Plain English Summary
Background and study aims
Heart failure occurs when the heart is unable to pump blood around the body as well as it used to do. It often is caused due to heart attacks and usually requires hospitalisation. When patients with heart failure are discharged, they often have to go back to the hospital due to complications. Readmissions to the hospital represent a major cause of burden and cost to healthcare systems. One of the main type of patients who are readmitted are patients who are hospitalised with heart failure. The early transition period from discharge to first medical visit is crucial because of possible lack of follow-up. Research is needed to see how possible actions, effective and cost-effective, that would improve patient’s follow-up in the first weeks after discharge. The aim of this study is to evaluate the effectiveness of a transition plan after discharge is at reducing readmission rates.
Who can participate?
Adults aged 18 or older who are hospitalized with heart failure.
What does the study involve?
Participants are consecutively enrolled in the study while they are hospitalised with symptomatic heart failure and discharged at home. The study programme consists of a comprehensive discharge plan provided by a research nurse acting as transition coach with medical supervision and by a clinical pharmacist. The programme includes targeted therapeutic education, caregiver therapeutic education, medication reconciliation, setup of an appointment with the GP, notification of the GP, community nurses notification, patient-centered discharge information, follow-up call at the third, seventh and 18th day after discharge, optional consultation, and a hotline. The data collected is compared to medical records of patients hospitalized from 2009 to 2012.
What are the possible benefits and risks of participating?
Participants may benefit from receiving counselling, education, double check of their prescription, and follow-up after discharge, in addition of standard care. There is a risk of mismanagement of communication between patient, GP and hospital's physicians. This will be addressed with personal calls and, if requested, with help of IUMG physicians, acting as mediator. Due to alarming sign or symptoms, it is possible that a patient is counselling to visit his GP or emergency room but ending with no acute heart failure nor new diagnosis. We consider it to be more an inconvenient.
Where is the study run from?
Lausanne University Hospital (Switzerland)
When is the study starting and how long is it expected to run for?
January 2013 to December 2016
Who is funding the study?
Who is the main contact?
Dr Antoine Garnier
Effectiveness of a discharge plan to Lower EArly Readmission of patients hospitalized with Heart Failure: The LEAR-HF study
Multidisciplinary discharge plan, including a clinical pharmacist, a nurse (“transition coach") with medical supervision, before and after the patient’s discharge, reduces by 50 percent the number of days of hospitalization as readmission within 30 days, for patients with symptomatic heart failure hospitalized in internal medicine, compared with the data from 2009 to 2012.
The Vaud Cantonal Ethical Committee for Human Research, 24/09/2013, ref: protocol number 278/13
This is a prospective, single-centre, before-and-after study
Primary study design
Secondary study design
Non randomised study
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet.
Adult patients with symptomatic heart failure hospitalized in internal medicine discharged at home
This is a before and after study. The pre-intervention group consists of patients hospitalised from 2009 to 2012. Participants are consecutively enrolled in the study while they are hospitalised with symptomatic heart failure and discharged at home. The intervention consists of a comprehensive discharge plan provided by a research nurse acting as transition coach with medical supervision and by a clinical pharmacist. Once included in the study, participants receive a transition plan applied by a nurse, a clinical pharmacist and a physician. The plan includes the following steps:
Targeted therapeutic education: Based on existing material of the Swiss Heart Foundation for the patient, the nurse provides structured focused education on self-monitoring, instability sign and compliance.
Caregiver therapeutic education: The nurse gives the same education to the caregiver, if the patient had dementia or language issue.
Medication reconciliation at admission: The clinical pharmacist collects three sources of information to build the best available list of home medication, certified during an interview with the patient.
Medication reconciliation at discharge: The clinical pharmacist reviews and proposes improvement of the discharge prescription, based on the medication reconciliation on admission. The patient, the outpatient pharmacy and the general practitioner (GP) receive a commented medication plan.
Setup of an appointment with the GP: The nurse strongly encourages the patient to visit his GP within seven days after discharge, by helping him and reminding him during follow-up calls.
Notification of the GP: The nurses send a message including discharge date, diagnosis, and medication to the GP to improve his awareness.
Community nurses notification: If the participant benefits from the community nurses services, they are informed about the transition plan either in writing or by phone.
Patient-centered discharge information: Before discharge, participant awareness is challenged with three questions: "What is my diagnosis? What is my medication? When and where is my next appointment? "
Follow-up call: The nurse calls the patient at the third, seventh and 18th day after discharge, using structured interviews to identify instability signs, motivate the patient to self-monitoring, and, if needed, to call his GP. The calls where supervised by the senior physician.
Optional consultation: To overcome unavailability of a GP, the patient might ask for a follow-up visit at hospital, within the week after discharge.
Hotline: During office hours, the participant can call the nurse for any reason could call the nurse for any reason.
Patients are followed up by telephone calls at three, seven, 18 and 90th day after discharge to see if they have be re-admitted to the hospital with any complications.
The data collected is compared to medical records of patients hospitalized from 2009 to 2012.
Primary outcome measure
Fraction of days spent in hospital because of a readmission within 30 days, based on medical-administrative database of the hospital interrogated six months after end of study.
Secondary outcome measures
Potentially avoidable readmission rates, based on medical-administrative database of the hospital interrogated six months after end of study.
Overall trial start date
Overall trial end date
Reason abandoned (if study stopped)
Participant inclusion criteria
1. Adult patient (≥18 years)
2. Hospitalized in Internal Medicine Service at CHUV
3. Diagnostic of heart failure
4. NYHA class II or higher
Target number of participants
Participant exclusion criteria
1. Being transferred to other hospital or service, to rehabilitation centre or to retirement home
2. Being regularly under haemodialysis
3. Actively listed for heart transplantation
4. Failure to obtain signature of consent form
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
University Hospital of Lausanne
Rue du Bugnon 42
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Publication in a high-impact peer reviewed journal.
IPD sharing statement:
The datasets generated during and/or analysed during the current study is not expected to be made available due to presence of significant amount of information about hospital and patient outside the scientific question of the study.
Intention to publish date
Participant level data
Not expected to be available
Basic results (scientific)