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Clinician Update
Intensive Management to Reduce Hospitalizations
in Patients With Heart Failure
Akshay S. Desai, MD, MPH
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C
ase Presentation: A 65-year-old
man with idiopathic dilated cardiomyopathy is admitted with an acute
heart failure exacerbation shortly after
returning from a holiday weekend.
This is his second admission for heart
failure management within the last 3
months. He is treated with intravenous
diuretics with resolution of his symptoms. An echocardiogram done during
the hospital stay confirms a dilated left
ventricle with severe left ventricular
dysfunction and a left ventricular ejection fraction of 25%. The house officer
is arranging hospital discharge and
asks you about strategies to limit recurrent hospital admissions. What do you
advise?
Patients with heart failure are at
high risk for recurrent hospitalization.
In the Medicare-eligible population,
roughly 1 in 4 patients is readmitted
within 30 days of hospitalization, and
nearly half are readmitted within 6
months.1 Although financial penalties
have focused attention on early readmissions, patients with heart failure are
at risk for hospitalization well beyond
the 30-day mark. Data suggest that hospitalization rates peak in the early postdischarge interval, decline and plateau
as the disease is stabilized, and then
reaccelerate as patients near the end of
life.2 Accordingly, effective strategies
to reduce heart failure readmission vary
with time from hospital discharge and
disease severity, the burden of comorbid medical illness, and overall goals
of care. Although it is neither desirable
nor possible to eliminate all hospitalizations, it is possible to define strategies
to reduce the risk of readmission that
do not compromise patient outcomes.3
In this Clinician Update, we summarize evidence-based best practices for
reducing heart failure readmission rates
(Table) and evolving models for outpatient heart failure disease management.
Assessing Readiness for
Hospital Discharge
Reduction in early readmission rates
after hospital discharge begins with
ensuring effective treatment of heart
failure during the inpatient hospital
stay. Although there is a limited evidence base to guide optimal management of patients with acute heart
failure, guidelines highlight a few
core therapeutic goals. First, clinicians must identify and manage the
factors responsible for precipitating
heart failure decompensation because
they may serve as triggers for recurrent admission. Common precipitants
include cardiovascular factors such as
uncontrolled hypertension, worsening
coronary artery disease, and uncontrolled arrhythmias; noncardiovascular comorbidities such as pneumonia,
renal failure, and chronic obstructive
pulmonary disease; and patient factors
such as medication nonadherence and
dietary indiscretion.4
Second, efforts should be made
to effectively decongest patients
and to optimize pharmacological
therapy before hospital discharge.
Independently of the ejection fraction
or pathogenesis, most cardiovascular hospitalizations in patients with
heart failure are related to congestive
exacerbations driven by a progressive
rise in intracardiac filling pressures.5
Accordingly, patients who are inadequately decongested at discharge
have higher rates of readmission and
mortality. Recent data suggest that as
many as 40% of patients are discharged
despite moderate to severe congestion,
even from specialized heart failure
centers.6 Mere symptom relief is not
an adequate surrogate for decongestion
From Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA.
Correspondence to Akshay S. Desai, MD, MPH, Advanced Heart Disease Section, Cardiovascular Division, Brigham and Women’s Hospital, Boston,
MA 02115. E-mail [email protected]
(Circulation. 2016;133:1704-1707. DOI: 10.1161/CIRCULATIONAHA.115.017594.)
© 2016 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.115.017594
1704
Desai Reducing HF Hospitalizations 1705
Table. Strategies to Limit Risk of Recurrent Heart Failure Hospitalization
Timeframe
Before discharge
Effective Strategies
Identification and treatment of triggers for recurrent heart failure
decompensation
Aggressive decongestion to optimize volume status
Initiation and titration of guideline-directed medical therapy
Patient education for self-management (“teach back”)
Risk stratification to identify patients who may benefit specialized
interventions (advanced therapies, home care, long-term skilled nursing,
palliative care/hospice)
Careful handoff of care to ambulatory providers
Early after discharge
Contact with patients at 24–48 h for clinical reasssessment and clarification
of postdischarge plan
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Medication reconciliation by pharmacist or specialty nurse
Home visits for selected high-risk patients
Timely clinic follow-up (7–10 d)
Later after discharge
Surveillance for recurrent congestion
Aggressive treatment of recurrent congestion, leveraging ambulatory
(nonhospital) alternatives
Engagement of multidisciplinary supports (nutrition, pharmacy, social work,
palliative care)
Management of noncardiac comorbidities
Frequent reassessment of goals of care
because patients may report symptom
improvement well before optimization
of filling pressures occurs. Extending
the duration of the inpatient stay to
optimize volume status and to ensure
reintroduction and tolerance of neurohormonal antagonists before discharge
may be critical to limiting the risk of
early readmission for recurrent congestion or drug-related adverse effects.
Transitioning From
the Hospital
The risk for readmission depends on
several factors, including the severity of illness, burden of comorbidities,
patient engagement and self-efficacy,
and access to care. Accordingly, comprehensive, multidisciplinary transitional care management strategies
that provide predischarge education to
enhance self-care, intensive care coordination, early follow-up, and specialty
nursing support after hospital discharge
are consistently effective in reducing readmission rates and mortality.7
However, the specific components of
transitional care strategies that are most
effective in reducing readmission rates
are not well established. Moreover, no
approach is likely to be effective for all
patients, and care plans must be individualized to attend to specific patient
needs.
The recent American Heart
Association “Transitions of Care in
Heart Failure”8 statement identified
several core elements of effective transitional care interventions. Key among
them are predischarge patient education
emphasizing “teach back” to ensure
adequate uptake of self-care strategies, early postdischarge follow-up/
reassessment, nurse- or pharmacist-led
medication reconciliation, and timely
communication for effective handoff
of care from inpatient to post-hospital
providers.9 Despite data supporting
lower-risk standardized readmission
rates among hospitals providing early
clinic follow-up after discharge from
heart failure admissions,10 as many as
half of patients readmitted to hospital
within 30 days have no interval physician visits.11
Current treatment guidelines recommend a follow-up visit within 7 to
10 days of discharge from heart failure hospitalization,12 with evidence
supporting greater efficacy of collaborative care with cardiovascular
specialists rather than primary care
providers alone.13 Adherence to scheduled postdischarge follow-up may
be enhanced by providing a schedule
of postdischarge follow-up appointments to patients before discharge,
by the engagement of caregivers, and
by bridging interventions such as a
telephone call at 24 to 48 hours for
clinical reassessment, medication reconciliation, reinforcement of guidance
for self-care, education about warning signs of clinical deterioration, and
reminders of scheduled follow-up.
Because transitional care frequently
requires multidisciplinary engagement by nurses, pharmacists, social
workers, primary care physicians, subspecialists, and home care providers,
fragmentation of care is a significant
risk. Accordingly, efficient care coordination and clear lines of accountability are critical, particularly in the
gap between the hospital discharge
and the first clinic appointment. Non–
English-speaking patients and those at
particularly high risk for readmission
and adverse events as a result of cognitive impairment or learning disabilities may require more individualized
case management strategies. Cognitive
impairment has emerged as an underappreciated and potent contributor to
readmission risk, affecting as many as
1 in 4 hospitalized patients, suggesting
the potential importance of systematic
screening of cognitive function before
discharge.14
Chronic Ambulatory
Management
Because patients with heart failure
remain at risk for congestive exacerbations well beyond the early postdischarge period, long-term management
requires some form of longitudinal surveillance to enable early detection of
recurrent congestion. Because patients
spend most of their time outside the
direct view of their providers, clinicbased follow-up alone is likely inadequate, particularly for those at high
risk. Because changes in body weight
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correlate with short-term changes in
fluid status, remote surveillance of
daily weight and vital signs with telemonitoring has become the central
focus of most heart failure disease
management efforts. However, weight
has proven to be a relatively insensitive sign of worsening congestion over
longitudinal follow-up, and clinical
deterioration sufficient to require hospital admission frequently occurs with
little or no change in body weight.15
It has been difficult to demonstrate
a clear incremental value of weightbased telemonitoring programs as an
adjunct to clinic-based heart failure
follow-up.16 Device-based heart failure diagnostics such as intrathoracic
impedance or heart rate variability
track more closely with filling pressures, but remote heart failure management guided by these parameters does
not reduce heart failure hospitalizations. Direct measurement of filling
pressures with implantable hemodynamic monitors may be a more effective approach for selected high-risk
patients, with data supporting readmission reduction at 30 days and beyond
in selected patients with recurrent heart
failure decompensation.17
Early detection of clinical deterioration is helpful only if it triggers
a timely and effective intervention to
relieve congestion.18 For those in whom
clinical symptoms are unresponsive to
empirical titration of oral diuretics or
vasodilators, intravenous therapy is
frequently necessary. Although in the
past such treatment has obligated inpatient admission, intensive management
of hemodynamically stable patients
with mild to moderate congestion can
now occur at home, in the heart failure
clinic, or in observation unit extensions
to the emergency department (Figure).
Preliminary data suggest that these
ambulatory approaches provide a realistic alternative to hospitalization that
may allow relief of patient symptoms
at reduced cost without compromising
clinical outcomes.19
As heart failure progresses, the
anticipated efficacy of ambulatory
heart failure management strategies
predictably declines, with an attendant
rise in the proportion of unavoidable
hospitalizations. For those who are not
candidates for advanced therapies such
as mechanical circulatory support or
transplantation, the onset of refractory
symptoms or end-stage disease should
prompt open discussions of goals of
care. Confronted with a limited prognosis, many patients will opt to trade
quantity for quality of life and accept
palliative interventions. Although hospice care is frequently underused or
deployed too late in practice, selecting appropriate patients with advanced
heart failure for hospice referral may be
a powerful means of reducing readmission rates at 30 days without enhancing
the rates of near-term mortality.20
Case Resolution
The patient’s heart failure exacerbation
is attributed to excessive dietary salt
intake during his holiday celebrations.
Despite the improvement in his symptoms, his physical examination reveals
residual jugular venous distention
and peripheral edema. Discharge is
deferred to permit further decongestion
with intravenous diuretics. After optimization of volume status, he is transitioned to a maintenance oral regimen
and observed for 24 hours to ensure
clinical stability. In that time, he meets
with a nurse who clarifies medication
changes made during the admission
and advises him about dietary changes
that may help to reduce his risk of hospital readmission. He is educated about
symptoms and signs of worsening congestion, encouraged to track his weight
on a daily basis after discharge, and told
to contact the heart failure clinic with
Figure. Enhanced ambulatory treatment strategies to reduce heart failure hospitalization. Home-based, clinic-based, and emergency
department observation unit–based approaches to administration of intravenous diuretics and other heart failure therapies may facilitate
ambulatory treatment of worsening congestion without the need for hospitalization. The efficacy of this approach may depend on early
detection of recurrent congestion through remote monitoring of physiological signals.
Desai Reducing HF Hospitalizations 1707
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any concerning changes. An implantable hemodynamic monitor is considered but deferred given his New York
Heart Association class I functional
capacity after treatment. An appointment is scheduled in the heart failure
clinic within 7 days, and the patient
confirms he will attend. The nurse calls
the patient 48 hours after discharge to
reassess his condition and confirms that
he has secured his medications, understands the discharge instructions, and
knows when to return for follow-up.
When he returns for his clinic visit in
7 days, the patient is doing well without evidence of recurrent congestion.
Additional follow-up is advised with
the nurse in 1 month and the physician
in 3 months for reassessment.
Disclosures
Dr Desai has been a paid consultant to
Novartis, St. Jude Medical, Merck, and
Relypsa.
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Intensive Management to Reduce Hospitalizations in Patients With Heart Failure
Akshay S. Desai
Circulation. 2016;133:1704-1707
doi: 10.1161/CIRCULATIONAHA.115.017594
Downloaded from http://circ.ahajournals.org/ by guest on August 1, 2017
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