Heart Failure Readmission Reduction Research Articles

Ramipril After Transcatheter Aortic Valve Implantation in Patients Without Reduced Ejection Fraction: The RASTAVI Randomized Clinical Trial.

Patients with aortic stenosis may continue to have an increased risk of heart failure, arrhythmias, and death after successful transcatheter aortic valve implantation. Renin-angiotensin system inhibitors may be beneficial in this setting. We aimed to explore whether ramipril improves the outcomes of patients with aortic stenosis after transcatheter aortic valve implantation. PROBE (Prospective Randomized Open, Blinded Endpoint) was a multicenter trial comparing ramipril with standard care (control) following successful transcatheter aortic valve implantation in patients with left ventricular ejection fraction >40%. The primary end point was the composite of cardiac mortality, heart failure readmission, and stroke at 1-year follow-up. Secondary end points included left ventricular remodeling and fibrosis. A total of 186 patients with median age 83 years (range 79-86), 58.1% women, and EuroSCORE-II 3.75% (range 3.08-4.97) were randomized to receive either ramipril (n=94) or standard treatment (n=92). There were no significant baseline, procedural, or in-hospital differences. The primary end point occurred in 10.6% in the ramipril group versus 12% in the control group (P=0.776), with no differences in cardiac mortality (ramipril 1.1% versus control group 2.2%, P=0.619) but lower rate of heart failure readmissions in the ramipril group (3.2% versus 10.9%, P=0.040). Cardiac magnetic resonance analysis demonstrated better remodeling in the ramipril compared with the control group, with greater reduction in end-systolic and end-diastolic left ventricular volumes, but nonsignificant differences were found in the percentage of myocardial fibrosis. Ramipril administration after transcatheter aortic valve implantation in patients with preserved left ventricular function did not meet the primary end point but was associated with a reduction in heart failure re-admissions at 1-year follow-up. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03201185.

Approach to Congestive Heart Failure Readmission Reduction in a Community-Based Setting: A Field Report

This article examines how a midsize community hospital designed a readmission reduction project with the goal of decreasing readmissions for patients with a primary diagnosis of congestive heart failure. Multicomponent interventions were implemented for patient enrollment in this quality improvement initiative with clear inclusion criteria. The study concluded that a structured transition of care plan with remote patient monitoring, together with well-defined criteria for the initiation of rescue medications, has the potential for decreasing avoidable hospital readmissions.

Abstract 13291: Virtual Pharmacist Approach to Comprehensive Medication Management in Post-Discharge Heart Failure Patients: A Randomized Quality Improvement Initiative

Introduction: Successful management of Heart Failure (HF) patients post-discharge requires a multi-faceted approach including close medication management to decrease preventable readmissions. Methods: We conducted a one-year single center, single-blinded randomized trial of HF patients post-discharge comparing standard of care vs. intensive virtual care on HF readmission rates. The intensive virtual care included comprehensive medication management by a Virtual Clinical Pharmacist (VCP). Results: Among the 591 participants, the median age was 73.2 years, 52.5% male, and 56.2% white. There were 308 patients randomized into the intervention group of which 165 (53.5%) enrolled. During VCP visits, 155 patient concerns were identified including active symptoms (45.2%), lack of clarity of medication regimen (40.6%), concurrent uncontrolled hyperglycemia or hypertension (9%) and non-adherence with provider follow up appointments (5.2%). There were 625 VCP interventions in 165 HF patients. Of these patients, VCPs increased access to medical care (33.9%), optimized guideline directed medical therapy (17.6%), addressed symptoms of HF exacerbations (7.9%), and other impactful interventions (Table). VCP recommendations had a 59% acceptance rate into the patient’s treatment plan when clinicians were contacted directly. A 6.9% decrease in 30-day readmission rates was demonstrated (p=0.03) in the intervention group, in addition to a decrease from 24.4% to 19.2% in emergency department visits (p=0.15). For patients readmitted, the intervention arm had a shorter length of stay, 5.6 days, when compared to control, 6.8 days (p=0.14). Conclusion: This single center randomized trial demonstrated that Virtual Clinical Pharmacist-led comprehensive medication management identified key interventions with high-level clinician engagement for post-discharge HF patients that resulted in a 6.9% reduction in HF readmissions.

Ivabradine in Cardiovascular Disease Management Revisited: a Review.

Ivabradine is a unique agent that is distinct from beta-blockers and calcium channel blockers as it reduces heart rate without affecting myocardial contractility or vascular tone. Ivabradine is a use-dependent inhibitor targeting the sinoatrial node. It is approved for use in the United States as an adjunct therapy for heart rate reduction in patients with heart failure with reduced ejection fraction. In this scenario, ivabradine has demonstrated improved clinical outcomes due to reduction in heart failure readmissions. However, there has been conflicting evidence from prospective studies and randomized controlled trials for its use in stable ischemic heart disease regarding efficacy in symptom reduction and mortality benefit. Ivabradine may also play a role in the treatment of patients with inappropriate sinus tachycardia, who often cannot tolerate beta-blockers and/or calcium channel blockers. In this review, we highlight the evidence for the nuances of using ivabradine in heart failure, stable ischemic heart disease, and inappropriate sinus tachycardia to raise awareness for its vital role in the treatment of select populations.

Impact of Remote Pulmonary Artery Hemodynamic Monitoring System in Reducing Heart Failure Readmissions Among Patients with Heart Failure and Atrial Fibrillation

Background Pulmonary artery (PA) pressure monitor guided therapy using CardioMEMS device has shown to reduce heart failure readmissions. Heart failure (HF) and atrial fibrillation (AFib) frequently coexist and atrial fibrillation itself can cause alterations in PA hemodynamics. Current study was designed to study the impact of remote pulmonary artery hemodynamic monitoring in reducing heart failure readmissions among patients with HF and AFib. Methods Retrospective data was collected for patients with HF who had CardioMEMS device implanted as per FDA indications from April 2015 to June 2018. Data including number of all cause and HF hospitalizations, emergency department (ED) visits and HF clinic visits was collected for 1-year pre- and 1-year post-implantation. Readmission data for patients with and without Afib was compared. Results CardioMEMS device was implanted in 117 patients during the study period. Of this population 53.8% were male and 52.6% had Afib. There was significant reduction in HF readmissions in patient with Afib after CardioMEMS implantation, 1- year pre (1.87 ± 1.38) vs 1- year post implantation (0.44 ± 0.82), p-value Conclusion Remote PA hemodynamic monitoring device decreases HF readmissions in HF patients with AFib, similar to patients without AFib.

Reengineering the Discharge Management of Heart Failure Patients Discharged to Skilled Nursing Facilities Utilizing a Multidisciplinary Team Approach Reduces 30-day Readmission Rate

Introduction Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge is the large volume of hospitalized Heart Failure (HF) patients (4,000/year) with a historically high 30-day readmission rate (27%). HF patients discharged to Skilled Nursing Facilities (SNF) (23%) were at higher risk of readmission, p-value Hypothesis Development of a designated multidisciplinary HF Team (NP, PharmD, Case manager and SNF leadership) approach that integrates a standardized comprehensive pre/post discharge multidisciplinary management plan will decrease 30-Day readmission rates. Methods January 15 - April 1, 2019 was the implementation phase of the SNF Heart Failure Readmission Reduction Initiative (SNF -HFRRI) Pilot Project which included generation of a daily patient list with Primary HF (ICD-10) and HF anticipated discharge list from case management. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients identified to be discharged to a SNF were flagged for further in-depth pre-discharge HF NP consult/PharmD counsel and to develop a warm handoff to SNF leadership. Post discharge HF weekly telephone assessment with SNF senior RN leadership and attendings were conducted. Retrospective review of prospectively collected data was analyzed based on age, gender, NYHA, ACC stage, LOS, Unit of discharge and 30-Day Readmission and included Pre-SNF-HFRRI (June 1, 2018 - January 15, 2019); Implementation Phase (January 15, 2019 -March 31, 2019); Post SNF-HFRRI (April 1, 2019 November 15, 2019). Results We identified 182 HF patients (88-Pre-SNF-HFRRI and 94 Post SNF-HFRRI). Continuous variables (age, LOS) and categorical variables (gender, NYHA, LVEF, ACC stage, reason for readmission, hospital unit discharged and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank, chi square and Fisher's exact test. The groups were comparable to age, LOS, LVEF, ACC class, units discharged. A structured weekly post discharge phone assessment incorporating Guideline-Directed Medical Therapy was statistically significant, p Conclusion Our newly integrated multidisciplinary HF team approach that incorporates a structured post-discharge collaborative approach can prevent avoidable 30-day readmissions and improve discharge preparedness.

Improving Value Through Heart Failure Care Coordination: The Allina Health Experience

Reducing readmission following heart failure is emerging as a target of quality initiatives in the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program. In response to higher readmission rates than desired following heart failure (HF) hospitalization, Allina Health hospital's cardiovascular subspecialty care developed an HF nurse care coordinator program to reduce readmissions. The nurse HF care coordinator serves as the bridge to help manage care following hospital discharge and ensure adherence to protocols developed by the HF management program. This effort was initially developed and implemented at Mercy and Unity Hospital and was associated with a 4.3% reduction in HF readmissions. Subsequent expansion of the HF nurse care coordinator program to United and Abbott Northwestern Hospitals was associated similar reductions in HF readmissions. Concurrently, all-cause mortality at 6 months post-discharge was also significantly lower following implementation of the program (mortality pre-HF care coordinator program 12.6% vs. post-HF care coordinator program 18.8%, P = .047) in propensity matched analysis. The findings of this effort suggest the potential for care coordination programs to improve the care and outcomes of patients with HF.

Value and Acceptability of a Novel Machine Learning Technology for Heart Failure Readmission Reduction: Qualitative Analysis of Clinical Roles and Workflows

Value and Acceptability of a Novel Machine Learning Technology for Heart Failure Readmission Reduction: Qualitative Analysis of Clinical Roles and Workflows

The Hospital Readmissions Reduction Program-learning from failure of a healthcare policy.

Heart failure is the leading cause of readmissions in patients aged ≥65 years with high associated societal and economic costs. The utilization metric of 30-day risk standardized readmission rates (RSRRs) has therefore become a target to reduce healthcare costs. In this review, we discuss in detail the implementation, effectiveness, and unintended consequences of the Hospital Readmissions Reduction Program (HRRP)-the major healthcare policy approach in the U.S. to reduce readmissions by financially penalizing hospitals with higher than average 30-day RSRRs. The HRRP was enacted by the Patient Protection and Affordable Care Act of 2010 (popularly known as 'Obamacare'). The public reporting of RSRRs began in June 2009 and the HRRP readmission penalties went into effect starting fiscal year 2013. The policy had limited success in achieving its primary objective of reducing readmissions as the achieved reduction in heart failure readmissions was much smaller (∼9%) than anticipated (∼25%) with some of the reduction in RSRRs attributable to the artifact of administrative upcoding post-HRRP rather than an actual decline in readmissions. From the time of passage of this law, there have been significant concerns regarding gaming of the system such as increase in observation stays, delaying readmissions beyond discharge day 30, and inappropriate triage strategies in emergency departments in order to achieve lower readmission rates to avoid penalties. A series of independent reports have now suggested that implementation of the HRRP was associated with an increase in 30-day, 90-day, and 1-year risk-adjusted heart failure mortality in the U.S. with reversal in decade long trend of declining heart failure mortality. We review the evidence behind effect of the HRRP on readmissions and mortality outcomes as well as discuss various lessons to be learned from the design, implementation, and consequences of this policy.

Abstract 197: Root Cause Analysis of 30-day Heart Failure Readmission Elucidates Acute Kidney Injury as a Common Offender

Background: Hospitalization for heart failure (HF) and heart transplant is associated with a high likelihood of readmission within 30 days of discharge. Our study objective was to identify risk factors and causes for readmission at a high acuity tertiary academic medical center in order to develop targeted interventions aimed at HF readmission reduction. Methods: We retrospectively reviewed 49 sequential cases of patients readmitted within 30 days of hospitalization for HF (41) or heart transplant (8) between Q3-Q4 2014. Two unblinded reviewers determined the root causes of readmission, likelihood of readmission prevention, and interventions most likely to prevent similar readmissions from recurring. Results: HF exacerbation was the primary reason for readmission in 47% (23/49) of cases. Also in 47% (23/49) of the readmissions, the possibility for preventing the readmission had an appropriate intervention been implemented was determined to be at least 50%. The other 53% (26/49) of readmissions were considered unlikely to have been readily preventable. Medical complications were the primary cause of readmission in 14% (7/49) of cases, of which acute kidney injury (AKI) was the most common. Over one-fourth (13/49) of all readmissions were found to have at least a 15% increase in creatinine level from time of discharge to time of readmission. Dietary indiscretion (8% i.e. 4/49), psychosocial factors (8%), and progression of disease (8%) were other notable root causes for readmission. When assessing the most likely part of patient care to address to prevent readmission, more proactive follow-up/monitoring was considered to be the most high-yield intervention in 14% of cases i.e. 7/49. Also of note, reclassifying admissions as observation status based on length of stay would have prevented 33% (16/49) of cases from meeting readmission criteria. Conclusion: Our study supports a multifaceted, multidisciplinary approach to reducing HF readmissions, given the array of readmission causes and targeted areas for intervention identified. It also demonstrates that AKI may be an underappreciated cause for readmission, with 28% of all-cause readmissions presenting with creatinine elevations of at least 15%. Therefore, in addition to a multidisciplinary approach to discharge planning, we recommend institutions implement specific strategies to reduce AKI.

381 - Heart Failure Care Transitions: A Queuing Theory Approach to Quantify the Impact of Vacation Periods on Discharge Clinic Wait Times

Background: Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in follow-up availability owing to clinician vacations. This variability thwarts the timeliness of follow-up, negates the benefit of transitional care planning, and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to analyze the impact of clinician vacation periods on clinic performance. Objective: To analyze the impact of clinician vacation periods on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches. Methods: Higher risk hospitalizations requiring active transitional care heart failure management were detected using an electronic data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity and clinician vacations on wait time to an appointment. Results: During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing 40 discharge clinic appointments per week (99% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days. A clinician vacation reducing clinic capacity by 25% for 1 week takes 24 weeks for recovery. Clinic redesign using queuing theory: Providing five extra discharge appointment slots per week (88% utilization) reduces the expected waiting period to 1.1 days (versus 18.3), with 99.8% of patients seen within 7 days (versus 31.9%). In this scenario, recovery time to steady state after the 1 week vacation period is reduced from 24 weeks to 9 days. Conclusions: Deployment of queuing theory allows for a more precise quantification of clinical capacity needed to accomplish appropriate HF follow-up. Our simplified model demonstrates that, in the absence of a modest capacity buffer, variability in hospital discharge rates leads to both excessive clinic wait times and recovery times from vacation periods, consequently exposing patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10–15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.

Heart Failure Readmission Reduction.

Little is known regarding effectiveness of readmission reduction programs over time. The Heart Failure Management Program (HFMP) of St. John's Physician Group Practice (PGP) Demonstration provided an opportunity to assess outcomes over an extended period. Data from an electronic health record, an inpatient database, a disease registry, and the Social Security Death Master File were analyzed for patients admitted with heart failure (HF) for 5 years before (Period 1) and 5 years after (Period 2) inception of PGP. HF admissions decreased (Period 1, 58.3/month; Period 2, 52.4/month, P = .007). Thirty-day all-cause readmission rate dropped from Period 1 (annual average 18.8% [668/3545]) to year 1 of Period 2 (16.9% [136/804], P = .04) and remained stable thereafter (annual average 16.8% [589/3503]). Thirty-day mortality rate was flat throughout. HFMP was associated with decreased readmissions, primarily related to outpatient case management, while mortality remained stable.

Abstract 161: Heart Failure Care Transitions: A Queuing Theory Approach to Match Variable Hospital Discharge Rate With Outpatient Clinic Capacity

Background: Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in discharge caseload. This variability thwarts the timeliness of follow-up, negates the benefit of transition care planning and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to determine if caseload can be determined more precisely in a manner that sufficiently accommodates HF discharge variability. Objective: To analyze the impact of hospital discharge rate variability on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches. Methods: Higher risk hospitalizations requiring active transitional care heart failure management were detected using an enterprise data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity on wait time to an appointment. Discharge clinic was modeled as a single 7-day follow-up appointment, with an acceptable scheduling window of 5 to 9 days post-discharge. Results: During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing one discharge slot for every hospital discharge (100% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days, and 38.9% of appointments scheduled within 9 days. Clinic re-design (queuing theory): Providing five extra discharge appointment slots per week (88% utilization or 13.6% excess capacity) reduces the expected waiting period to 1.1 days, with 99.8% of patients seen within 7 days, and virtually all patients seen within 9 days of discharge. Conclusions: Deployment of queuing theory allows for a more precise quantification of needed clinical capacity to accomplish appropriate HF follow-up with a reasonable degree of certainty. Our simplified model demonstrates that variability in hospital discharge rates leads to excessive clinic wait times in the absence of a modest capacity buffer and consequently exposes patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10-15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.

Experience of a Newly Established Multidisciplinary Heart Failure Clinic at a VA Hospital

Experience of a Newly Established Multidisciplinary Heart Failure Clinic at a VA Hospital

Reduction in Heart Failure Readmissions Using Mobile Technology

Reduction in Heart Failure Readmissions Using Mobile Technology

Interventions to prevent heart failure readmissions: The rationale for nurse-led heart failure programs

Background: Readmission to hospitals for heart failure is one of the greatest economic burdens on Medicare, and has become a major focus of healthcare reform. In an attempt to stem the overwhelming number of readmissions and improve heart failure outcomes, hospitals have employed multiple interventions. Nurse-led heart failure management programs have been an effective strategy in reducing hospital readmissions for heart failure. Purpose: We conducted an integrative review of the literature that assessed the value of interventions to reduce heart failure readmission rates. We focused on the important role of nursing care in successfully implementing many of these interventions. Methods: An integrative review of the literature was performed. A computerized search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library (reviews and clinical trials) was performed to locate articles published from 2004 to 2014. Key words used included “heart failure nursing” , “heart failure readmissions”, “heart failure programs” and “interventions for heart failure readmission”. Preference was placed on articles published in the last 10 years. Articles referenced by national heart failure guideline documents and expert consensus statements were given a high priority. Eighty-eight articles were screened initially by two reviewers; these were then screened to leave 40 relevant articles. Conclusions: Several specific interventions have a proven favorable effect in reducing heart failure readmissions. These include optimal medical management, patient education and self-care instruction, and ensuring adequate post-discharge follow-up. Despite this knowledge there remains a wide variation of readmission rates across the U nited S tates . This may be partly due to the variability in the adequate implementation of interventions and/or the absence of a required number of interventions in different centers. Each single intervention in itself has only a very small beneficial effect. The implementation of several interventions is essential to produce a meaningful reduction in heart failure readmissions. The ability to successfully employ numerous interventions together may explain the promising results of structured nurse-led heart failure programs.

Impact of Patient Education Class for Inpatients Admitted for Heart Failure on Rates of 30 Day Readmission

Impact of Patient Education Class for Inpatients Admitted for Heart Failure on Rates of 30 Day Readmission

Implementation of a heart failure readmission reduction program: a role for medical residents

Background: Congestive heart failure (CHF) is one of the leading causes of hospital readmissions within 30 days of discharge. Due to the substantial costs associated with these readmissions, several interventions to reduce CHF readmissions have been developed and implemented.Methods:To reduce CHF readmissions at our community teaching hospital, the Smooth Transitions Equal Less Readmission (STELR) program was developed. Utilizing the Plan-Do-Check-Act cycle for quality improvement, resident physicians tracked patients enrolled in the STELR program. The resident contribution to the program was substantial in that they were able to quantify the improvement in both physician practices and patient readmissions. This provided insight into program areas requiring further modification, which the hospital would not have obtained without resident participation.Results: The readmission rate for patients diagnosed with heart failure decreased from 32% prior to program implementation, to 24% hospital wide (including patients who were not tracked in the STELR program), and 21% among patients tracked by the residents.Conclusion: This effective CHF readmission reduction program requires less financial resources compared to government funded programs. The resident involvement in the STELR program helped to assess and improve the program and also allowed the residents to gain an awareness of the resources available to their patients to facilitate their transition home. The program exposed the residents to systems-based practice, a fundamental element of their residency training and, more generally, community care.

Improvement but no cure of left ventricular systolic dysfunction in treated heart failure patients

Recent advances in pharmacological and pacemaker-based treatments for heart failure (HF) have brought about significant improvements in left ventricular function. To identify the proportion of treated systolic HF patients in whom left ventricular systolic function improves and/or returns to normal. This was a retrospective analysis of 221 HF patients. Improvement in left ventricular function was defined as an improvement in ejection fraction (LVEF) of > or =10% on echocardiography. Return to normal was defined as an improvement of LVEF to > or =50% and a reduction in left ventricular end diastolic diameter to < or =55 mm. Changes in BNP were also recorded. Improvement in LVEF was observed in 44.3% of patients and return to normal systolic function in 10.9%, only 2.3% had both a return to normal echocardiographic parameters and a BNP<100 pg/ml. A higher percentage of the improved group were on target doses of beta-blockers (p=0.004). Baseline BNP was not a predictor of improvement. There was a trend towards a reduction in HF readmissions in the improved group (p=0.07) but no difference in the risk of death or all-cause readmission. While a substantial proportion of treated HF patients have an improvement in left ventricular function over time, only a small proportion return to normal dimensions and LVEF, underlining the permanent nature of ventricular damage in the vast majority of patients.