Session 9: Key Strategies to Keep Heart Failure Patients Out of the Hospital Learning Objectives

Transcription

1 Session 9: Key Strategies to Keep Heart Failure Patients Out of the Hospital Learning Objectives 1. Evaluate the risk factors and clinical interventions for heart failure. 2. Identify the importance of early follow-up care by PCPs in keeping heart failure patients from being readmitted. 3. Apply new initiatives that PCPs can participate in to help reduce hospital readmissions and improve patient quality of life.

2 Session 9 Key Strategies to Keep Heart Failure Patients Out of the Hospital Faculty Richard F. Wright, MD, FACC President Pacific Heart Institute Santa Monica, California Dr Richard Wright is president, research director, and director of the heart failure center at Pacific Heart Institute, Santa Monica, California. He previously served as director of the heart institute and of critical care at Saint John s Health Center, California, and is also on the clinical faculty at the University of California, Los Angeles. Dr Wright earned his medical degree from the Harvard Medical School, where he also completed his medical residency and cardiology fellowships at the Brigham and Women s Hospital. Dr Wright is currently codirector of the medicare contractor advisory committee for California, chair of the American College of Cardiology National Carrier Advisory committee, and the cardiology advisor to the relative value update committee of the American Medical Association. He has served as president of the American College of Cardiology California chapter, and on the medical advisory board at the Los Angeles Zoo, where he served as the cardiologist for the great apes. Dr Wright is a renowned lecturer on cardiovascular topics and was a coauthor of the US guidelines on management of patients with heart failure. A recipient of the specialist of the year award from the American College of Cardiology, California, he continues to be listed in peer surveys as one of the top cardiologists in California. Faculty Financial Disclosure Statement The presenting faculty reports the following: Dr Wright has no financial relationships to disclose.

3 SESSION 9 11:15am 12:15pm Key Strategies to Keep Heart Failure Patients Out of the Hospital SPEAKER Richard F. Wright, MD, FACC Presenter Disclosure Information The following relationships exist related to this presentation: Richard F. Wright, MD, FACC, has no financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objectives Evaluate the risk factors and clinical interventions for heart failure Identify the importance of early follow-up care by PCPs in keeping heart failure patients from being readmitted First, a primer on heart failure Apply new initiatives that PCPs can participate in to help reduce hospital readmissions and improve patient quality of life Lifetime Risk for Developing Heart Failure From Risk Factors to Heart Failure: The Cardiovascular Continuum Men Lloyd-Jones, et al. Circulation. 2002;106: Women At age 40 years, the lifetime risk for HF was 21.0% (95% CI, 18.7%-23.2%) for men and 20.3% (95% CI, 18.2%-22.5%) for women CAD Atherosclerosis LVH Risk factors Hyperlipidemia Hypertension Diabetes Insulin resistance Coronary thrombosis Myocardial ischemia A Myocardial infarction Dzau V, et al. Am Heart J Apr;121(4 Pt 1): Loss of muscle B Arrhythmia Remodeling (due to neurohormonal activation) Ventricular dilation D Sudden death Heart failure Death C 1

4 STAGE A Heart Failure At Risk for Heart Failure At high risk for HF but without structural heart disease or symptoms of HF e.g. Patients with: hypertension atherosclerotic disease diabetes obesity metabolic syndrome Therapy Goals Treat hypertension Encourage smoking cessation Treat lipid disorders Encourage regular exercise Discourage alcohol intake, illicit drug use Control metabolic syndrome OR using cardiotoxins with FH of cardiomyopathy Structural heart disease Drugs ACEI or ARB in appropriate patients with vascular disease or diabetes STAGE B Heart Failure At Risk for Heart Failure Structural heart disease but without signs or symptoms of HF. e.g. Patients with: previous MI LV remodeling including LVH and low EF Asymptomatic valvular disease Therapy Goals All measures under Stage A Drugs ACEI or ARB in appropriate patients Beta-blockers in appropriate patients Development of symptoms of HF STAGE C Heart Failure Heart Failure Structural heart disease with prior or current symptoms of HF STAGE D Heart Failure Heart Failure Refractory HF requiring specialized interventions. e.g. Patients with: known structural heart disease and shortness of breath and fatigue, reduced exercise tolerance Therapy Goals All measures under Stages A and B Dietary salt restriction Drugs For Routine Use Diuretics for fluid retention ACEI Beta-blockers Refractory symptoms of HF Drugs in Selected Patients Aldosterone antagonist ARBs Digitalis Hydralazine/ nitrates Devices In Selected Patients Biventricular pacing Implantable defibrillators e.g. Patients who have marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions) Therapy Goals Appropriate measures under Stages A, B, C Decision re: appropriate level of care Options end-of-life care Extraordinary measures Heart transplant Chronic inotropes Permanent mechanical support Experimental surgery or drugs Therapies Demonstrated to Reduce Mortality in Systolic Heart Failure- All Class I, LOE A ACE Inhibitors (ARB) Beta Blockers Aldosterone Antagonists Hydralazine-Isosorbide dinitrate ICD (LVEF < 35, Class II or II) Cardiac Resynchronization + ICD LVEF < 35, QRS > 120 ms, Class III or IV Do the HF clinical practice guidelines actually work in unselected real world patients? The CONSENSUS Trial Study Group. N Engl J Med. 1987;316: Packer M, et al. N Engl J Med. 1996;334: Pitt B, et al. N Engl J Med. 1999;341: Moss A, et al. N Engl J Med. 1996;335: Abraham WT, et al. N Engl J Med. 2002;346: LOE A = Level of Evidence - A 2

5 Baseline Quality Measures Conformity with Quality Measures at Baseline Baseline Measure Conformity: Alive vs. Dead at 24-Month Follow-Up Eligible Patients Treated 100% 80% 60% 40% 20% 0% 86.2% 79.8% 34.4% ACEI/ARB Beta-blocker Aldosterone Antagonist CRT-P only ICD only 68.6% 61.8% 48.8% 37.7% 31.7% 31.4% 17.2% 6.3% Anticoagulation CRT ICD HF education for AF N = 11,165/ 11,868/ 987/ 2,910/ 580/ 4,799/ 9,373/ 13,987 13,772 2,870 4,244 1,540 9,830 15,177 Fonarow GC, et al. Circ Heart Fail. 2008;1(2): The baseline process measure conformity was significantly lower among patients who died compared with those who survived for 5 of 7 individual measures. Fonarow GC, et al. Circulation. 2011;123(15): Improved Adherence to HF Guidelines Translates to Improved Clinical Outcomes in Real World Patients Each 10% improvement in guideline recommended composite care was associated with a 13% lower odds of 24-month mortality (adjusted OR 0.87; 95% CI, 0.84 to 0.90; P<0.0001). SUMMARY #1 The risk for HF is ubiquitous in the adult population Exercise a high level of surveillance in ALL adult patients For those with HF and reduced EF, adherence to evidence-based guideline driven care improves all outcomes and should be the first order of importance Fonarow GC, et al. Circulation. 2011;123(15): Case I Why the focus on HF-related readmissions? JG 57-year-old African American man with a non-ischemic dilated cardiomyopathy; ACC/AHA stage C/NYHA class III HF; LVEF 0.19 Meds- carvedilol, lisinopril, furosemide, ISDN/HYD, digoxin; intermittently adherent Has not consistently seen his PCP Three hospitalizations for HF in the past 9 months 3

6 Case II LF 71-year-old WF with HTN, DM, chronic AF, obesity, CKD (estimated GFR ~ 30 ml/min/1.73 m 2 ), obstructive sleep apnea and a history of HF; no evidence of coronary artery disease; LVEF ~ Meds- Digoxin, lisinopril, metoprolol, metformin, furosemide, ASA, amlodipine, CPAP Four admissions in the last 12 months, all heralded by the onset of dyspnea and worsening peripheral edema Case III RS 76-year-old man with a known past medical history of severe coronary artery disease; s/p prior large anterior wall MI, urgent PCI and multivessel CABG. Residual LVEF = 0.17 Meds: carvedilol, spironolactone, lisinopril, bumetamide, potassium supplementation, amiodarone. Has CRT-D device in place Usual BNP ~ 3,000 pg/ml Four prior admissions for symptomatic class III/IV HF; not a candidate for transplant due to age and has declined LVAD Scenario All three patients have you as the primary care physician of record and have been flagged by your hospital s quality improvement officer as opportunities to reduce readmissions and avoid hospital penalties levied by CMS. You are asked to focus on these patients as prototypes and to develop best practices that might impact the overall readmission profile for the hospital Discussion Case 1: would benefit from social services and community based care support Case 2: would benefit from early transition of care with prompt post hospital follow-up and disease management in a nurse directed multidisciplinary program Case 3: would benefit most from a palliative care referral and possibly hospice CMS = Centers for Medicare and Medicaid Services The Natural History of HF s/p HF Hospitalization 100 Hospital Readmissions 100 Mortality Rehospitalization in Medicare Beneficiaries Risk-standardized readmission rate, % 50% % % 25 12% RSRR 0 30 days 6 months 0 30 days 12 months 5 years.2 Median hospital LOS: 6 days Annual mortality rate NYHA class III HF: 12% [COPERNICUS Class 3 DATA] NYHA class II HF: 7% [SCD-HeFT Class 2 DATA] Jong P, et al. Arch Intern Med. 2002;162(15): Ross JS, et al. Circ Heart Fail. 2010;3(1):

7 Survival and Readmission After Hospitalization for Heart Failure: VA Healthcare System SUMMARY #2 50,125 first HF hospitalizations Mortality decreased while rehospitalization for HF remained flat or slightly increased over time. Evidence-based therapies have been established for reduced EF HF The natural history after an index admission for HF portends a poor prognosis The burden of HF hospitalization is great There is a disconnect between improving mortality rates and worsening readmission rates Data not shown: Similar results were seen for HF defined as a primary or secondary diagnosis: c-statistic = 0.76 for HF as a primary diagnosis and 0.75 for mortality J Am Coll Cardiol. 2010;56(5): doi: /j.jacc Medicare Provisions in PPACA Readmissions HR 3590 Readmissions Policy Overview Timing of Penalty Initiation: FY 2013 Targeted Conditions: HF, AMI, pneumonia May expand to additional conditions in FY 2015: PCI, COPD, vascular, CABG Payment Penalties: MS-DRG payment adjusted for excessive readmission rate or by set threshold (FY 2013: 1%; FY 2014: 2%; FY 2015 and thereafter: 3%) Medicare Provisions in PPACA Readmissions Hospitals will have readmission rates made publically available Hospitals with high risk adjusted readmissions with no steps to reduce readmission will be required to report on process The CBO score is - $0.5 billion for FY2010-FY2014, and - $7.1 billion for FY2010-FY2019 Source: US House of Representatives, Amendment in the Nature of a Substitute to H.R. 4872, as Reported, March 18, 2010; US Senate, The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, December 24, 2009; Health Care Advisory Board interviews and analysis. Medicare Provisions in PPACA Readmissions A risk-adjustment model which factors in patient age, gender, past medical history, and other diseases or conditions (comorbidities) that patients had when they arrived at the hospital that are known to increase their risk will be used in determining excessive readmissions. Hospitals with excessive readmission rates (where observed rates are higher than expected rates as reported in data collected from 2009) for HF, AMI, and pneumonia collectively are seeing reduced payments by 1% on all MS- DRGs beginning in FY SUMMARY #3 The cost of hospitalization for HF is unsustainable The penalties are real, have already been deployed and will increase over time All hospital systems now have sharpened focus on readmissions 5

8 In-Hospital and Follow-Up Outcomes by Process of Care Improvement Tool Use Strategies to reduce readmissions: are there any proven to be effective? Patients (%) In-Hospital Mortality P PrCI Tool Use No PrCI Tool Use Patients (%) 60- to 90-Day Mortality and Rehospitalization P< PrCI Tool Use No PrCI Tool Use PrCI tool use (admission order set or discharge checklist) was reported during hospitalization in 45.3% of patients (n=22,017/48,612). Fonarow GC, et al. Arch Intern Med. 2007;167(14): Early Physician Follow-Up and 30-Day Readmission among Medicare Beneficiaries Hospitalized with Heart Failure Observed 30-Day Outcomes Adrian F. Hernandez, MD a, Melissa A. Greiner, MS a, Gregg C. Fonarow, MD b, Bradley G Hammill, MS a Paul A. Heidenreich, MD c, Clyde W. Yancy, MD d, Eric D. Peterson, MD, MPH a and Lesley H. Curtis, PhD a on behalf of the Get With The Guidelines Steering Committee and Hospitals Hernandez AF, et al. JAMA May 5;303(17): Day Mortality p= 0.44; 30-Day Readmission, p <0.01 Note: Quartiles 3 & 4 represent follow-up within 1 and 2 weeks after admission Hernandez AF, et al. JAMA May 5;303(17): Relationships between domain scores and 30-day risk-standardized readmission rates 35 Clinical Service Organization for Heart Failure: a Cochrane Review Risk-Adjusted Readmission Rate Discharge Process / Transitional Care Domain Score. P=.03 Review of 25 published trials, n=5,942 patients Multidisciplinary interventions associated with reduction in readmissions, including all cause; OR 0.46 (95% ) From 100 US GWTG-HF hospitals deploying quality improvement programs Kociol RD, et al. Circ Heart Fail. 2012;5(6): Takeda A, et al. Cochrane Database Syst Rev Sep 12;9. 6

9 Fee-For-Service Incentive for Early Follow-up Post Discharge New Transitional Care Management billing codes: (moderate complexity) and (high complexity) Payment for decision-making on patient transitioning from any health care facility setting to the patient s community setting Each code covers from day of discharge through day 29 Only billable on or after day 30, and only by one physician Interaction required within 2 business days post-discharge Can be phone call, , or direct Can be billed in addition to any other required E&M service Not billable by a physician under a global procedure period One face-to-face meeting required within 14 days for 99495, within 7 days for RVU for 99495, 3.05 RVU for SUMMARY #4 Reducing readmissions requires a focus on processes of care Early follow-up works Multidisciplinary disease management programs appear to be most effective Transition of care models may be modestly beneficial but at what cost? Unforeseen Implications of the Readmissions Focus Risk-Adjusted Hospital Readmission Rates and Mortality Rates 30 Days after Admission for Heart Failure Excess mortality may be a consequence Safety net and teaching hospitals are disproportionately impacted by penalties Readmissions are front-loaded in the 30-day window; a 30-day period is not physiological Fewer than half of the causes for readmission are related to the primary illness This may be a uniquely Medicare population issue Gorodeski EZ, et al. N Engl J Med. 2010;363(3): Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program 30-Day Readmissions After Hospitalization for Heart Failure Heart Failure Hospitalizations All readmissions, 13.4% All readmissions, 31.7% All readmissions, 61.0% Teaching Hospital Safety Net Hospital Excerpted from JAMA. 2013;309(4): Dharmarajan K, et al. JAMA. 2013;309(4): Days Following Hospital Discharge 7

10 Patients Readmitted With Common Readmission Diagnoses During Cumulative Periods Following Hospitalization for Heart Readmission Failure Diagnosis Only 50% of patients discharged with HF dx were readmitted for HF; comorbidities in nearly half of HF patients were not adequately addressed Renal Disorders Pneumonia Arrhythmias Septicemia/shock Cardiorespiratory failure COPD Heart Failure Three-phase terrain of lifetime readmission risk after heart failure hospitalization Readmission Rate Initial Discharge Transition Phase Plateau Phase Death Palliation & Priorities CC=complications of care Dharmarajan, K et al. JAMA. 2013;309(4): Chronic angina/cad AMI Cumulative periods after discharge, days CC 30-Day Readmissions, % Median Time from Hospital Discharge Desai AS, et al. Circulation. 2012;126: SUMMARY #5 The solution to the readmissions conundrum is complicated and though misguided in part, the economic imperative cannot be dismissed Best practices at present include a sharp focus on process of care Questions? Beware the unintended consequence; an increase in mortality rates at 30 days is an unacceptable price to achieve cost reductions 8