Related Experiment Video
Updated: May 2, 2026
A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions
Michael H Hall1, Rick A Esposito1, Renee Pekmezaris2
1Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Manhasset, New York; Hofstra North Shore-LIJ School of Medicine, Hempstead, New York.
Insights
A transitional care program significantly reduced 30-day readmission and death rates for coronary artery bypass graft (CABG) patients. This program improved post-discharge care continuity, highlighting the value of nurse practitioner involvement in cardiac surgery recovery.
Area of Science:
- Cardiovascular Surgery
- Transitional Care Medicine
- Nursing Practice
Background:
- Coronary artery bypass graft (CABG) surgery necessitates effective post-discharge care to prevent adverse outcomes.
- Continuity of care and medication management are critical for recovery after CABG operations.
- Existing care models may not adequately address the complexities of patient transition from hospital to home.
Purpose of the Study:
- To evaluate an innovative transitional care program involving cardiac surgery nurse practitioners.
- To assess the program's impact on improving care continuity after CABG surgery.
- To determine the program's effect on reducing the composite endpoint of 30-day readmission and death.
Main Methods:
- A cohort of 401 coronary artery bypass graft (CABG) patients was analyzed.
- The "Follow Your Heart" transitional care program enrolled 169 patients; 232 received usual care.
- Propensity score matching with 13 covariates was used to compare outcomes between groups.
Main Results:
- The "Follow Your Heart" program was the only significant variable in preventing the composite outcome (p=0.015).
- The intervention group had a significantly lower 30-day readmission/death rate (3.85%) compared to the usual care group (11.54%, p=0.023).
- Predictors for readmission included dialysis, Medicaid status, female sex, non-Caucasian ethnicity, COPD, diabetes, and congestive heart failure.
Conclusions:
- A home transition program managed by nurse practitioners significantly reduced 30-day readmission/death after CABG.
- Continuity of care, communication, and medication management are key components of the successful program.
- Targeted resource allocation based on readmission risk factors can further enhance outcomes and may be applicable to other patient populations.
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.
Related Concept Videos
01:23Peripheral Artery Disease V: Postoperative Nursing Management
01:28Cardiomyopathy VII: Pre and Post Operative Nursing Management
01:27Coronary Artery Disease V: Interprofessional Care
01:26Cardiac Catheterization IV: Nursing Management
01:22Aneurysm IV: Nursing Management
01:17Aortic Regurgitation IV: Nursing Management