Reducing heart failure readmissions at 30 days

"Prevention of heart failure readmissions begins with effective in-hospital treatment and efficient care transitions," says Akshay S. Desai, MD in a presentation at the 2015 AHA Fall Conference meeting.

“Prevention of [heart failure] readmissions begins with effective in-hospital treatment and efficient care transitions,” said Akshay S. Desai, MD, director for heart failure disease management, in the cardiovascular division, of Brigham and Women’s Hospital in Boston. Desai was speaking on strategies for reducing heart failure readmissions at 30 days and beyond initial hospitalization during his presentation entitled “Practice: Clinical Initiatives to Address Readmission” at the American Heart Association (AHA) meeting.

Effective in-house treatment includes effectively managing congestion, with evidence showing that most heart failure hospitalizations are related to worsening congestion and prognosis related to the efficacy of decongestion. Citing data from a study by Logeart et al (J Am Coll Cardiol 2004), Desai showed that the risk of death and readmissions increases significantly with increases in brain natriuretic peptide (BNP). Data from Lala et al (J Card Fail 2013) show that 40% of patients have moderate to severe congestion at discharge, and that recurrent congestion after discharge is frequent.

“Keeping patients well requires an effective strategy for detection of worsening congestion,” emphasized Desai.

To help improve patient outcomes and prevent readmissions, Dr. Desai walked participants through a number of evidence-based strategies that highlight the importance of multidisciplinary interventions to address comorbidities and social factors contributing to heart failure risk:

Educate patients prior to discharge on issues such as lifestyle (diet, activity level), medications (schedule, adherence, titration), follow-up appointments (ensuring the when and with whom are set up), self-evaluation (including weight monitoring, and knowing warning signs of recurrence), and having a rescue plan (what to do and who to call).

Recognize cognitive impairments that are prevalent and impact readmissions. Data show that cognitively impaired patients may need additional support after discharge.

Provide a seamless handoff from inpatient to outpatient provider, which may include nurses managing medication reconciliation, arranging for follow-up visits before discharge, sending discharge summaries to primary care physicians, and assigning staff to follow-up on test results after discharge.

Data from a study by McAlister et al (J Am Coll Cardiol 2004) show that smoothing the transition from the hospital to home reduced not only heart failure readmissions (26%), but also overall mortality (25%) and overall hospitalization (19%) and was generally cost-saving or cost neutral.

Once the patient is at home, Desai said that the use of home-monitoring devices may be helpful in reducing readmissions, as demonstrated in a study of a wireless pulmonary artery (PA) pressure monitoring system that significantly reduced the rates of readmissions compared to patients treated with standard care (Adamson et al. Circulation 2014). He cautioned that more data does not necessarily provide more information, citing data showing that a weight-based telemonitoring device was not effective as a stand-alone disease management strategy (Koehler F. Circulation 2011) and that use of an implanted diagnostic tool to measure intrathoracic impedance increased heart failure hospitalizations (van Veldhuisen et al. Circulation 2011).

Desai concluded his talk by addressing the need for more palliative and hospice care for heart failure patients in whom their disease has advanced beyond treatment.

“Clear definition of goals of care and early introduction of palliative care considerations are important as patients near end of life,” he said.