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Effects of a transitional palliative care model on patients with end-stage heart failure: a randomised controlled trial
  1. Frances Kam Yuet Wong1,
  2. Alina Yee Man Ng1,
  3. Paul Hong Lee1,
  4. Po-tin Lam2,
  5. Jeffrey Sheung Ching Ng3,
  6. Nancy Hiu Yim Ng2,
  7. Michael Mau Kwong Sham4
  1. 1School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
  2. 2Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong, China
  3. 3Department of Medicine, Haven of Hope Hospital, Hong Kong, China
  4. 4Palliative Medical Unit, Grantham Hospital, Hong Kong, China
  1. Correspondence to Professor Frances Kam Yuet Wong, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China; frances.wong{at}


Objective To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge.

Methods This was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using χ2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS).

Results The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% χ2=6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires.

Conclusions This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF.

Trial registration number HKCTR-1562; Results.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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