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Failing at heart failure treatment

Readmission reduction efforts target most common DRG

From the August ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Stacey Butterfield

Your heart failure patients have probably become familiar by now. The six days that they spend on average during a hospitalization provides time to get to know them, and then a quarter of them will be back in the hospital within the month. Another quarter will show up at the hospital at least once in the next six months.

But in this case, familiarity breeds problems—financial ones for hospitals, and even more pressing ones for patients. Heart failure patients face a 12% mortality risk in the month after their first hospitalization, and that statistic goes up after every return to the hospital, according to research published in the American Heart Journal in 2007.

Illustration by Getty Images.

Illustration by Getty Images.



Meanwhile, their long stays outstrip the Centers for Medicare and Medicaid Services (CMS) diagnosis-related group (DRG) reimbursements that pay for most heart failure care. “The break-even point for most U.S. hospitals on this DRG is somewhere around 4.2 days, so on average, hospitals are losing money on what is their most common DRG,” said Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California, Los Angeles.

The situation has motivated everyone from Medicare to individual physicians to focus on methods of improvement. “I don't think anybody can look at these recent statistics and say more doesn't need to be done for this patient population,” said Dr. Fonarow during a session on preventing heart failure readmissions at the Society of Hospital Medicine's annual meeting in April.

Whether they're joining major quality improvement initiatives or just making changes to the care of individual patients, the involvement of hospitalists is critical to reducing readmissions and improving care for heart failure patients, according to Dr. Fonarow and other experts.

Consider the causes

The effort against readmissions starts when a patient is admitted to the hospital. “We want to initially assess the patient for the adequacy of systemic perfusion, estimate their volume status and then, very importantly, we want to look for precipitating factors and comorbid conditions,” said Dr. Fonarow. “How are we going to prevent the next hospitalization if we don't look into what precipitated this hospitalization and try and remove that?”

The majority of patients have one or more precipitating factors, with pneumonia, ischemia/acute coronary syndrome, arrhythmia and hypertension being among the most common.

Non-clinical precipitants are also common. “The vast majority of recurrent potentially avoidable rehospitalizations for patients with heart failure are caused by human factors—psycho-social, behavorial, education, engagement in self-management,” said Amy Boutwell, MD, a hospitalist and principal investigator of the STAAR initiative, an Institute for Healthcare Improvement (IHI) effort to reduce rehospitalizations.

After assessment, physicians should proceed rapidly to treating the patient, with the goal of alleviating symptoms and relieving congestion while not compromising organ function, Dr. Fonarow advised. Since most patients will be volume overloaded, the solution will usually be loop diuretics. “The concept is to administer those agents effectively and early, not have the patient sit for 6, 12, 24 hours before initiating this therapy because that needlessly prolongs the patient's remaining symptoms and prolongs hospitalization,” he said.

Other recommended medical therapies should also be used. “The guidelines are now very clear. In the absence of contraindications such as hypotension, for those heart failure patients who are admitted on an ACE [angiotensin-converting enzyme] inhibitor, ARB [angiotensin-receptor blocker] and beta-blocker therapy, therapy should be continued. We should not be withholding these medications just because the patient was hospitalized with worsened heart failure,” said Dr. Fonarow.

Once the patient is stabilized, it's time to start thinking about her intermediate and long-term management, including medications. This is an area where hospitalists need to assert themselves, according to the experts.

“You may say, ‘I don't want to step on anybody's toes. We'll let them get discharged and I'm confident that their outpatient physician is going to start them on treatment on the first follow-up visit,’“ said Dr. Fonarow. But research has shown that when heart failure patients leave the hospital without a recommended drug, beta-blockers for example, very few of them are put on it in the following months.

Inpatient physicians, therefore, need to prescribe needed medications. “Guideline-recommended heart failure medications, particularly ACE inhibitors, ARBs and beta-blockers, but other therapies as well if indicated, including aldosterone antagonists and the combination of hydralazine and nitrates, known to improve outcomes in those with chronic heart failure, should be initiated prior to hospital discharge,” said Dr. Fonarow.

The process is not always as easy as it sounds, noted Alison Mudge, FRACP, a physician of internal medicine and aged care at the Royal Brisbane and Women's Hospital in Australia. “Many heart failure patients are elderly and have comorbid conditions, and may have difficulty tolerating therapies due to side effects, particularly hypotension and accompanying worsening renal function,” she said.

Think about the outside

Dr. Mudge and colleagues piloted a heart failure quality improvement program (published in the March Journal of Hospital Medicine) only to find that it increased readmission rates while showing a trend toward improved mortality. Since then, she's concluded that a successful intervention requires working with the outpatient system on many fronts, including medication management. “Slow medication titration in the post-hospital phase can often address [tolerance problems], but requires a coordinated approach between hospital and community providers,” she said.

Her experience led to a similar conclusion about patient education, which many experts consider another critical component of heart failure treatment. “We found that education in-hospital was poorly retained, in keeping with recent findings that transient cognitive impairment is common in these patients,” said Dr. Mudge.

The Brisbane program moved more of its education to the outpatient setting, but another solution is to write things down. “It is critically important that patients receive comprehensive written instruction regarding the nature of the hospitalization and what follow-up care is necessary. These patients should get a copy, their caregivers should get a copy, and there needs to be communication about post-discharge care plans to all of the caregivers that will be involved,” said Dr. Fonarow.

A major component of that plan will cover the complex medication regimens that heart failure patients are typically on. “That means reconciling medications, evaluating medication lists very carefully to make sure that patients are not on drugs that a) are not indicated or b) might result in perilous drug-drug interactions or c) are unaffordable,” said Frederick A. Masoudi, FACP, associate professor of cardiology at Denver Health Medical Center and the University of Colorado.

The plan should also include clear instructions on what to do if the patient's condition worsens after discharge, an issue about which patients and families are often uncertain, said Harlan Krumholz, MD, professor of cardiology and public health at Yale University. “If they didn't even have a regular doctor, they didn't have a cardiologist or they weren't seen by the person they see as an outpatient, they're confused: Do I go to the emergency room? Should I wait it out? Is this normal? Who do I talk to?”

Follow-up is critical

Of course, patients are less likely to run into that problem if they have a follow-up appointment soon after they leave the hospital. The advice that patients should have an outpatient appointment scheduled before discharge is well established, but just setting up the follow-up is not sufficient, according to a study published in the May 5 Journal of the American Medical Association.

Almost all of the 30,000 studied patients had an appointment scheduled, but fewer than 40% of them were actually seen within a week of discharge. “The checked box [of an appointment scheduled] isn't enough. What we find is that hospitals that have their patients follow up earlier tend to have lower readmission rates,” said Adrian F. Hernandez, MD, lead author of the study and a cardiologist at Duke University.

One potential solution is to do the follow-up yourself. “You can imagine hospitalists taking the greater responsibility and deciding as a group to provide early physician follow-up care for heart failure patients themselves, if it is otherwise not able to take place within the first seven days post-discharge, or have colleagues who will be available to provide early follow-up,” said Dr. Fonarow.

The Australian program found another answer: instituting a multidisciplinary team that, among other tasks, addresses any issues that might prevent patients from getting follow-up, such as frailty or transportation difficulties. “Hospital physicians are vital drivers of this process, and our experience is that inpatient physicians can provide leadership and governance of such a service without taking over medical follow-up of every patient,” said Dr. Mudge.

“The most important feature of early follow-up is that it happens,” not which provider it's done by, said Dr. Boutwell. “Getting all discharged patients in to see a physician within three to five days [can be] very daunting.”

Optimal care for heart failure patients really necessitates a team approach, the experts agreed. “It shouldn't be that there's an expectation that this is on the shoulders of hospitalists. The hospitalists should ensure that the hospital is attending to it as a team, and the hospitalist has an important role in it, but the transitions from inpatient to outpatient status occur through teamwork,” said Dr. Krumholz.

His concept of the team includes not only the nurses, doctors, social workers and pharmacists in the hospital, but also the receiving physicians and other providers on the outside. “Too often there's a sense on one side [that] we just have to get this patient out the door and on the other side; it's like we're catching the patient, but we'll find out what we need to know when the patient gets here,” Dr. Krumholz said. Fixing that dynamic requires more in-depth, timely communication than a notification phone call or a discharge summary (which frequently arrives too late), he added.

“The future will see inpatient and outpatient settings working in a much more interactive mode than we currently do,” predicted Dr. Boutwell. “We know it is possible, because improved inpatient and outpatient communication and care coordination, including titrating medications in complex patients and intensively monitoring in the outpatient setting, have been demonstrated in best practice examples around the country.”

Not ready to go

The rush to send heart failure patients out the door causes problems in itself, the experts said. “We'll often see many patients at the time of hospital discharge still have persistent symptoms and signs of volume overload. Exacerbating factors and potential targets for therapy are not fully evaluated or managed,” said Dr. Fonarow.

He offered a list of the criteria that should be met before a patient is discharged: He or she should be at close to optimal volume, should be taking and being monitored on oral drugs and should have guideline-recommended therapy initiated.

“In patients with recurrent admissions or who are at high risk, the recommendations go further,” said Dr. Fonarow. Those patients should have been on a stable oral regimen and off IV therapy for at least 24 hours; they should have ambulated; and there should be plans for comprehensive post-discharge care, possibly including a heart failure disease management program.

Dr. Krumholz suggested a number of questions for hospitalists to ask themselves before sending a patient out. “Have there been efforts to understand any particular issues which might be obstacles for them, like are they markedly depressed or do they have a smoldering urinary tract infection? Is there any other issue that puts them at particularly high risk of something flaring up?”

Some of his questions should actually be addressed to the patient, he noted. “In addition to knowing their medications and having an appointment and being able to go, are they weighing themselves? Do they understand the relationship between their diet and their heart failure?”

There are a lot of questions to remember. That's why the American Heart Association's Get With The Guidelines program offers a Web-based tool that allows participating physicians to compare the care of an individual heart failure patient with all the relevant guidelines. “The use of these standardized forms, templates and checklists translates into better quality of care, translates into better outcomes,” said Dr. Fonarow, who is a member of the program's steering committee.

In the ADHERE study, hospitals that followed the program showed dramatic improvements in care. “If it had happened nationwide, there would have been 880,000 fewer hospital days for heart failure, 21,000 fewer patients on ventilation, 14,000 fewer in-hospital deaths,” Dr. Fonarow said.

The Hospital to Home (H2H) program, sponsored by the American College of Cardiology and the IHI, is also aiming for some big drops in the statistics on heart failure, specifically a 20% reduction in 30-day readmissions for all patients discharged with cardiovascular conditions. “It's a very specific goal. It's built on a previously successful program, the Door-to-Balloon (D2B) [Alliance],” said Dr. Masoudi, who is a member of the H2H steering committee. Both programs already have more than 600 hospitals enrolled and invite more hospitals and hospitalists to get involved.

Improvement, not perfection

Reducing heart failure readmissions may prove to be a more challenging project than the D2B program, Dr. Masoudi acknowledged, because there's less clear evidence on what needs to be done and what level of readmissions is achievable and acceptable.

“It is important that readmission is not seen as a failure of the service or of the patient. This is a complex patient group and it is not unreasonable to expect that some of their care will need to be provided in the inpatient setting,” said Dr. Mudge.

Still, it's clear that the current statistics can be improved, according to Dr. Masoudi. “The reason to believe that is if you look at risk-adjusted readmission rates across the country, which are now being publicly reported by CMS, there's substantial variation even after you account for differences in patient characteristics,” he explained.

Dr. Fonarow confirmed the point, citing studies of medication use. “There are some hospitals that have 100% of eligible patients treated day in and day out and other hospitals where the patient had a better chance of winning the lottery than getting guideline-recommended, evidence-based therapy,” he said.

Rather than waiting on the right number to hit, heart failure experts wants hospitalists to take action. “It's my message to hospitalists: Get involved, be part of the change, and take advantage of your training and perspective to make a difference in these readmission rates,” said Dr. Krumholz.

Hospitalists are already on the mission, according to Dr. Boutwell. “The challenge of heart failure readmissions is but an illustration of the patient population we care for every day—complex hospitalized patients, many with poor self-management skills, many with poor social supports, many with poorly coordinated care in the outpatient setting,” she said. “It is our perspective as generalists and as managers of a wide variety of illnesses that will help hospitals improve the transitions in care for all patients, thereby reducing avoidable rehospitalizations.”

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