Reducing Readmission Rates in Heart Failure Patients Aged 60 and Older Through Education and Follow-Up Calls.

A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure

Review question/objective: The objective is to identify the best available evidence on effectiveness of nurse coordinated transitioning of care between hospital and home on all hospital readmission rates in hospitalized adult patients with heart failure. Inclusion criteria: Types of participants: This review will consider studies that include adult patients, 18 years of age or older, hospitalised with heart failure being discharged to home. Types of intervention(s)/phenomena of interest: This review will consider studies that evaluate all models of nurse coordinated transitioning of care from hospital to home, limited to inpatient care coupled with post-discharge home-based and/or telephone education and support by a nurse. Types of outcomes: This review will consider studies that include the following outcome measures: all hospital readmission rates with a focus on 30 day readmissions.

Reduction of 30-day all-cause readmissions for heart failure (HF) has become an important quality-of-care metric for health care systems. Many hospitals have implemented quality improvement programs designed to reduce 30-day all-cause readmissions for HF. Electronic medical record (EMR)-based measures have been employed to aid in these efforts, but their use has been largely adjunctive to, rather than integrated with, the overall effort. We hypothesized that a comprehensive EMR-based approach utilizing an HF dashboard in addition to an established HF readmission reduction program would further reduce 30-day all-cause index hospital readmission rates for HF. After establishing a quality improvement program to reduce 30-day HF readmission rates, we instituted EMR-based measures designed to improve cohort identification, intervention tracking, and readmission analysis, the latter 2 supported by an electronic HF dashboard. Our primary outcome measure was the 30-day index hospital readmission rate for HF, with secondary measures including the accuracy of identification of patients with HF and the percentage of patients receiving interventions designed to reduce all-cause readmissions for HF. The HF dashboard facilitated improved penetration of our interventions and reduced readmission rates by allowing the clinical team to easily identify cohorts with high readmission rates and/or low intervention rates. We significantly reduced 30-day index hospital all-cause HF readmission rates from 18.2% at baseline to 14% after implementation of our quality improvement program ( P = .045). Implementation of our EMR-based approach further significantly reduced 30-day index hospital readmission rates for HF to 10.1% ( P for trend = .0001). Daily time to screen patients decreased from 1 hour to 15 minutes, accuracy of cohort identification improved from 83% to 94.6% ( P = .0001), and the percentage of patients receiving our interventions, such as patient education, also improved significantly from 22% to 100% over time ( P < .0001). In an institution with a quality improvement program already in place to reduce 30-day readmission rates for HF, an EMR-based approach further significantly reduced 30-day index hospital readmission rates.

Background: Current research and guidelines vary greatly on the ideal time for initial post-discharge follow-up for acute coronary syndrome (ACS) and congestive heart failure (CHF). BRIDGE is a nurse practitioner-delivered cardiac transitional care program for patients lacking primary care or cardiology follow-up at discharge. BRIDGE referrals are seen within 14 days of discharge. This study aimed to determine the ideal timeframe for initial post-discharge follow-up. Methods: Retrospective data from the BRIDGE registry were abstracted for ACS and CHF patients referred to BRIDGE and readmitted within 30 days. Patients were divided into 4 cohorts based on the number of days to readmission: Time (T)1=0-3 days, T2=4-7 days, T3=8-14 days, and T4=15-30 days. Readmissions were further classified as the same cardiac reason as index admission, “Different Cardiac” or “Non-Cardiac.” ACS and CHF readmissions were compared by time to readmission and reason for readmission . Results: Of 2367 patients (mean age 64.9, 58% male and 85.3% white), 733 patients had an admission for ACS and 548 for CHF. Regardless of BRIDGE attendance, 16.8% (n=123) of ACS patients and 25.4% (n= 139) of CHF patients and were readmitted within 30 days. The majority of readmissions within 30 days (ACS 62.6%, CHF 53.2%) were on or before the 14th day post-discharge. Nearly half of T1 readmissions (ACS=47.6%, CHF=55.6%) were for Non-Cardiac reasons. For all other timeframes, ACS patients had more readmissions for Different Cardiac reasons, and CHF patients more often were readmitted for CHF. In contrast to 30 day readmission rates for the entire population (16.8% and 25.4%), the 30-day readmission rate for ACS and CHF patients who attended their BRIDGE appointment was 6.4% and 15.4% respectively . Conclusions: For both CHF and ACS patients, greater than 50% of readmissions occurred before 14 days, with the majority of cardiac-related reasons occurring after the 3rd day post-discharge. Based on BRIDGE readmission rates, follow-up at 14 days substantially reduces 30-day readmissions in both ACS and CHF patients. However, seeing patients earlier or additionally during the 4-7 day period may further reduce 30-day readmissions.

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

Reducing Heart Failure Readmissions: A Clinical Business Analytics Approach

An introduction: (comprising context and problem statement) Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of heart muscles which results in fluid builds up around the heart and causes it to pump inefficiently. Patients who develop decompensated CHF need to attend daily clinics in the hospital and are frequently admitted to hospital for periods of at least 2 days. Short description of practice change implemented: In consultation with nurse specialists, consultant cardiologist and the Community Intervention Team (CIT) a care pathway is developed for the patient’s treatment in the community, supported by electronic health records. Sample case study to highlight practice change: Patient prescribed intravenous (IV) frusemide in Outpatients. Referral and prescription electronically sent to CIT. IV medication is administered in patients’ home 2 days a week. Only 1 visit per week is now required to the CHF clinic. Patient is monitored and educated on the efficiency of the medication. Patient and family / carers are educated in what to look for in case of worsening symptoms. There is frequent feedback from the CIT to the hospital on the patient’s condition. Achieving the objectives: Safe management of CHF patients in the community: Symptoms that previously required admission to the acute setting are observed earlier in the home and acted upon thus reducing the opportunity for problems to build up. Consequent reduction in admissions to acute settings: Quality of patients’ life improved significantly, measured by the reduction of IV treatment, massive reduction of oedema and related discomfort; independence gained in activities of daily living (ADL’s). Aim and theory of change: The close IT-enabled communication between hospital and community ensures that all clinicians involved with the patients’ treatment are aware of changes in condition and treatment. This holistic approach avoids admission to hospital. Targeted population and stakeholders: CHF patient population deemed suitable for management in the community as identified by cardiologist and CHF nurse. Stakeholders: Primary: community intervention team (CIT), GP, public health etc. Secondary: Cardiac Failure Nurse specialists, outpatient departments, consultants etc. Highlights: (innovation, Impact and outcomes) The integrated care approach for a CHF patient is the first of its kind in this community, with high patient and clinician satisfaction. CHF patients are often referred to as palliative as their medical condition is irreversible. However quality of life and longevity can be achieved on this programme through the close monitoring of the patient at home, compatibility with other medication, reduced chance of the patient acquiring hospital infection superimposing on top of their CHF condition thus weakening overall health This intervention is both sustainable and transferable to other CHF patients throughout the country. Discussion and conclusion: Problems arising from CHF are multi-faceted as they vary from shortness of breath, reduced mobility, to fatigue etc. Managing this complexity in the community requires excellent integrated care between primary and secondary providers. Lessons Learned: Communication between primary and secondary healthcare professionals is essential to keeping patients in the community.

Reducing Readmissions for Heart Failure.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

TUG1 is an lncRNA that plays a critical role in kidney injury. Our preliminary sequencing analysis showed altered TUG1 expression in both congestive heart failure (CHF) patients and CHF patients complicated with chronic kidney disease (CKD). We then studied the role of TUG1 in these two diseases. We enrolled 120 CHF patients without obvious complications, 60 CHF patients complicated with CKD, and 60 healthy volunteers. TUG1 expression in plasma samples from these participants was determined using RT-qPCR. The diagnostic value of TUG1 for CKD development in CHF patients was evaluated by ROC curve analysis. A 2-year follow-up was performed to detect the correlation between TUG1 expression levels and the development of CKD in CHF. TUG1 was lowly expressed in CHF patients and was further downregulated in CHF patients complicated with progressive CKD. ROC curve analysis showed that plasma TUG1 expression levels could be used to distinguish CHF patients complicated with CKD from CHF patients without CKD and healthy controls. During the 2-year follow-up, high CHF expression levels predicted a low incidence of progressive CKD among CHF patients. With the treatment of progressive CHF + CKD, plasma TUG1 was upregulated. LncRNA-TUG1 downregulation may develop the progressive CKD among patients with CHF.

It is known that baroreflex sensitivity (BRS) is impaired in cardiac patients with myocardial infarction (MI). Nevertheless, it is unknown whether factors other than a reduced ejection fraction play a role in the baroreflex impairment of these patients. Heart failure patients [congestive heart failure (CHF), n = 31, age 63 +/- 1.2 years, mean +/- SEM)], age-matched controls (n = 29) and coronary artery disease (CAD) patients without MI (n = 29) had RR interval and arterial blood pressure (BP) continuously monitored. Baroreflex function was assessed by the slope of the regression of RR interval, and BP responses to graded (-10, -20 and -40 mmHg) neck suction stimulation, the slope of bradycardic or tachycardic responses to spontaneous increases or reductions of SBP (sequence analysis) and the baroreflex efficiency index. Pulse wave velocity (PWV) was also measured.Compared with controls, CHF patients had RR interval and BP reflex responses to neck suction reduced by -36 and -54%, respectively (P < 0.01). By contrast, no differences were found between CHF and CAD patients. Similar reductions were observed for the sequence analysis (P < 0.01) in both CHF and CAD patients. Multiple regression analysis showed that in CHF and CAD patients, PWV and SBP and not ejection fraction were correlated with BRS. The baroreflex function is impaired in CHF patients, the extent and the degree of baroreflex impairment being similar to that of CAD patients without MI. In CHF and CAD patients, the baroreflex impairment correlates significantly with the increased PWV and not with ejection fraction.

AimsLong-acting natriuretic peptide (LANP) is one of the peptide hormones in atrial natriuretic peptide (ANP) pro-hormone. Low levels of natriuretic peptide may lead to reduced lipolysis and excessive weight gain in obese patients. The aim of this study was to investigate the relationship between fasting serum LANP level and the metabolic syndrome (MetS) among congestive heart failure (CHF) patients.MethodsFasting blood samples were obtained from 186 patients with normal renal function in cardiac clinic outpatients. CHF defined by the American College of Cardiology Foundation and the American Heart Association 2005 Guidelines. MetS and its components were defined using diagnostic criteria from the International Diabetes Federation.ResultsNinety-eight patients (52.7%) had CHF. There was a tendency of increased fasting LANP levels as the NYHA CHF functional classes increased (p = 0.002). Forty-six of the CHF patients (46.9%) had MetS. Fasting LANP level negatively correlated with MetS among CHF patients (p < 0.001). Univariate linear regression analysis showed that BUN (p = 0.026) positively correlated with fasting serum LANP levels, while body weight (p = 0.009), BMI (p = 0.004), homeostasis model assessment of insulin resistance (HOMA-IR; p = 0.024) and HOMA-β (p = 0.001) negatively correlated with fasting serum LANP levels among the CHF patients. Multivariate forward stepwise linear regression analysis of the significant variables showed that the HOMA-β (R2 change = 0.292, p < 0.001) and HOMA-IR (R2 change = 0.081, p = 0.019) were independent predictors of fasting serum LANP levels in CHF patients.ConclusionsLANP level is significantly reduced in CHF patients affected by MetS. HOMA-β and HOMA-IR were independent predictors of serum LANP levels in CHF patients.

Reducing preventable hospitalization for congestive heart failure (CHF) patients is a challenge for health systems worldwide. CHF patients who also have a recent or ongoing mental disorder may have worse health outcomes compared with CHF patients with no mental disorders. This study examined the impact of mental disorders on 28day unplanned readmissions of CHF patients. This retrospective cohort study used population-level linked public and private hospitalization and death data of adults aged ≥18years who had a CHF admission in New South Wales, Australia, between 1 January 2014 and 31 December 2020. Individuals' mental disorder diagnosis and Charlson comorbidity and hospital frailty index scores were derived from admission records. Competing risk and cause-specific risk analyses were conducted to examine the impact of having a mental disorder diagnosis on all-cause hospital readmission. Of the 65861 adults with index CHF admission discharged alive (mean age: 78.6±12.1; 48% female), 19.2% (12675) had at least one unplanned readmission within 28days following discharge. Adults with CHF with a mental disorder diagnosis within 12months had a higher risk of 28day all-cause unplanned readmission [hazard ratio (HR): 1.21, 95% confidence interval (CI): 1.15-1.27, P-value<0.001], particularly those with anxiety disorder (HR: 1.49, 95% CI: 1.35-1.65, P-value<0.001). CHF patients aged ≥85years (HR: 1.19, 95% CI: 1.11-1.28), having ≥3 other comorbidities (HR: 1.35, 95% CI: 1.25-1.46), and having an intermediate (HR: 1.34, 95% CI: 1.28-1.40) or high (HR: 1.37, 95% CI: 1.27-1.47) frailty score on admission had a higher risk of unplanned readmission. CHF patients with a mental disorder who have ≥3 other comorbidities and an intermediate frailty score had the highest probability of unplanned readmission (29.84%, 95% CI: 24.68-35.73%) after considering other patient-level factors and competing events. CHF patients who had a mental disorder diagnosis in the past 12months are more likely to be readmitted compared with those without a mental disorder diagnosis. CHF patients with frailty and a mental disorder have the highest probability of readmission. Addressing mental health care services in CHF patient's discharge plan could potentially assist reduce unplanned readmissions.

Background Congestive heart failure (CHF) is a leading cause of hospitalizations and readmissions, placing a significant burden on the healthcare system. Identifying factors associated with readmission risk is crucial for developing targeted interventions and improving patient outcomes. This study aimed to investigate the impact of socioeconomic and demographic factors on 30-day and 90-day readmission rates in patients primarily admitted for CHF. Methods The study was carried out using a cross-sectional study design, and the data were obtained from the Nationwide Readmissions Database (NRD) from 2016 to 2020. Adult patients with a primary diagnosis of CHF were included. The primary outcomes were 30-day and 90-day all-cause readmission rates. Multivariable logistic regression was used to identify factors independently associated with readmissions, including race, ethnicity, insurance status, income level, and living arrangements. Results A total of 219,904 patients with a primary diagnosis of CHF were used in the study. The overall 30-day and 90-day readmission rates were 17.3% and 23.1%, respectively. In multivariable analysis, factors independently associated with higher 30-day readmission risk included Hispanic ethnicity (OR 1.18, 95% CI 1.03-1.35), African American race (OR 1.15, 95% CI 1.04-1.28), Medicare insurance (OR 1.24, 95% CI 1.12-1.38), and urban residence (OR 1.11, 95% CI 1.02-1.21). Higher income was associated with lower readmission risk (OR 0.87, 95% CI 0.79-0.96 for highest vs. lowest quartile). Similar patterns were observed for 90-day readmissions. Conclusion Socioeconomic and demographic factors, including race, ethnicity, insurance status, income level, and living arrangements, significantly impact 30-day and 90-day readmission rates in patients with CHF. These findings highlight the need for targeted interventions and policies that address social determinants of health and promote health equity in the management of CHF. Future research should focus on developing and evaluating culturally sensitive, community-based strategies to reduce readmissions and improve outcomes for high-risk CHF patients.

Background: Obesity is a well-established risk factor for the development of congestive heart failure (CHF), yet its impact on hospital readmission rates remains unclear. Some studies suggest an “obesity paradox,” where higher body mass index (BMI) may be associated with better short-term outcomes in CHF patients. However, this phenomenon has not been thoroughly explored in underserved populations, where both obesity and CHF are highly prevalent. Research Question: Does BMI category influence 30-day readmission rates in CHF patients at a community safety-net hospital? Methods: We conducted a retrospective chart review of 385 CHF patients (mean age 65±13.8 years; 57.4% male; 74.8% Black/ 2.6% White/ 13.8% Hispanic individuals) admitted to NYC Health + Hospitals/Harlem between February 2019 and December 2020. Patients were categorized by BMI per WHO guidelines. The primary outcome was readmission within 30 days of discharge. Associations between BMI categories and 30-day readmissions were assessed through chi-square tests, Cochran-Armitage trend tests, and nested logistic regression models adjusting for demographic and clinical covariates. Results: Among these patients with CHF, 30.6% (n = 118) had a healthy weight (BMI &lt; 25 kg/m 2 ), 24.7% (n = 95) were overweight, and 44.7% (n = 172) were classified as obese. Each stepwise increase in BMI category was associated with lower likelihood of 30-day readmission (trend test: p = 0.0006). Compared to those with Class III obesity, healthy weight patients had a higher risk of readmission (OR 4.5 [95% CI: 1.5–13.4]; p = 0.001), even after controlling for age, sex, race, and ejection fraction (adjusted OR 4.4 [1.4–14.0]; p = 0.03). When BMI was modeled as a continuous variable, each 5 kg/m 2 increase was associated with a 28% reduction in readmission risk (OR 0.72 [95% CI: 0.59–0.89]; p = 0.0017). Conclusions: This study replicates the “obesity paradox” observed in predominantly White cohorts, demonstrating that higher BMI is similarly associated with lower 30-day readmission rates among CHF patients in a racially and socioeconomically diverse community safety-net hospital. These findings highlight the importance of validating clinical observations across varied demographic groups. Further research is needed to understand the mechanisms underlying this paradox and to inform tailored weight management strategies in CHF care.