Reducing 30-day Rehospitalization for Heart Failure: An...

Reducing 30-day Rehospitalization for Heart Failure: An Attainable Goal?

Reducing 30-day Rehospitalization for Heart Failure: An Attainable Goal?

Ileana L. Piña, MD, MPHProfessor of Medicine, Epi/BiostatsCase Western Reserve University

Graduate VA Quality ScholarCleveland Ohio

If we want to work with a system to influence its direction -- a normal

desire as we work with human organizations--the place for us to

work is deep in the dynamics of the system where [its] identity is taking

form.

Wheatley & Kellnor-Rogers, 1996

Contemporary Application of Evidence-based Care for Acute and Chronic Heart Failure Contemporary Application of Evidence-based Care for Acute and Chronic Heart Failure

• Heart failure results in substantial morbidity and mortality

• Fortunately, a number of evidence-based, life-prolonging drug and device therapies have been developed and are now widely available for managing patients with heart failure

• Despite overwhelming clinical-trial evidence, expert opinion, national guidelines, and a vast array of educational conferences, these evidence-based, life-prolonging drug and device therapies continue to be underutilized in both the inpatient and outpatient settings

Fonarow GC. Rev Cardiovasc Med. 2002;3:S2-S10.

Definition of Quality

“Degree to which health care services increase the likelihood of desired health outcomes and are consistent with current professional knowledge”

– Are you doing the right things?

– Are your patients better off for it?

Challenges in Measuring HF Quality of Care

• HF is not a single entity– Systolic vs diastolic HF– Etiology (ischemic vs other)– Severity (NYHA class I-IV)

• Limited data on what processes works, particularly in the acute setting

• Even less information how process of care delivery factors affect outcomes

• Longitudinal disease– Yet measurement often cross-sectional

Heart failure readmission

rates are quite high.

Almost half of the patients were readmitted within6 months

Copyright CWRU-CME 2003All Rights Reserved

Heart Failure is the most common reason for 30 day reshospitalization

nn Jencks et al.Jencks et al. N Engl J Med 2009;360:1418-28.

Krumholz, H. M. et al. Circ Cardiovasc Qual Outcomes 2009;2:407-413

Heart failure 30Heart failure 30--day Riskday Risk--Standardized Standardized Readmission Rate DistributionReadmission Rate Distribution

ADHERE Variation in ACE Inhibitor Use for HF ADHERE Variation in ACE Inhibitor Use for HF

ADHERE: Dec 2002, 206 Hospitals; 23,193 patients (subset with LVEF ≤

.40, no CI)

Fonarow GC et al. Arch Intern Med. 2005;165:1469-1477.

ORYX Core Measure: HF 3 - LVEF < 40% prescribed ACEI at discharge

Rate

(%)

020

4060

8010

0

ADHERE Hospitals

Outcomes in Patients Hospitalized With HFOutcomes in Patients Hospitalized With HF

Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3Jong P et al. Arch Intern Med. 2002;162:1689

0

25

50

75

100

20%

50%

30Days

6Months

Hospital Readmissions

0

25

50

75

100

12%

50%

30Days

12Months

Mortality

33%

5Years

Mean LOS: 6.5 days Annual mortality rate-NYHA class III HF-12% [COPERNICUS DATA]NYHA class II HF-7% [SCD-HeFT DATA]

HF readmission can be decreased.

Comprehensive discharge planning plus post- discharge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.


52% of heart failure patients are not seen in the first 30 days after a hospitalization

nn Jencks et al. Jencks et al. N Engl J Med 2009;360:1418-28

Why Does it Matter to Providers?Why Does it Matter to Providers?

• Putting the patient first• Improving transitions of care• The right treatment at the right time for the right reason for

all patients• Fulfilling requirements • Finding opportunities to improve care• Use measurement as a tool to create an imperative to

improve and provide perspective regarding performance• Clinicians should engage constructively in this effort and

should examine adverse outcomes within their institutions

Relative-Risk 2 Year Mortality

None - - 35%

ACE Inhibitor 23% 27%

Aldosterone Ant 30% 19%

Beta-Blocker 35% 12%

CRT +/- ICD 36% 8%

Cumulative risk reduction if all four therapies are used: 77%Absolute risk reduction: 27%, NNT = 4

Updated from Fonarow GC. Rev Cardiovasc Med. 2000;1:25-33.

Cumulative Impact of Heart Failure Therapies

Cumulative Impact of Heart Failure Therapies

Is it omission, or commission in the hospital stay?????

Inadequate diuresis without other considerations? Removal of life-saving therapies? Fear of hypotension, renal dysfunction? Avoiding phone calls? No uptitration Late visits

Is it omission, or commission in the hospital stay?????

Inadequate diuresis without other considerations? Removal of life-saving therapies? Fear of hypotension, renal dysfunction? Avoiding phone calls? No uptitration Late visits

Source: Wall Street Journal

8% 7%

13%

24%

32%

11%

3% 2%

0

5

10

15

20

25

30

35

(<-20) (–20 to –15)(-15 to –10)(–10 to –5)(–5 to 0) (0 to 5) (5 to 10) (>10)

Change in Weight (lbs)

No Mention

11%

Asymptomatic44%

Improved

(but still

symptomatic)40%

Clinical Status at Discharge Evidence for Incomplete Relief from Congestion

Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

Medication Change Analysis Medication Change Analysis

p=0.0044p=0.0044

p=0.0025p=0.0025

p<0.001p<0.001

5.13

4.02

2.11

0.20 0.18 0.23

4.02

2.97

1.37

0.15 0.23 0.19

0

1

2

3

4

5

6

All Drugs All CV Drugs Diuretics ACE/ARB Beta Blockers Vasodilators/Nitrates

Cha

nges

/ Pa

tient

Mon

th

CHRONICLE CONTROL

2 6

Large Treatment Gaps for Newer Guideline Recommended Therapies Including ICD

25

0.6

2624

1.6

2824

3.5

2624

3.2

2624

8.6

25

0102030405060708090

100

Aldosterone Antagonist Hyd/Nitrates in Black Pts ICD in LVEF <= 30%

Baseline Q1 Q2 Q3 Q4

P=0.0017

Data from 97 GWTG-HF hospitals and 18,516 HF patients were collected from 1/05-3/06Fonarow GC et al. AHA 2006 abstract

P<0.0001

P=0.0498

Years 2005 to 2006

Yancy CW et al. HFSA 2008 abstract

Variation in HF Quality of Care in US Cardiology Practices: IMPROVE-HF

The frequency distribution of conformity rates by practice

Use of Hydralazine/Nitrates in Black Patients

Median, 0.0Mean, 7.3

2 8

Mean Dose and Frequency of Dose Changes of β-Blockade Post HF Hospital Discharge

Mean Daily Dose (mg)

At Discharge At 60-90 day Follow-up

Carvedilol 17.8 ± 17.5 20.3 ± 17.3

Newly started on carvedilol 12.5 ± 14.2 16.9 ± 15.2

Metoprolol succinate 68.3 ± 52.8 68.7 ± 52.2

Newly started on metoprolol succinate 57.5 ± 47.9 68.6 ± 57.8

Immediate-release metoprolol tartrate 81.7 ± 55.2 82.2 ± 56.4

Atenolol 43.7 ± 30.9 47.1 ± 37.8

Fonarow GC, et al. Am J Cardiol 2008;102:1524-9

Continuity of HF Care Reliable Care: Not Missing the Steps Continuity of HF Care Reliable Care: Not Missing the Steps

Fonarow GC. Rev Cardiovasc Med. 2006;7:S3-11.

OutpatientOutpatient

•• On right meds?On right meds?•• On right dose?On right dose?•• Volume statusVolume status•• ReRe--assess EFassess EF•• Device?Device?•• Self Manage?Self Manage?•• Other Issues? Other Issues?

Early Early Post DCPost DC

•• Right meds?Right meds?•• TitrationTitration•• Pt Pt

EducationEducationDiseaseDiseaseManageManage

•• ContinuityContinuityDevice?Device?

DCDC

•• Oral MedsOral Meds•• Other Rx?Other Rx?•• Other evalOther eval•• Pt EdPt Ed•• F/UF/U•• DiseaseDisease

ManageManage

CCUCCUTelemetryTelemetry

•• IV MedsIV Meds•• Oral MedsOral Meds•• LV functionLV function•• Echo and/orEcho and/or

Cath?Cath?•• OtherOther

EvaluationEvaluation•• Tx to FloorTx to Floor

HospitalHospitalEDED

• • DiagnosisDiagnosis•• Admit Admit

•• CCU?CCU?•• Acute RxAcute Rx

•• EvaluationEvaluation

* Who is responsible????

Black hole* Black hole*

Black hole* Black hole*

The “Perilous”

Time• 40% of HF patients do not get discharged to

home– Skilled Nursing Facility– Long Term Care– Rehabilitation Facility

• Home discharge– Hospital Home– Visiting Nurse– Home physician visits

• Timing to next decompesation

Causes of Hospital Readmission for Congestive Heart Failure

17%Other

19%Failure to Seek

Care

16%Inappropriate Rx

Rx Noncompliance24%

Diet Noncompliance24%

Annals of Internal Medicine 122:415-21, 1995

Over 2/3 of HF Hospitalizations Preventable

Post d/c monitoring

Patient or Clinician driven

Home visits

• Home based nursing with special training in HF

Stewart S, et al. Circulation 2002;105:2861

Efficacy of Heart Failure Management Programs


6-Month All Cause Mortality Rates by Randomization Arm

0%

10%

20%

30%

40%

50%

60%

0 50 100 150 200

Alere Standard Care

Days After Study Entry

p=0.24

11.2%

7.0%

All-

caus

e m

orta

lity

How we improvewhat we make

What society needs

How we create, make health care

Understanding health care Understanding health care as a systemas a system

Tools are critical

♦ “Aid” to practitioners to apply “best care”♦Making tools attractive by not “adding more

work”♦Non threatening♦Easily integrated into the current practice♦Need to understand better the barriers that

exist to implement quality measures♦Promoted by physician “champions”

The Heart Failure Continuum• A successful care process must

address ALL areas of heart failure care– SNF care– Ambulatory clinic care– ED decisions to send– Home health care when discharged home

• Goals:– Decrease hospitalizations– Decrease length of stay– Improve QOL– Prolong survival– Improve symptoms


Integration Of The Care Process

HF teamHF patient

Hospital, clinic,referring MD

Flow ofinformation

Flow ofinformation

Communication

Flow ofinformation


HFH

EA

RT

FA

ILU

RE

Evaluate AssessmentHospital team reviews summary

reports and current protocols

Refine ProtocolsHospital team identifiesareas for improvement

Implement Refined ProtocolsHospital team coordinates

implementation of refined protocols

Find and Support a ChampionFind and Support a Champion

Assess HF Treatment RatesMeasure current treatment rates

and process-of-care indicators

GWTG-HF Cycle of Quality Improvement

A Call to Action• Care about core measures, performance

measures, and outcomes!• Get involved with the development of the

measures – know what it means for you• Understand what is required of you to meet

performance measures• Document your adherence to guidelines/PM• Find opportunities for improvement• Demonstrate to your patients that you have

quality outcomes

What is H2H?

• National Rallying Point• Catalyze Action• Leverage Other Initiatives• Rapid Learning Community• Building on Success

Hospital to Home (H2H)Hospital to Home (H2H)A national quality improvement initiative of the American College of Cardiology and the Institute for Healthcare Improvement

Building on SuccessBuilding on Success•ACC’s Door to Balloon: An Alliance for Quality•IHI’s 100K Lives & 5M Lives Campaigns

GoalGoalReduce 30 day, all-cause, risk standardized readmission rates (RSRR) for patients discharged with cardiac conditions by 20% by December 2012.

H2H Core ConceptsH2H Core Concepts• Post-discharge medication management. Patients must

not only have access to the proper medications, they need to be properly educated on how to use them.

• Early follow-up. Discharged patients should have a follow- up visit scheduled within a week of discharge, as well as the means of getting to that appointment.

• Symptom management. Patients must recognize the signs and symptoms that require medical attention, as well as the appropriate person to contact if those signs/symptoms appear.

“Hospitals and clinicians have no way to assess and benchmark overall clinical performance from the patient’s perspective.”Krumholz

and Normand, Circ 2008

After all…..Isn’t it all about the PATIENT?

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