Tuesday, June 1, 2010

Have We Improved Outcomes for Elderly Patients Admitted with Heart Failure?


Hospitalization for heart failure is exceedingly common, accounting for more than 1.1 million hospitalizations in 2006. It is also the leading cause of hospitalization in patients older than 65 years of age, accounting for at least 20% of all hospital admissions in this age group. The good news, according to a new paper by Bueno and colleagues published in JAMA today, is that we are doing a great job in the hospital of making them better and shipping them out. The bad news is that patients are more likely to end up in a skilled nursing facility or be readmitted within 30 days.

The JAMA study analyzed 6,955,461 Medicare fee-for-service hospitalizations for heart failure from 1993 and 2006, and importantly also looked at a 30-day post-discharge follow-up period. What they found was that length of stay decreased from 8.8 days to 6.3 days between 1993 and 2006. In hospital mortality was cut in half from 8.5% to 4.3% and overall 30 days mortality dropped as well from 12.8% to 10,7%. We rock, right? Well, not really. The study also saw discharges to skilled nursing facilities jump up by half (13% to 17%) and 30 day readmission rates increase from 17% to 20%. Post-discharge mortality also increased from 4.3% to 6.3%.

These findings are similar to a study by Curtis and colleagues published in the Archives of Internal Medicine in 2008. This study looked at 2.5 million Medicare beneficiaries hospitalized with heart failure between 2001 and 2005 and showed a reduction in in-hospital mortality from 5.1% to 4.2%, however re-hospitalizion within 30 days of discharge remained at 23%. By 6 months more than half of patients were readmitted to the hospital, and by one year more than 2/3rds were readmitted. The mortality data was even more striking. Within 30 days of hospitalization for heart failure more than 1 in 10 Medicare beneficiaries died. Six months out from hospitalization more than 1 in 4 patients died, and at one year one in three were dead.

How should we put this data together? Well, in 2006 the United States spent $30 billion dollars to treat patients with heart failure; $18 billion of which was related to in-hospital care. All this money spent in the hospital seems to be doing something, at least in the hospital. The problem is that we still remain abysmal at care transitions.

How can we improve? The literature supports some type of interdisciplinary support team for these patients, both at the time of discharge and post-discharge. One randomized, controlled study of 223 patients with systolic heart failure found that a 1-hour teaching session with a nurse educator led to a 35% reduction in the combined end point of re-hospitalization or death in a 180-day follow-up period. Costs of care, including that of the intervention, were shown to be lower in patients receiving the education intervention group than in control group by $2823 per patient.

Adding some form of interdisciplinary post-discharge support to inpatient discharge planning for older patients hospitalized with heart failure can also significantly reduce readmission rates, as well as improve quality of life and functional status. A 2004 meta-analysis of 18 studies that involved 3304 older inpatients with heart failure found that there was a 25% relative reduction in the risk of readmission, a trend toward 13% relative reduction in mortality, and an improvement in quality of life scores in studies in which a post-discharge support system was in place.

It is time for our health care system to change.  We can't continue to ignore that patients do poorly once discharged due to our fragmented care delivery model.  Studies, like the one by Bueno, are a great step in moving us forward.

by: Eric Widera

9 comments:

Leah said...

Hey, Eric, can we have a few citations towards the end of your blog? I'm pretty familiar with the literature in this neck of the woods but still would have liked to know what particular study you were referencing....

Thanks

Anonymous said...

Excellent post! I too would love to see the citations.

Eric Widera said...

Sorry, rookie mistake. I added hyperlinks to the articles mentioned in the above post. These include:

Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation
2005; 111:179–185.

Phillips CO, Wright SM, Kern DE, et al. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004; 291:1358–1367

Alex Smith said...

Interesting. These studies address limited prognosis and hospitalization. I wonder about symptom managment. Two quick questions:
1. Wonder how well heart failure managment teams care for these patients? Do they attend to symptoms? Might these patients be better cared for by heart failure home teams than hospice?
2. Do hospice providers have the expertise to manage these patients well? I've had some patients in hospice with heart failure where opioids seemed to be the only treatment for shortness of breath. Other patients cared for by different hospice providers had the expertise to consider adjusting diuretic, blood pressure, and heart rate control medications.

Sue APN said...

More fuel to get Palliative Care teams involved sooner than later with heart failure.

Eileen Kennedy said...

As a discharge planning nurse, there is no doubt that the # of readmissions of this group of patients has increased. I have began to get a team of my colleagues, including the telehealth team, home care agencies and the CHF NP's to explore what can be done to keep these patients at home. I know from experience that close monitoring of these pts in the home setting is very effective, but more education to patients and case managers is needed.
By monitoring symptoms and treating effectively, the treatment of late stage CHF patients is truly palliative care medicine.
Eileen Kennedy

Eric Widera said...

Two great questions Alex. I haven't heard of a heart failure home care service outside of something like AIM or hospice, or some other home based primary care program. The hardest thing for many patients with advance heart failure is coming to clinic, although outpatient heart failure clinics have been shown to decrease hospitalizations.

I also think more education needs to happen within hospice on how to treat patients with non-cancer diagnoses like heart failure. There have been hospice programs that have collaborated closely with heart failure management clinics. This is often a win-win for both programs on multiple different fronts.

ken covinsky said...

It seems an implication of this discussion is that many patients with heart failure would benefit from hospice services, and that for advanced heart failure, the hospice model has a lot to offer many patients who are not in hospice.

It seems that this is a aituation where the CMS driven requirement that hospice patients be willing to give up life prolonging care or curative care (a misnomer, as this does not exist for CHF) works to the detriment of many patients.

It seems perfectly reaonable that a patient with advanced CHF would want their care focused on comfort, quality of life, and symptom management, yet also want life prolonging care that does not substantially distract from the quality of life goal. In some cases, this life prolonging care could reasonably go as far as ICU care and intubation. For example, a patient might feel that if they have a sudden exacerbation, they would be willing to tolerate a short ICU stay if they could return to their baseline state and then continue their symptom directed care.

While the medicare rules and reimbursement policies make it very unlikely such a patient would get hospice care, there does not seem to a good clinical rationale for denying such a patient hospice care. It is a shame this option, or alternative programs like AIM are generally not available for this type of patient.

Tim Cousounis said...

Medicare reimbursement is likely the reason why most heart failure teams are based in outpatient settings. Unless there is an acute episode, the Medicare home health benefit doesn't cover chronic care in the home. And as other commenters have noted, patients and families may not be ready to utilize the hospice benefit. New organizational models (like PACE, The Program of All-Inclusive Care for the Elderly) that are positioned to accept bundled or fixed monthly payments may be the best answer at this time. One of the key questions, of course, are the roles of the attending physician, cardiologist, and geriatricians, HPM physicians in these cases. In other words, what are the rules of engagement for the various physicians who currently are involved in the care of these patients. And as the cost curve is bent,which physicians stand to lose the most in the reconfiguration of chronic care ?