Positive Impact of Recent Metrics

Transcription

1 Seeing Faces on Readmissions and Unmet Metrics Who is getting readmitted after heart failure hospitalizations? Who with HFrEF is discharged without guideline-based medications? Positive Impact of Recent Metrics Hospital focus on readmissions: Attention and engagement of hospital staff previously focused on length of stay Focus on medication reconciliation and prescriptions Support for HF management infrastructure -?maintenance Get with the Guidelines program Identification of GDMT as a key value for patient care Education and engagement of hospital staff for discharges Focus on medication reconciliation and prescriptions Resources and feedback to improve individual provider performance 1

2 Metrics for Readmission Adjusted for Severity 6,302,380 Medicare episodes at 3259 HRPP hospitals and 1115 control hospitals (AMI, heart failure, pneumonia) Hospital Incentives PRE HRPP POST HRPP Control 1115 hosps HRPP 3259 hosps ( especially renal disease, HTN, electrolyte disorders) Average # Co Morbidities Ibrahim et al JAMA Int Med 2018: 178: 83 5 UNADJUSTED ADJUSTED FOR CO MORB What Are Our Re-Admissions To Target? Index hosp Terminal Non Card With HF Index Non HF Readmit Non Cardio Renal HF or Cardiorenal Both Admits Munoz et al VUMC Readmits 2016 to early 2018 HF Both Admits Index non card terminal+hf Index non card Readmit non CardioRenal 2

3 Types of Patients Readmitted WITH HEART FAILURE Persistently Limited Adherence = Near Refractory PLAD Others left Wet Other Munoz D, Choma N et al Vanderbilt Heart and Vascular Institute Average 6 readmissions In preceding 12 months Typical single hosp: heart failure History: HFrEF non-ischemic 2 hospitalizations in past 3 years for congestion, once after elective gall bladder surgery at another hospital, once shortly after Thanksgiving trip during which she did not take Lasix given long flights When not in hospital: Shows up to most appointments, generally knows what foods/fluids to avoid; water aerobic class 3x/week Her words: I can usually tell when I start holding onto extra fluid. When my weight goes up, I double my Lasix and get better, sometimes it s not enough. 3

4 Familiar face: heart failure Lost touch with family, rents a room in group home. Comorbidities: DM, COPD, OSA, morbid obesity Hospital history: HfpreservedEF 8 admissions in past 18 months for volume overload, usually lbs more than when he last left hospital. Easy to diurese in the hospital. Orders fast food delivery to his room. When not in hospital: Rarely shows up to appointments, does not answer RN calls or open door to home health. Not sure of medications. Eats what I can take home with me His words: I don t know why these doctors can t just get me better. Late stage, advanced heart failure Family Information: Married, 5 grandchildren Medical history: HFrEF first MI 25 years ago, HTN, DM, egfr 25 cm, torsemide dose 200 bid The past year: 6 hospitalizations at VUMC for shortness of breath and GI symptoms. RV failure with RAP=PCW 18 on last cath. During last stay, needed short course of IV inotrope When not in hospital: Shows up to all of his appointments with his wife, communicates well/frequently with medical team, fills prescriptions on time. His words: I realize my disease is getting worse, but I want to see my grandchildren graduate from college and keep my wife company. 4

5 Seeing Faces on Readmissions and Unmet Metrics Who is getting readmitted after heart failure hospitalizations? Who with HFrEF is discharged without guideline-based medications? SCAMP = Standardized Care and Management Plan All quality improvement is local. Encourage and standardized quality care established by guidelines Document and understand deviations 226 discharges from HF inpatient service 132 from academic hospital 94 from community hospital with dedicated HF management program Gilstrap,Stevenson,Small,Parambi, Hamershock.Greenberg,Carr,Ghazinouri, Rathman,Han,Mehra,Desai. J Am Heart Assoc 2018;118:

6 Guidelines Reflect the Need for Individualized Care 6

7 Reasons for Lower Dose or No Beta Blockers at Discharge HYPOTENSION Inotropic Therapy 37% of HFrEF patients discharged On lower doses or no beta blockers Gilstrap et al J Am Heart Assoc 2018; 7, 1 8 HF Program in Academic Hosp Expert HF Program In Community Hosp Reasons for Lower Dose or No ACEI/ARB at Discharge 47% of HFrEF discharged on lower doses Or no ACEI/ARB inhibition 28% not on at admission or discharge 18% stopped or lower dose 52% initiated or maintained 2% changed from ACEI to ARB HF Program in Academic Hosp Expert HF Program In Community Hosp Gilstrap et al J Am Heart Assoc 2018; 7, 1 8 7

8 Guideline Adherence and Readmissions CONGESTED CONGESTED Better with ACEI/ARB Therapy or Patient? Conception of the Changing Gap After Getting With the Guidelines Good to go With Guidelines??? Beyond Guidelines Propensity to Match or Mismatch Patients and Therapies? European J Heart Failure 2017; 20:

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