Physician-Specific Practice Patterns About Discharge Readiness and Heart Failure Utilization Outcomes

Abstract

Background: Although hospitalization for acute decompensated heart failure (HF) is common and associated with poor outcomes and high costs, few evidence-based recommendations are available to guide patient management. Thus, management of inpatient HF remains heterogeneous. We evaluated if physician-specific self-reported HF practice patterns were associated with 2 important contributors to resource utilization: length of stay (LOS) and 30-day readmission. Methods and Results: A 5-point Likert scale survey was created to assess physician-specific HF discharge strategies and administered to all cardiologists and hospitalists at a single large academic teaching hospital. Practice patterns potentially impacting LOS and discharge decisions were queried, including use of physical examination findings, approaches to diuretic use and influence of kidney function. Likert scale responses are reported as means with any value above 3.00 considered more influential and any value below 3.00 considered less influential. Physician-specific LOS and 30-day readmission rates from July 1, 2015, to June 30, 2016, were extracted from the electronic record. We received survey responses and HF utilization metrics from 58 of 69 surveyed physicians (32 hospitalists and 26 cardiologists), encompassing 753 HF discharges over a 1-year period. Median LOS was 4.5 days (interquartile range, 4.0–5.8) and total 30-day readmission rate was 17.0% (128 unique readmissions). Physicians with below-median LOS placed less importance on observing a patient on oral diuretics for 24 hours before discharge (Likert 2.54 versus 3.30, P =0.01), reaching documented dry weight (Likert 2.93 versus 3.60, P =0.02), and complete resolution of dyspnea on exertion (Likert 3.64 versus 4.10, P =0.03) when compared with those above-median LOS. In contrast, no surveyed discharge practices were associated with physician-specific 30-day readmission. Conclusions: We identified specific inpatient HF discharge practice patterns that associated with shorter LOS but not with readmission rates. These may be targets for future interventions aimed at cost reduction; additional larger studies are needed for further exploration.

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes

“…On the other hand, subtle data of congestion or hypoperfusion could have remained unidentified during ED evaluation in patients erroneously classified as warm‐dry phenotype. Fifth, study patients were from a single country with a universal public healthcare system, and since international heterogeneity in organizational and transition processes is high, our results should be confirmed in other countries with different healthcare system models. In particular, we report 24% of direct discharge home after ED care, which is higher than that observed in other countries, such as the United States .…”

Analysis of standards of quality for outcomes in acute heart failure patients directly discharged home from emergency departments and their relationship with the emergency department direct discharge rate

“…We tried to partly cover the limited number of EDs by running regression analyses weighted by the number of patients discharged home by each ED, thus, we performed analyses at a centerand individual-level. Third, the patients came from a nationwide cohort with a universal public healthcare system, and since international heterogeneity in organizational and transition processes is high [29], external validation of our results should be carried out in further studies in other countries, like Japan, with different healthcare system models. One fundamental concept to keep in mind if this analysis is repeated in other countries is that in the event their EDs are not able to provide observation (as in the case of the UK, USA, or Japan, for example), the standards of use proposed in the expert consensus document are different from those considered in the current study [5].…”

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

“…Third, in this real-life cohort without intervention, attending physicians followed their usual local protocols and did not receive any specific instructions about the precise time for hospital discharge and patient transition. Fourth, the patients were from a single country with a universal public health care system, and since international heterogeneity in organisational and transition processes is high [29], external validation of our results should be carried out in further studies in other countries with different healthcare system models. And fifth, we recorded the department which was responsible for admission once emergency department care was completed, but we did not track further patient transfers from the initial department to others.…”