Reducing Rates of Readmission and Development of an Outpatient Management Plan in Pulmonary Hypertension: Lessons From Congestive Heart Failure Management

Abstract

PURPOSE: Pulmonary Hypertension (PH) is a progressive group of diseases that remains difficult to treat and carries significant morbidity and mortality despite available medical therapy. There are currently minimal guidelines on chronic outpatient management and prevention of hospitalization owing to the low number of patients and orphan status of the disease. In contrast, congestive heart failure (CHF) outpatient management interventions have been investigated in multiple trials. A common reason for admission in PH and CHF is heart failure exacerbation. The disease states share similar dietary and fluid management challenges, disease management and compliance issues. CHF has well established intervention models that have successfully decreased hospital readmission rates and mortality. We aimed to analyze outpatient CHF disease management interventions that have shown reductions in hospital readmissions and mortality as a starting point for developing an outpatient pulmonary hypertension intervention and management plan. METHODS:A comprehensive review of literature was performed, including original trials and meta-analysis and reviews. We reviewed the topics of outpatient CHF interventions to decrease CHF mortality and readmission and patient management strategies in CHF. RESULTS:The most studied interventions included case management (CM-specialist nurse driven, education pre/post discharge, specialist nurse home visits, scheduled telephone calls for symptom management, when to seek help), multidisciplinary Intervention ( MI-coordinated interventions and communications; specialist nurse driven, patient-caregiver education regarding disease, medication and diet, nurse clinic visits, regular telephone calls, individualized follow-up plan, access to physician, nurse, dietician, pharmacist, social worker), remote monitoring programs consisting of structured telephone strategy (STS-monitoring collected data via human-human or human-machine interactive response system) or tele-monitoring (TM-physiologic data transmission of EKG, blood pressure, weight, respiratory rate digitally). Clinic visits did not have a significant effect on CHF readmission or mortality. CM showed decreased all-cause mortality (ACM) at 12 months, all-cause readmission (ACR) at 12 months and CHF readmission at 6 and 12 months. MI resulted in decreased ACR and CHF readmission. There was some discrepancy on effectiveness of TM programs alone in individual studies, however large meta-analysis suggests TM provided a reduction in ACM and risk of CHF hospitalization. STS had similar results to TM including decreased risk of CHF hospitalization, without an effect on mortality. CONCLUSIONS:Extrapolating from CHF data, it seems that strategies to improve the health of PH patients should include structured telephone strategy and/ or tele-monitoring, case management strategies and multi-disciplinary interventions. CLINICAL IMPLICATIONS:There is no consensus on the most effective outpatient management of PH or strategies to reduce hospital readmission. Succe...