The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure

Zaya, Melody; Phan, Anita; Schwarz, Ernst R.

doi:10.1007/s10741-011-9256-0

Cited by 20 publications

(11 citation statements)

References 103 publications

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“…[1][2][3] Multiple exacerbations of CHF result in frequent use of acute health care services by these patients, known as revolving door users. After discharge, 25% of patients are readmitted within the first 30 days, 4,5 and 50% within the first 6 months. 6,7 This frequent use of health care services is mainly due to lack of understanding of a treatment plan, nonadherence to medical therapy, unawareness of CHF symptom exacerbation, and irregular follow-up.…”

Section: Introductionmentioning

confidence: 99%

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Vedel

Khanassov

2015

The Annals of Family Medicine

104

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PURPOSE We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration. METHODSWe conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration. RESULTSWe identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious. CONCLUSIONS Clinicians and managers who implement TCIs in primary carecan incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option. INTRODUCTIONC ongestive heart failure (CHF) imposes an increasingly heavy burden on health care systems, most of which can be attributed to numerous hospital readmissions and emergency department (ED) visits. [1][2][3] Multiple exacerbations of CHF result in frequent use of acute health care services by these patients, known as revolving door users. After discharge, 25% of patients are readmitted within the first 30 days, 4,5 and 50% within the first 6 months. 6,7 This frequent use of health care services is mainly due to lack of understanding of a treatment plan, nonadherence to medical therapy, unawareness of CHF symptom exacerbation, and irregular follow-up. [8][9][10][11][12] Lack of coordination and communication between hospitalists and primary care physicians (PCPs) has been documented. 13,14 PCPs too often do not receive discharge summaries, 15 and when they do receive them, the summaries often lack appropriate documentation of medication indication and advice for follow-up. It is therefore difficult for PCPs to plan an appropriate follow-up after hospital discharge. 16To address these issues, transitional care interventions (TCIs) have been implemented with a common objective of reducing the rate of hos- 563pital readmis...

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Section: Introductionmentioning

confidence: 99%

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Vedel

Khanassov

2015

The Annals of Family Medicine

104

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“…Readmissions are a widespread and costly problem for hospitals across the United States [1-4]. In 2012, the average rate of 30-day readmission for Medicare patients was 24.7% for congestive heart failure (CHF), 18.5% for pneumonia (PNA) and 19.8% for acute myocardial infarction (AMI) [5].…”

Section: Introductionmentioning

confidence: 99%

Diagnosis-specific readmission risk prediction using electronic health data: a retrospective cohort study

Hebert

Shivade

Foraker

et al. 2014

BMC Med Inform Decis Mak

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BackgroundReadmissions after hospital discharge are a common occurrence and are costly for both hospitals and patients. Previous attempts to create universal risk prediction models for readmission have not met with success. In this study we leveraged a comprehensive electronic health record to create readmission-risk models that were institution- and patient- specific in an attempt to improve our ability to predict readmission.MethodsThis is a retrospective cohort study performed at a large midwestern tertiary care medical center. All patients with a primary discharge diagnosis of congestive heart failure, acute myocardial infarction or pneumonia over a two-year time period were included in the analysis.The main outcome was 30-day readmission. Demographic, comorbidity, laboratory, and medication data were collected on all patients from a comprehensive information warehouse. Using multivariable analysis with stepwise removal we created three risk disease-specific risk prediction models and a combined model. These models were then validated on separate cohorts.Results3572 patients were included in the derivation cohort. Overall there was a 16.2% readmission rate. The acute myocardial infarction and pneumonia readmission-risk models performed well on a random sample validation cohort (AUC range 0.73 to 0.76) but less well on a historical validation cohort (AUC 0.66 for both). The congestive heart failure model performed poorly on both validation cohorts (AUC 0.63 and 0.64).ConclusionsThe readmission-risk models for acute myocardial infarction and pneumonia validated well on a contemporary cohort, but not as well on a historical cohort, suggesting that models such as these need to be continuously trained and adjusted to respond to local trends. The poor performance of the congestive heart failure model may suggest that for chronic disease conditions social and behavioral variables are of greater importance and improved documentation of these variables within the electronic health record should be encouraged.

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“…However, it is not standard to test for cognitive dysfunction and minimal HE in cirrhosis 5 . Another essential aspect of daily functioning that is not routinely inquired is the socio-economic status (SES), which could affect insight into the disease and adherence with medications and follow-up 6-8 . There is limited single-center evidence of the association of SES with cognition in cirrhosis; a multi-center analysis is needed to increase generalizability 9 .…”

Section: Introductionmentioning

confidence: 99%

Cognitive Dysfunction Is Associated With Poor Socioeconomic Status in Patients With Cirrhosis: An International Multicenter Study

Bajaj

Riggio

Allampati

et al. 2013

Clinical Gastroenterology and Hepatology

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Background & Aims In patients with cirrhosis, cognitive dysfunction most often results from covert hepatic encephalopathy (HE). These patients are not routinely tested for cognitive dysfunction, despite single-center evidence that it could be associated with poor socio-economic status (SES). We investigated the association between SES and cognition in a multi-center study of cirrhosis. Methods In a cross-sectional study, 236 cirrhotic patients from 3 centers (84 subjects from Virginia, 102 from Ohio, and 50 from Rome, Italy; age 57.7±8.6 y; 14% with prior overt HE) were given recommended cognitive tests and a validated SES questionnaire, which included questions about employment, personal and family income, and overall financial security. Comparisons were made among centers and between subjects who were employed or not. Regression analysis was performed using employment and personal income as outcomes. Results Only 37% of subjects had been employed in the last year. Subjects had substantial financial insecurity—their yearly personal income ranged from $16,000 to $24,999 and their family income ranged from $25,000 to $49,999. They were only able to maintain a residence for 3–6 months if their income stopped, and their current liquid assets were $500–$4999 (<$500 if debt was subtracted). Cognition and SES were worst in Ohio and best in Virginia. Cognition correlated with personal and family income, within and between centers. On regression analysis, cognitive performance (digit symbol, lures, and line tracing) was associated with personal yearly income, after controlling for demographics, country, employment, and overt HE. Unemployed subjects had a higher rate of overt HE, worse cognition, and lower personal income than employed subjects. On regression analysis, performance on digit symbol, line tracing, inhibitory control test lures, and serial dotting tests remained associated with income, similar to employment. Conclusions In an international, multi-center study of patients with cirrhosis, socio-economic condition, based on employment and personal income, was strongly associated with cognitive performance, independent of age, education, and country.

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The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure

Cited by 20 publications

References 103 publications

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Diagnosis-specific readmission risk prediction using electronic health data: a retrospective cohort study

Cognitive Dysfunction Is Associated With Poor Socioeconomic Status in Patients With Cirrhosis: An International Multicenter Study

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