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Quality Improvement | May 2018
Moving the needle on heart failure
Financial penalties have failed to dent readmissions, so new strategies are needed.
By Janet Colwell
Heart failure is one of the most common reasons for readmission within 30 days of hospital discharge and a significant driver of national health care spending. However, despite considerable efforts in recent years by payers and hospitals, readmission rates and clinical outcomes have remained largely unchanged.
For example, a study published in the Journal of the American College of Cardiology: Heart Failure in December 2016 found comparable quality of care among hospitals with high versus low readmission rates.
Another, published in Circulation: Heart Failure in June 2016, found that only 1 of 70 U.S. hospitals achieved the 20% relative reduction in readmissions targeted by the American Heart Association's Get with the Guidelines-Heart Failure program. And teaching hospitals had among the highest rates—suggesting that even hospitals with high-quality care and significant resources have limited ability to prevent readmissions.
It's led many to question the effectiveness of Medicare's Hospital Readmission Reduction Program (HRRP), which took effect in 2012 and under which hospitals with excess risk-adjusted 30-day readmission rates for heart failure, acute myocardial infarction, and pneumonia are penalized up to 3% of their annual Medicare reimbursement.
"Policymakers assumed that it would be relatively simple for hospitals to prevent readmissions for heart failure, given sufficient economic incentives, but it has proven to be far more difficult and complex," said Gregg Fonarow, MD, senior author of the Circulation: Heart Failure study and co-chief of the division of cardiology at the Ronald Reagan University of California, Los Angeles, Medical Center.
"Many attempts to identify effective strategies have been unsuccessful or backfired, and after a decade of declining, mortality for patients hospitalized with heart failure has modestly increased," he added.
To improve heart failure readmissions and outcomes, hospitalists and the health care system will need to employ new, multipronged strategies, experts say.
"No one would question a cancer readmission within 30 days, but that's what we're doing with heart failure, which is another serious chronic condition," said Elke Platz, MD, an emergency physician at Brigham and Women's Hospital in Boston whose research focuses on heart failure and ultrasound. "We need strategies that encompass care in and outside of the hospital."
Length-of-stay dilemmas
Hospitalists face competing pressures when deciding when to discharge a patient, noted Harlan Krumholz, MD, a cardiologist and health care researcher at Yale University in New Haven, Conn.
On the one hand, patients shouldn't be discharged until they are sufficiently decongested and prepared to manage their disease at home. On the other, incentives encourage shorter stays, and longer admissions, even when clinically necessary, can trigger other issues.
"Call it post-hospital syndrome—you're so battered by the circadian rhythm disruption, inactivity, poor nutrition, pain, and confusion that your physiologic systems become weakened and make you susceptible to a wide range of other problems," said Dr. Krumholz. "The stress leads to problems downstream that may or may not have to do with the original illness."
Discharging patients before they are fully decongested is a common problem, said cardiologist Nisha Gilotra, MD, an assistant professor of medicine at Johns Hopkins Medicine in Baltimore and an expert in advanced heart failure.
"The current standard of care to determine if a patient is decongested enough to be discharged relies heavily on physical exam and symptoms," she said. "However, we know that filling pressures can remain high even when a patient may appear to have improved on the surface."
One problem is lack of training and expertise in measuring central venous pressure to guide fluid resuscitation, said Esther Shao, MD, a cardiologist and medical director of heart failure at Maine Medical Center in Portland. Instead, it's common practice to discharge patients based on the absence of fluid in their lungs on auscultation.
"About a third of patients who have elevated wedge pressure on right-heart catheterization have clear lung fields," she said. "Just because a patient's lungs are clear doesn't mean they aren't in congestive heart failure."
Dr. Shao has implemented a heart failure education program in Maine to address the issue. The program trains clinicians to accurately read central venous pressure with the goal of establishing a common standard of care for assessing and managing heart failure, she said.
Greater use of lung ultrasound may be another solution. Patients with residual pulmonary congestion on ultrasound at the time of discharge were at high risk for readmission, according to a study Dr. Platz and colleagues published in the September 2017 European Journal of Heart Failure. "This easy-to-learn technique represents a more sensitive method for the detection of subclinical pulmonary congestion and could improve the predischarge assessment of patients with heart failure," Dr. Platz said.
Technological tools that could help are being developed, including hemodynamic sensors capable of detecting elevated pulmonary artery pressures. The devices, which can be implanted in an outpatient clinic, upload data in real time, allowing clinicians to continuously monitor patients' status and initiate interventions as needed, potentially preventing decompensation.
Pulmonary artery pressure-guided management led to significant reductions in heart failure admissions, according to a follow-up study of the CHAMPION trial, which enrolled patients with class III heart failure symptoms and a previous hospital admission. Compared with a control group, patients using hemodynamic sensors had a 33% decrease in heart failure hospitalizations over an average of 18 months. The findings were published in January 2016 in The Lancet.
Such tools, along with other research being pursued, have the potential to help alleviate the pressures clinicians face to both prevent readmissions and limit length of stay, said Dr. Gilotra.
"It can be tough to convince hospitals and providers to keep patients long enough to really dry them out," she said. "That's where some novel diuretic strategies currently being researched may help, where diuresis is as effective as inpatient intravenous diuresis, but patients can do it at home for a few days after discharge."
Transition strategies
Although hospitals and physicians are well aware that heart failure patients are extremely vulnerable to setbacks in the weeks following discharge, they have implemented strategies to smooth the transition with varying success, said Dr. Krumholz.
"The key is coordination, collaboration, and communication, but we are not doing a good enough job with these," he said. "When patients go home, there is still a lot of confusion, especially in the days between discharge and seeing an outpatient provider."
Prior to discharge, the hospitalist should communicate with the patient's outpatient physician to outline the plan of care, Dr. Platz recommended. Ideally, a social worker or case manager should provide support, such as making sure patients have transportation to follow-up appointments and to a pharmacy to fill prescriptions.
In addition, patients should receive counseling from a nurse and pharmacist to help them understand their discharge instructions, including information about any new medications prescribed and how to take them, as well as instructions around nutrition and fluid intake.
At Maine Medical Center, discharge triggers a multipronged transition process, said Dr. Shao. It includes a follow-up call from a nurse in 24 hours, a follow-up appointment with an outpatient clinician in a week, remote weight monitoring, self-care education, and a nursing hotline for postdischarge questions.
A recent study of heart failure patients at one hospital in Australia found that a targeted educational program was successful in lowering readmissions. Participants underwent an individualized learning needs assessment, watched a DVD about heart failure self-care, and talked one-on-one with a nurse heart failure specialist. They were also given the DVD and a written manual to use at home.
After 12 months, out of 171 total participants, 24 in the intervention group had an unplanned readmission compared to 44 in the control group—a 30% reduced risk of readmission. The findings were published in February in the European Journal of Cardiovascular Nursing.
Patient education can be challenging because heart failure is often not perceived in the same way as other life-threatening chronic conditions, said Dr. Shao. It's not uncommon for patients to leave the hospital feeling "cured" after their symptoms have been treated and their lungs cleared.
"Patients with cancer are typically very willing to go through multiple rounds of chemotherapy that makes them quite ill and are very concerned about their cancer coming back," she said. "But if I tell a patient with heart failure that they need to take their medications and change their diet, about half of them will say they're never going to do it."
Patient behavior and perceptions about heart failure are among the arguments some experts make against using 30-day readmissions as a marker of quality. Readmissions seem unavoidable for at least some patients, especially those who don't engage in self-care or are incapable of doing so, yet hospitals are penalized.
Dr. Shao offers one example of a patient with a personality disorder who has returned many times to Maine Medical Center. While in the hospital, the man is hostile to nurses and sneaks soda from the cafeteria; at discharge, he refuses to leave a forwarding address or phone number and will not make a follow-up appointment.
"Three weeks later he's back, 30 pounds heavier, stays another two weeks and repeats the cycle," she said. "All hospitals have these types of patients—they will float in and out of the hospital no matter what we do."
Mortality rate may be an accurate alternative method to assess quality of care and improve long-term outcomes, according to a recent study led by Dr. Fonarow. The study, published by JAMA Cardiology in March, found that patients discharged from hospitals with lower 30-day risk-standardized mortality rates (RSMRs) had better long-term survival. Hospitals with better RSMRs were also more likely to adhere to key processes of care, offer advanced heart failure therapies, and provide postdischarge follow-up.
"Unlike the 30-day risk-stratified readmission rate—which is the predominant focus of CMS yet has little to no association with quality of care or long-term survival—the 30-day RSMR metric is actionable, associated with one-, three-, and five-year survival, and a far more effective means to incentivize better care and outcomes for patients with heart failure." said Dr. Fonarow.
Another challenge of the HRRP is that hospitals are penalized based on the percentage rather than actual number of readmitted patients—so theoretically, a hospital could have an 80% 30-day readmission rate because the same 10 out of 100 patients were admitted multiple times while the remaining 90 did not return. A population-based metric, such as whether a hospital lowered the number of hospital days per year per 1,000 heart failure patients, would be more reflective of quality of care, Dr. Shao said.
Reducing readmissions also hinges on rethinking how to care for heart failure, including outpatient alternatives to hospitalization, said Dr. Platz. Home hospital programs, for example, provide close telemonitoring supervision by specialists, and IV diuretics can be administered in patients' homes or qualified outpatient clinics.
A small pilot study of a home hospital program sponsored by Brigham and Women's Hospital in Boston, for example, suggests that it can be effective in reducing costs and improving quality of life. In the study, the median direct cost of the acute care episode was 52% lower for home care versus hospital care, and home patients were more physically active and got more sleep. Findings were published online in February in the Journal of General Internal Medicine.
"Efforts to prevent rehospitalizations are worthwhile, but we need to move toward preventing heart failure admissions in the first place and optimizing outpatient treatment alternatives," said Dr. Fonarow. "Focusing narrowly on 30-day readmissions is not patient-centered and needs to change."
Janet Colwell is a freelance writer in West Hartford, Conn.
Elements of effective transitions
A scientific statement by the American Heart Association published in the February 2015 Circulation: Heart Failure outlined common themes of successful transitions-of-care interventions to prevent heart failure readmissions. Most programs include a nurse leader who acts as care coordinator and health coach. Successful programs also tend to have the following eight characteristics:
Patient education. Provide patients with information and instructions about diet, signs and symptoms of heart failure, self-care expectations, and medication counseling.
Telephone follow-up. Call patients or caregivers within 48 to 72 hours of discharge.
Early follow-up. Before discharge, make an appointment for the patient to see an outpatient physician within seven to 10 days after discharge.
Early assessment of discharge conditions. Assess patients' home situation prior to discharge to identify any special needs or barriers to care.
Medication reconciliation. Perform reconciliation at admission and immediately before discharge.
Caregivers. Identify caregivers early to determine availability and to include them in predischarge education and planning.
Home visits. Nurses should make one or more visits to the home up to six months after discharge to reinforce education and help patients with self-care decisions.
Handoffs. Before discharge, communicate with outpatient clinicians about hospital events, diagnostic results, procedures performed, medications ordered, and therapies implemented.
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