients who were younger, lived alone, experiencing first hospitalization, or having longer hospital stays were among the patients that seemed to experience a more difficult transition and discharge.
The authors, both RNs are nurse practitioners employed by a medical center and a school of nursing. The information was gathered by experts and helps to give credibility to the review. The references are not new, and fall between 5-10 years and >10 years old. This unfortunately, does not add to the validity. The source does although come from a scholarly, peer-reviewed journal; and evidence-based practice was incorporated into the concluding data.
This article did not prove to be new information on hospital readmissions. It reiterated much information I already have. But, it does offer in the appendix a summary of the included studies that would be beneficial in my project. The summary gives methods, participants, interventions and outcomes for the patient with a difficult discharge. It would give me some added areas to peruse if needed for additional information.
Kadda, O., Marvaki, C., & Panagiotakos, D. (2012). The role of nursing education after a cardiac event. Health Science Journal, 6(4), 634-646. Retrieved from:
This article’s intentions were to look at the role of education in nursing for the patient who has suffered a cardiac event or procedure. They discuss how nursing education and support can increase the health outcomes and reduce the risk of future events that are cardiac related. A comprehensive literature review of the roles of nursing in cardiac patients was performed. Study design, sample size, follow-up duration and degree of adjustment all went into the review. Evidence based findings included: nursing education as a beneficial effect on exercise, quality of life, survival rates, weight and blood pressure. Intense rehabilitation efforts were shown to be best started before patients left the hospital. The conclusion makes note the importance of a community based approach to follow-up care, with supervision and reinforcement in the forefront.
The authors are credible in that they are professionals in a school of medicine, school of nursing and a university department of nutrition and dietetics. This was a systematic review of literature involving dates between 2002 and 2011, 13 of the 31 references were within 5 years, giving increased credibility. There is no hidden agenda for the writing of this article, increasing the reliability. The authors make note of quantitative statistical data to support their decisions and give evidence-based practice information. The article is printed in a scholarly, peer-reviewed journal.
The information gained from this article gave me new thoughts I had not previously considered. Coronary Artery Bypass Graft (CABG) patients who have new or previously diagnosed heart failure present with new problems that must be addressed; emotional and life-style changes were among the most important. I will use the information gained in my project especially when it comes to citing the importance of education in the heart failure clientele.

McCarthy, D. (2012). Innovations in care transitions. University of California, San Francisco Medical Center: Reducing Readmissions through heart failure care management. Retrieved from: /Case%20Study/2013/Jan/1635_McCarthy_care_transitions_UCSF_case_study_v3.pdf
This article is a case study, that looked at a program started by the San Francisco Medical Center. The objective was to reduce readmissions by 30% for patients with heart failure (HF). The program was to create an ideal transition from hospital to home. Certain interventions were utilized; teach-back education techniques, multidisciplinary approach to care, follow-up telephone calls, collection of data on readmission for evaluation measures, collaborative communication across the continuum of care and scheduling appointment. These were carried out by HF nurse coordinators. Assessments of readiness to change were included along with new teaching modalities. Overall in conclusion, the program was a success and all goals were met. The study discusses next steps in continuing this process.
The author is a senior research advisor for the Commonwealth Fund, aimed in the conduction of studies that improve healthcare. The study and program was funded by the Commonwealth Fund, but no bias was stated or shown, lending to the validity of the study. Nine of the 13 references were current within the last five years. There does not appear to be a hidden agenda found in the article, and there is no mention of bias. The site and intentions of the Commonwealth Fund are to give accurate, evidenced-based practice.
I loved this case study. It gives so much interesting information. I will use this in my health proposal project. Not only the content will be great to refer to, but the appendix lists four teaching tools I would like to incorporate into my project. They are a phone list with numbers, a CHF zone chart that helps the patient know where they stand in their current state, how to read a nutrition facts sheet (like a soup can) especially for salt, and a daily weight record. Exact steps for creation of a clinic are spelled out, along with teaching strategies, readiness to change strategies, and evaluation choices.

Sochalski, J., Jaarsma, T., Krumholz, H., Laramee, A., McMurray, J., Naylor, M., & ... Stewart,
S. (2009). What works in chronic care management: the case of heart failure. Health
Affairs, 28(1), 179-189. doi:
This article uses statistics from the Centers for Medicare and Medicaid Services (CMS) for rationale in the importance of a multidisciplinary approach to care management of the Congestive Heart Failure (CHF) patient. This study pooled and reanalyzed data from 10 trials. The Taxonomy of Disease Management framework was adopted from the American Heart Association (AHA); this allowed for Evidence-Based Practice (EBP) to become a part of the study. The study showed that there was a significant decrease in hospital readmissions due to the method and delivery of communication or education. The findings mirrored the AHA’s and the Chronic Care Model adding the importance of team-based approach in chronic care management.
The authors showed credibility in the area of accuracy of statistics used. The authors are all associated with universities that are very reputable in nature. The article comes from a scholarly and peer-reviewed journal, and is also evidence- based. There appears to be no hidden agenda, which also helps to establish reliability. The references are approximately 50% within five years of age, establishing validity.
This article had very useful information. The discussion regarding the usefulness of in-person communication vs. telephone communication was very interesting. Although both showed an increase in education and a decrease in hospital readmissions, in-person communication still wins out. That is important for my health promotion proposal in that I will need to keep in mind that before discharge communication is as important as follow-up phone conversations. I will refer to this information for my project.

Will, J., Valderrama, A. & Yoon, P. (2012). Centers for Disease Control & Prevention.
Preventable hospitalizations for congestive heart failure: establishing a baseline to

monitor trends and disparities. 9:110260. 1-9. Doi:org/10.5888/pcd9.110260.

This article looked at preventable hospitalizations and gave statistical values associated with race and gender. The authors used information from the National Hospital Discharge Survey (NHDS) data from 1995 through 2009. During their 15-year study period they narrowed different disparities and found that CHF readmissions were among the highest. They also found blacks in all categories were in the highest of all categories, including race, age, and gender. Heart failure disease management programs as well as management in aggressive risk factor analysis are an area the authors feel is needed to reduce preventable readmissions. Limitations were noted and the most concerning were the hospitals that were surveyed sometimes did not include race, therefore skewing of results is certainly possible.
The authors are affiliates and professionals of the Centers for Disease Control & Prevention (CDC). The article also comes from a journal that is scholarly written and peer-reviewed – Circulation. These both lend to the validity of the article and findings. Statistical data was gathered and evaluated appropriately. The authors make note that their data was able to provide confidence intervals that showed a degree of certainty showing significance between subpopulations; all lending to reliability.
This article-- although containing much useful information—is not one I will use in my community health promotion project. I may refer to their references, which have many data sites full of statistical information. This article gave me some new information, but not anything I would feel necessary to include in my project. The content was rather boring and uninteresting for me.

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