Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions

Ann Thorac Surg. 2014 May;97(5):1488-93; discussion 1493-5. doi: 10.1016/j.athoracsur.2013.12.049. Epub 2014 Mar 6.


Background: We designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death.

Methods: A total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The "Follow Your Heart" program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates.

Results: Binary logistic regression analysis identified "Follow Your Heart" as the only independently significant variable in preventing the composite outcome (p=0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group (p=0.023).

Conclusions: A home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Aged
  • Analysis of Variance
  • Cardiovascular Nursing / methods*
  • Cohort Studies
  • Continuity of Patient Care
  • Coronary Artery Bypass / methods*
  • Coronary Artery Bypass / mortality
  • Coronary Artery Bypass / nursing
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / mortality
  • Coronary Artery Disease / surgery*
  • Female
  • Follow-Up Studies
  • Graft Rejection
  • Graft Survival
  • Home Care Services / organization & administration
  • House Calls / statistics & numerical data*
  • Humans
  • Kaplan-Meier Estimate
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Nurse Practitioners
  • Odds Ratio
  • Patient Discharge / statistics & numerical data*
  • Patient Readmission / statistics & numerical data*
  • Radiography
  • Reference Values
  • Retrospective Studies
  • Survival Analysis
  • Treatment Outcome