30-day Heart Failure Readmission Research Articles

Impact of Pharmacy Student and Resident-Led Discharge Counseling on Heart Failure Patients

Purpose: Many health systems have implemented interventions to reduce the rate of heart failure readmissions. Pharmacists have the training and expertise to provide effective medication-related education. However, few studies have examined the impact of discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations. Methods: This was a nonrandomized intervention study evaluating the impact of a pharmacy student and resident-led discharge counseling program on heart failure readmissions. The primary end point was the 30-day heart failure readmission rate. Secondary end points included self-reported patient understanding of medications, number of medication errors documented, and estimated associated cost avoidance. Results: A total of 86 and 94 patients were enrolled into the intervention and control groups, respectively. No statistically significant difference in readmission rates was detected between the intervention and the control groups. Thirty-four medication errors and discrepancies were documented, or 1 for every 2.5 patients counseled, resulting in an estimated cost avoidance of $4241 for the institution. Eighty-nine percent of patients who received discharge counseling agreed they had a better understanding of their medications after speaking with a pharmacy resident or student. Conclusions: There was no statistically significant difference in readmission rates; however, several medication errors were prevented, and a large percentage of patients expressed an improved understanding of their medications.

Abstract 292: Predictors Of Heart Failure Readmission Rates, A Stanford Experience.

Introduction: The prevalence of heart failure (HF) is approximately 5.8 million, one in every five Medicare patients with HF are readmitted within 30 days. Heart failure readmissions cost 17.4 billion dollars annually. A major focus of health policy reform has been to contain costs by preventing readmission. Medicare has proposed criteria for HF reimbursement among which are readmissions within a 30-day period after the index hospitalization will not be reimbursed. The Medicare core measure aggregate has been sparsely validated in the literature and such validation of the core measures is essential. The aim of our study was to evaluate the predictive value of the Medicare core measure aggregate and if this aggregate is an effective proposed benchmark in reduction of HF readmission. Methods: A database was developed using RedCap (Research Electronic Data Capture), to study all patients admitted to Stanford Hospital and Clinics from September 2011 through January 2012. Inclusion criteria included those with a primary or secondary diagnosis of heart failure. Cardiac variables of interest beyond the core measures included among others, demographics, length of stay, and past medical history. Aggregate data from the Redcap database was analyzed by standard methods. Results: 101 patients were indexed during the retrospective cohort analysis. 100 were discharged alive. The overall 30-day readmission rate was 14%. There was no difference in readmission rates between patients who had core measures completed versus those who did not (13.8% vs. 14.3%; p= 0.944). In univariate Chi-square analyses, a phone call to the patient by a nurse within 24-48 hours post discharge was associated with significant reduction in rehospitalization rates (7.1% vs. 22.7%; p=0.026). Patients who were readmitted were found to have significantly more prior hospital admissions (3.0 +/- 2 vs. 1.7 +/- 2; p = 0.011) and prior ED visits (1.6 +/- 2 vs. 3.1 +/- 2; p=0.008). In multivariate logistic regression analysis, the phone call was associated with a 75% reduction in readmission (adjusted odds ratio = 0.254, 95% CI 0.066-0.981; p= 0.047). The predictor variable, systolic dysfunction (EF < 55%) approached significance, with an adjusted odds ratio of 6.962, 95% CI 0.979-49.5; p 0.052. Conclusions: High readmission rates for HF are present despite advances in its management. The achievement of Medicare core measure variables was not associated with a reduction in 30-day HF readmission. The reasons for this finding are still unclear, perhaps hospitalizations are in need to meet Medicare core measure guidelines rather then tailor the discharge care of each patient. It is unexpected and noteworthy that a phone call made by a nurse to the patient post discharge was associated with a 75% reduction in 30-day readmission rates. Predictors of HF readmission remain complex and an ideal aggregate for predictors in readmission have yet to be defined.

Abstract 181: Relationship Between 30-Day Readmission and 30-Day Mortality for Heart Failure and Acute Myocardial Infarction.

Background: Mortality and readmission at 30 days following admission for heart failure (HF) and acute myocardial infarction (AMI) are publically reported. It is unclear if these are influenced by similar (correlated) or different care processes (not correlated). Methods: We used publically available data from Hospital Compare of the Center for Medicare and Medicaid Services that includes hospital specific 30-day mortality and 30-day all-cause readmission rates adjusted for patient characteristics for US hospitals from 2010-2011. In multivariate analyses of 30-day outcome we included hospital level rates of the HF and AMI rates of process of care reported on Hospital Compare, hospital type (critical access vs. other) and used backward selection to determine those characteristics associated with outcome (p<0.05). All analyses were weighted for the number of discharges per facility. Results: There was a slight negative correlation (r= -0.17, p< 0.0001) for HF (hospitals with lower mortality had more readmissions, N=3990) and no correlation (r= 0.01, p=0.52) for AMI (N=2434, Figure). 30-day mortality for HF was correlated with 30-day mortality for AMI (r=0.37, p<0.0001), and a stronger correlation (r=0.50, p<0.0001) was observed for readmission (HF vs. AMI). In multivariate analysis, hospitals with a higher HF readmission rate were more likely to have a lower HF mortality rate, be a non-critical access hospital, have more documentation of discharge instructions and less documentation of ejection fraction. A higher HF mortality rate was associated with a higher HF readmission rate, less documentation of ejection fraction and hospitalization at a critical access hospital. A higher AMI readmission rate was associated with less aspirin use on arrival and longer door to balloon times. A lower AMI mortality rate was associated with more beta-blocker use and rapid door to balloon time. Conclusion: There is a slight inverse correlation for 30-day readmission and 30-day mortality following an admission for HF but not for AMI. Associations of recommended processes of care with less readmission were limited but consistent for AMI. Disparate associations were noted for HF readmission and processes of care.

National Survey of Hospital Strategies to Reduce Heart Failure Readmissions

Background— Reducing 30-day heart failure readmission rates is a national priority. Yet, little is known about how hospitals address the problem and whether hospital-based processes of care are associated with reductions in readmission rates. Methods and Results— We surveyed 100 randomly selected hospitals participating in the Get With the Guidelines-Heart Failure quality improvement program regarding common processes of care aimed at reducing readmissions. We grouped processes into 3 domains (ie, inpatient care, discharge and transitional care, and general quality improvement) and scored hospitals on the basis of survey responses using processes selected a priori. We used linear regression to examine associations between these domain scores and 30-day risk-standardized readmission rates. Of the 100 participating sites, 28% were academic centers and 64% were community hospitals. The median readmission rate among participating sites (24.0%; 95% CI, 22.6%–25.7%) was comparable with the national average (24.6%; 23.5–25.9). Sites varied substantially in care processes used for inpatient care, education, discharge process, care transitions, and quality improvement. Overall, neither inpatient care nor general quality improvement domains were associated with 30-day readmission rates. Hospitals in the lowest readmission rate quartile had modestly higher discharge and transitional care domain scores ( P =0.03). Conclusions— A variety of strategies are used by hospitals in an attempt to improve 30-day readmission rates for patients hospitalized with heart failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates, most current strategies are not associated with lower readmission rates.

Development of a Method to Risk Stratify Patients With Heart Failure for 30-Day Readmission Using Implantable Device Diagnostics

The aim of the present study was to evaluate whether diagnostic data collected after a heart failure (HF) hospitalization can identify patients with HF at risk of early readmission. The diagnostic data from cardiac resynchronization therapy defibrillator (CRT-D) devices can identify outpatient HF patients at risk of future HF events. In the present retrospective analysis of 4 studies, we identified patients with CRT-D devices, with a HF admission, and 30-day postdischarge follow-up data. The evaluation of the diagnostic data for impedance, atrial fibrillation, ventricular heart rate during atrial fibrillation, loss of CRT-D pacing, night heart rate, and heart rate variability was modeled to simulate a review of the first 7 days after discharge on the seventh day. Using a combined score created from the device parameters that were significant univariate predictors of 30-day HF readmission, 3 risk groups were created. A Cox proportional hazards model adjusting for age, gender, New York Heart Association class, and length of stay during the index hospitalization was used to compare the groups. The study cohort of 166 patients experienced a total of 254 HF hospitalizations, with 34 readmissions within 30 days. Daily impedance, high atrial fibrillation burden with poor rate control (>90 beat/min) or reduced CRT-D pacing (<90% pacing), and night heart rate >80 beats/min were significant univariate predictors of 30-day HF readmission. Patients in the "high"-risk group for the combined diagnostic had a significantly greater risk (hazard ratio 25.4, 95% confidence interval 3.6 to 179.0, p = 0.001) compared to the "low"-risk group for 30-day readmission for HF. In conclusion, device-derived HF diagnostic criteria evaluated 7 days after discharge identified patients at significantly greater risk of a HF event within 30 days after discharge.

22 Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure: Bolus, Drip or Both?

Study Objectives: Small studies suggest benefit when nitroglycerin is administered as an intravenous bolus using higher doses in patients with hypertensive heart failure but clinical experience is limited. We sought to compare outcomes with differing methods of intravenous nitroglycerin administration in patients with acute hypertensive heart failure. Methods: We performed a retrospective cohort study of patients who presented to the emergency department (ED) of an urban, teaching hospital with severe, acute hypertensive heart failure between Jan 2007 and July 2011 and received intravenous nitroglycerin. 3 subgroups were defined: 1) those given nitroglycerin by higher dose (≥ 0.5 mg) bolus alone (higher dose nitroglycerin); 2) those given nitroglycerin by continuous intravenous infusion alone (intravenous nitroglycerin); and 3) those given nitroglycerin by concurrent higher dose bolus and continuous IV infusion (higher dose intravenous nitroglycerin). Baseline and acute treatment data were compiled along with the following outcome measures: use of bilevel positive airway pressure or endotracheal intubation; intensive care unit [ICU] admission rate; ED, ICU and total hospital length of stay; rate of delayed-onset cardiac injury (ie, 2nd but not 1st troponin positive); inhospital mortality; 30-day heart failure readmission rate; and days out-of-hospital and alive through 30-days post-discharge. Descriptive statistics were applied and comparisons using chi-square, ANOVA or Kruskall-Wallis were performed. Results: Three hundred ninety-five patients (mean [SD] age 58 [15] yrs; 51% male, 88% black) were included: 124 (31%) higher dose nitroglycerin, 182 (46%) intravenous nitroglycerin, and 89 (22%) higher dose/intravenous nitroglycerin. While demographics were generally similar between groups, higher dose nitroglycerin patients were more likely to have a history of heart failure (72% versus 53% for intravenous nitroglycerin and 45% for higher dose intravenous nitroglycerin; p<0.001). At baseline, mean systolic blood pressure was significantly greater (p<0.001) in the higher dose/intravenous nitroglycerin group (Figure) while mean [SD] respiratory rate was lower in the intravenous nitroglycerin group (24[7] bpm versus 27 [11] in the higher dose nitroglycerin and 28 [8] higher dose/IV nitroglycerin groups; p<0.001). Most patients (∼75%) received similar mean [SD] intravenous furosemide dosing (64 [32] mg, 69 [53] mg, and 67 [35] mg in the higher dose nitroglycerin, intravenous nitroglycerin and higher dose/intravenous nitroglycerin groups, respectively; p=NS). Mean [SD] total dose of bolus higher dose nitroglycerin was greater in the higher dose/intravenous nitroglycerin group (3.9 [3.7] versus 2.4 [2.6] mg; p=0.001). No difference was found (Table) among the groups in use of bilevel positive airway pressure or endotracheal intubation, ED or ICU length of stay, rate of delayed cardiac injury, inhospital mortality, or out of hospital and alive. The ICU admission rate and total hospital length of stay however, were significantly lower among higher dose nitroglycerin patients and the 30-day heart failure readmission rate was substantial higher for the intravenous nitroglycerin group.Tabled 1 Conclusion: In this single-center, retrospective, unadjusted analysis of primarily African-American patients with acute hypertensive heart failure, nitroglycerin administered by higher dose bolus without concurrent intravenous infusion was associated with a significant decrease in ICU admissions and hospital length of stay. Based on our findings, bolus higher dose nitroglycerin appears to be a viable option for the management of such patients.

Extending the Continuum of Care in Congestive Heart Failure

The goal of this study was to determine if an interactive voice response system (IVRS) with daily self-management and clinical monitoring messages would be well accepted by patients and reduce 30-day congestive heart failure (CHF) readmissions. Patient adherence to a treatment regimen contributes to successful management following discharge for CHF. Cost-effective, scalable technology solutions can be useful tools in reducing readmissions. Sixty inpatients with a primary diagnosis of CHF were provided voice messages delivered via an Mp3 player. Following discharge, patients received daily IVRS messages with self-management tips based on self-reporting of symptoms. Greater than a 50% reduction in the 30-day readmission rate was realized for intervention patients. An IVRS self-management support system can be an effective technology to reduce CHF readmissions.

Heart Failure Rehospitalization of the Medicare FFS Patient

Heart failure readmission among the elderly is frequent and costly to both the patient and the Medicare trust fund. In this study, the authors explore the factors that are associated with states having heart failure readmission rates that are higher than the U.S. national rate. Acute inpatient hospital settings. 50 state-level data and multivariate regression analysis is used. The dependent variable Heart Failure 30-day Readmission Worse than U.S. Rate is based on adult Medicare Fee-for-Service patients hospitalized with a primary discharge diagnosis of heart failure and for which a subsequent inpatient readmission occurred within 30 days of their last discharge. One key variable found--states with a higher resident population speaking a primary language other than English at home--that is significantly associated with a decrease in probability in states ranking "worse" on heart failure 30-day readmission. Whereas, states with a higher median income, more total days of care per 1,000 Medicare enrollees, and a greater percentage of Medicare enrollees with prescription drug coverage have a greater probability for heart failure 30-day readmission to be "worse" than the U.S. national rate. Case management interventions targeting health literacy may be more effective than other factors to improve state-level hospital status on heart failure 30-day readmission. Factors such as total days of care per 1,000 Medicare enrollees and improving patient access to postdischarge medication(s) may not be as important as literacy. Interventions aimed to prevent disparities should consider higher income population groups as vulnerable for readmission.

DECREASED READMISSIONS AND IMPROVED QUALITY OF CARE WITH USE OF INEXPENSIVE CHECKLIST IN HEART FAILURE

There is a growing concern regarding the potential non-reimbursement for 30-day readmissions for heart failure (HF). Providing effective discharge instructions, education regarding HF monitoring appropriate dose up titration and strict follow up have all shown to decrease readmissions but are all

Abstract 17391: Effect of Advanced Heart Failure Care on the Risk of Early Readmission

Introduction: Risk adjusted rates of 30-day readmission (30DR) for heart failure (HF) have been publicly reported since 2008 and are included in the Medicare Shared Savings Program for Accountable Care Organizations. Whether the risk represented by HF patients followed in Advanced Heart Failure Programs (AHFP) offering LVAD and heart transplantation (HTX) services is adequately adjusted using the CMS model is unknown. To examine this issue, we sought to compare readmission risk and comorbidity distributions in patients under evaluation for LVAD or HTX and in patients followed by the AHFP at our institution. Methods: We collected data on patients discharged from the University of Michigan Hospital with a HF DRG from July, 2008 to November, 2010. Data collection included comorbidities used in the CMS risk model and laboratory values. LVAD and HTX evaluation status and discharging service type were determined. Patients &lt; 19 years old and those expiring in the hospital were excluded from the analysis. Result: A total of 1412 patients admitted for HF were analyzed in this sample (30DR 27%). Patients under evaluation for LVAD or HTX trended to have higher 30DR compared to other patients (34.5% vs 26.4%, p=0.06). Predicted probability of readmission for the AHFP team (n=407) was higher than other services (0.230±0.002 vs 0.218±0.002, p&lt;0.001), but 30DR was similar for the two groups (27.8% vs 26.8%, p=0.70). Logistic regression analysis, controlling for variables included in the CMS risk model and laboratory values, demonstrated that patients under evaluation for LVAD or HTX were more likely to experience 30DR (OR 1.76, 95% CI 1.10-2.82, p=0.018) while patients treated on the AHFP service were less likely to experience 30DR (OR 0.74, 95% CI 0.55-0.99, p=0.047). Conclusion: HF patients treated in our AHFP have higher predicted probability of readmission compared to those admitted to general cardiology or medicine services. Patients under evaluation for LVAD or HTX have a higher risk of readmission, and when controlling for these patients, our AHFP service demonstrated a reduced risk of early readmission compared to other services. Further study is needed to determine what elements of care provided through the AHFP are responsible for this reduced readmission risk.

Abstract P164: Reduction of Heart Failure Readmissions Through an Enhanced Internal Medicine Residency Curriculum

Background: Heart failure (HF) carries a significant economic burden and hospitalizations account for 70% of the total costs of heart failure. Rehospitalizations are particularly costly and potentially avoidable. As part of the National Initiative for Alliance of Independent Academic Medical Centers, we aimed to decrease the HF readmissions by 5% through enhancements in the Internal Medicine Residency Curriculum. Methods: Between 7/10-2/11, we implemented a HF lecture series, multidisciplinary rounds, article and case reviews. Cardiac Rehabilitation, Information Systems, HF Team, Case Managers/Social Work and Nursing staff collaborated to develop better documentation and discharge protocols. To determine the impact of our intervention, the change in 30-day readmission and pre and post questionnaire about HF knowledge/attitudes were statistically analyzed. Results: The pre test questionnaire showed: 1) Residents felt more confident in treating/ counseling patients with HF and were not as confident in identifying precipitants of readmissions or applying core measures. 2) Most residents felt the key factors to preventing readmissions were close post-discharge follow up and patient education. Post intervention questionnaire showed: 1) More residents were confident about the core measures, quality indicators, appropriate documentation of HF. 2) More residents were satisfied with the Internal Medicine Residency Curriculum. The average HF readmission rate reduced from 24.6% to 20.9% between 7/10-11/10 (above goal). January - August 2010 (Before Intervention) September - November 2010 (After Intervention) All HF Admissions 1178 464 All HF Readmissions 292 (24.8 %) 103 (22.2%) Primary HF Admissions 167 63 Primary HF Readmissions 40 (24.0%) 12 (19.0%) Statistical comparison of All HF p=0.483, OR 1.339, 95% CI 0.656-2.727 Statistical comparison of Primary HF p=0.276, OR 1.155 95% CI 0.895-1.491 Conclusions: A 6-month resident-oriented multidisciplinary intervention improved patient care, documentation, and resident understanding of HF syndrome. This led to promising trends towards a significant decrease in 30-day HF readmissions. Further improvement in outcomes should be evident at the completion of 12-month follow-up.

Abstract P33: Improving Heart Failure Metrics: A Multidisciplinary Team Approach

Background: Quality of care has become a priority as heart failure (HF) core measures and readmission have been publically reported on the Centers for Medicare &amp; Medicaid Services (CMS) Hospital Compare website. In an effort to decrease readmissions Vanderbilt University Medical Center (VUMC) joined the H2H (Hospital to Home) initiative. Based on the CMS data for 2005 to 2008 the middle Tennessee region was in the 5 th Quartile of readmission scores (25.2%-29.0%). The 30-day HF readmission rate at VUMC (25.7%) was comparable to the national rate of 24.5%. Aim: The goal of this project was to decrease readmissions by 20% as suggested by the ACC through participation with the H2H initiative. Method: A multidisciplinary team, including Physicians, Pharmacist, Case Management, Nutrition, Nursing, and a Social Worker, was structured to round on the heart failure floor each morning to identify HF patients as part of a demonstration project. All identified patients were assessed by the multidisciplinary team for teaching needs and self care abilities based on their specialties. Based on their initial assessment, teaching was performed for newly diagnosed or reinforcement teaching. Education materials were updated for all patients and given to all heart failure patients regardless of status in the demonstration project. Results: Thirty day follow-up has been completed on 52 patients and 7 have been readmitted for any cause. This has decreased the readmission rate from 25.7% to 13.4%. There are 5 interventions which could have been completed. The most frequent, the Pharmacy intervention was completed on 76% of the patients; however there is not a statistical correlation between this intervention alone and readmission. Discharge instructions in core measures were also associated with a positive trend as evidence by quarter 4 2009 at 88.4% and quarter 4 2010 at 96.8%. Conclusions: Our project targeted recognizing the needs of the patient and matching them with the appropriate consult. This approach has been associated with reduction in readmission rates and in an increase in core measure compliance. Further data collection will be needed to confirm findings.

12. Newly designed heart failure education in a H2H demonstration project

In an effort to decrease heart failure (HF) readmissions, Vanderbilt University Medical Center (VUMC) joined the H2H (Hospital to Home) initiative. Based on the Centers for Medicare & Medicaid Services (CMS) data for 2005 to 2008 the middle Tennessee region was in the 5th Quartile of readmission scores (25.2%-29.0%). The 30-day HF readmission rate at VUMC (25.7%) was comparable to the national rate of 24.5%.

Characteristics and Outcomes of Very Elderly Patients After First Hospitalization for Heart Failure

The very elderly (age 80 years and older) with heart failure (HF) is a growing population that is rarely included in clinical trials. The aim of this investigation was to describe the characteristics and outcomes of very elderly patients after a first HF hospitalization. We identified very elderly patients (age 80 years and older) discharged with HF from the Veteran's Administration National Patient Care Database from 1999 to 2008. Outcomes of interest were death during index admission, 30-day and 1-year mortality, and 30-day all-cause and HF readmissions. We used generalized estimating equations to evaluate outcome differences between age groups within the very elderly cohort (ages 80 to 84, 85 to 89, and 90 and older), adjusting for comorbidities, demographics, and clustering by treatment facility. We identified 21 397 very elderly veterans with a first HF hospitalization during the study period. Thirty-day mortality decreased from 14% to 7% (both P<0.001) and 1-year mortality decreased from 49% to 27% (P<0.001). Although these improvements were most notable for patients age 90 and older (1-year mortality improved by 25.9%), the adjusted odds of death within 1 year were highest for the oldest veterans (odds ratio, 1.85; 95% confidence interval, 1.64 to 2.09, using the 80- to 85-year age group as reference). For all patients, 30-day all-cause readmissions remained largely unchanged and did not differ between age groups. Mortality for very elderly HF patients has improved over time, but 30-day readmissions remain frequent. Future studies should identify interventions to reduce cardiac and noncardiac rehospitalization of very elderly HF patients.

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

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

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.