Mobile Integrated Health vs a Transitions of Care Coordinator for Patients Discharged After Heart Failure

作者：Ruth Masterson Creber, Brock Daniels, Meghan Reading Turchioe, Leah Shafran Topaz, Yihong Zhao, Jacky Choi, Melani Ellison, Roland C. Merchant, Erik Blutinger, Parag Goyal, Jiani Yu, Mark G. Weiner, Evan Sholle, Kumudha Ramasubbu, Shudhanshu Alishetti, Kelly Axsom, David J. Slotwiner, Maya K. Rao, Iván Díaz, John A. Spertus, Rahul Sharma, Rainu Kaushal · 发表于：JAMA Internal Medicine · 年份：2025 · DOI：10.1001/jamainternmed.2025.4483 · 被引用次数：3 · 研究领域：Heart Failure Treatment and Management、Mechanical Circulatory Support Devices、Chronic Disease Management Strategies

Importance: The comparative effectiveness of 2 transitions of care programs for improving health status and reducing readmissions among patients hospitalized with heart failure is unknown. Objective: To compare the effectiveness adding mobile integrated health (MIH) to a transitions of care coordinator for improving health status and reducing 30-day all-cause readmissions among patients discharged after heart failure. Design, Settings, and Participants: The Mighty-Heart randomized clinical trial included Medicare- or Medicaid-enrolled adult (≥18 years) patients hospitalized with heart failure in 11 New York City (New York) hospitals between January 2021 and September 2024. Participants were randomized 1:1 to MIH or TOCC. TOCC provided a follow-up call by a nurse 48 to 72 hours after discharge. MIH included the same TOCC postdischarge call, and added ongoing nurse care coordination, community paramedic home visits, and facilitated synchronous telehealth with emergency medicine physicians. Data analysis occurred between September 2024 and June 2025. Interventions: Receiving MIH plus TOCC or TOCC alone during the first 30 days after hospital discharge. Main Outcomes and Measures: Coprimary outcomes were health status at 30 days measured with the Kansas City Cardiomyopathy Questionnaire Overall Summary score, and 30-day all-cause hospital readmission, with heart failure-specific readmissions as a secondary outcome. Results: Among 2003 participants (median [IQR] age, 67 [58-78] ye...