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

Reducing 30-day Rehospitalization for Heart Failure: An Attainable Goal? Ileana L. Piña, MD, MPH Professor of Medicine, Epi/Biostats Case Western Reserve University Graduate VA Quality Scholar Cleveland 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 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 within 6 months

Heart failure 30-day Risk-Standardized Readmission Rate Distribution Krumholz, H. M. et al. Circ Cardiovasc Qual Outcomes 2009;2:407-413

ADHERE Variation in ACE Inhibitor Use for HF Rate (%) 0 20 40 60 80 100 ORYX Core Measure: HF 3 - LVEF < 40% prescribed ACEI at discharge ADHERE Hospitals 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.

Outcomes in Patients Hospitalized With HF 100 Hospital Readmissions 100 Mortality 75 75 50 25 20% 50% 50 25 12% 33% 50% 0 30 Days 6 Months 0 30 Days 12 Months 5 Years Mean LOS: 6.5 days Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3 Jong P et al. Arch Intern Med. 2002;162:1689 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 postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.

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

Cumulative Impact of Heart Failure Therapies 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.

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

Clinical Status at Discharge Evidence for Incomplete Relief from Congestion 35 32% Asymptomatic 44% Improved (but still symptomatic) 40% 30 25 24% 20 15 10 5 8% 7% 13% 11% 3% 2% No Mention 11% 0 (<-20) ( 20 to 15)(-15 to 10)( 10 to 5)( 5 to 0) (0 to 5) (5 to 10) (>10) Change in Weight (lbs) Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

Medication Change Analysis CHRONICLE CONTROL Changes / Patient Month 6 5 4 3 2 1 0 5.13 p=0.0044 4.02 4.02 p=0.0025 2.97 2.11 p<0.001 1.37 0.20 0.15 0.18 0.23 0.23 0.19 All Drugs All CV Drugs Diuretics ACE/ARB Beta Blockers Vasodilators/ Nitrates

Large Treatment Gaps for Newer Guideline 2 Recommended Therapies Including ICD 6 100 90 80 70 60 50 40 30 20 10 0 Baseline Q1 Q2 Q3 Q4 Years 2005 to 2006 P=0.0017 P=0.0498 25 24 24 24 24 0.6 P<0.0001 1.6 3.5 3.2 26 28 26 26 25 8.6 Aldosterone Antagonist Hyd/Nitrates in Black Pts ICD in LVEF <= 30% Data from 97 GWTG-HF hospitals and 18,516 HF patients were collected from 1/05-3/06 Fonarow GC et al. AHA 2006 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, 0.0 Mean, 7.3 Yancy CW et al. HFSA 2008 abstract

Mean Dose and Frequency of Dose Changes 2 of β-blockade Post HF Hospital Discharge 8 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 Immediate-release metoprolol tartrate 57.5 ± 47.9 68.6 ± 57.8 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 Hospital ED Diagnosis Admit CCU? Acute Rx Evaluation CCU Telemetry IV Meds Oral Meds LV function Echo and/or Cath? Other Evaluation Tx to Floor DC Black hole* Oral Meds Other Rx? Other eval Pt Ed F/U Disease Manage Early Post DC Right meds? Titration Pt Education Disease Manage Continuity Device? Black hole* Outpatient On right meds? On right dose? Volume status Re-assess EF Device? Self Manage? Other Issues? Fonarow GC. Rev Cardiovasc Med. 2006;7:S3-11. * Who is responsible????

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 Over 2/3 of HF Hospitalizations Preventable Diet Noncompliance 24% Rx Noncompliance 24% 16% Inappropriate Rx 19% Failure to Seek Care 17% Other Post d/c monitoring Annals of Internal Medicine 122:415-21, 1995

Patient or Clinician driven

Home visits Home based nursing with special training in HF

6-Month All Cause Mortality Rates by Randomization Arm Alere Standard Care 60% 50% All-cause mortality 40% 30% 20% p=0.24 10% 0% 11.2% 7.0% 0 50 100 150 200 Days After Study Entry

Understanding health care as a system How we improve what we make What society needs How we create, make health care

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 Copyright CWRU-CME 2003 All Rights Reserved

HF GWTG-HF Cycle of Quality Improvement Find and Support a Champion HEART FAILURE Assess HF Treatment Rates Measure current treatment rates and process-of-care indicators Implement Refined Protocols Hospital team coordinates implementation of refined protocols Evaluate Assessment Hospital team reviews summary reports and current protocols Refine Protocols Hospital team identifies areas for 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) A national quality improvement initiative of the American College of Cardiology and the Institute for Healthcare Improvement Building on Success ACC s Door to Balloon: An Alliance for Quality IHI s 100K Lives & 5M Lives Campaigns

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

H2H 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 followup 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?