Practices to Reduce Readmissions?
We previously categorized the causes of readmissions into the following groups; Preconditions, Lifestyle, Economic status, Treatment outcome and heart failure monitoring. Yet, when we look at the factors reducing readmission and how they relate to the causes of readmission, most causes can categorize most of them as either: Patient education measures or Follow-up service interventions.1
In the presence of chronic preconditions, comorbidities and lifestyle, patients need to be educated on how these conditions or routines exacerbate their heart failure status and how to mitigate these effects with medication or lifestyle modification. The evidence is overwhelming that the link between self-care and reduction in readmissions needs to be explained to patients. Patients must understand the reasons for compliance with the medication and any other necessary lifestyle changes, such as diet or exercise habits. Self-care education has been shown to reduce heart failure readmissions by 30%. Yet, the grim reality is that a patient’s economic status often determines their level of education and access to healthcare services to realize these benefits.2,3,4,5
Within the hospital care setting, the outcome of surgical procedures will be statistically better in hospitals with a high volume of heart failure patients. Surgeons and cardiologists will have ample opportunity to train and hone their skills, and hospital services will be familiar with all the processes for treating heart failure patients. Patients can be readmitted unnecessarily for issues arising from the expected post-surgery recovery without proper patient education.6
Remote monitoring tools
This brings us to monitoring and telemedicine as part of effective post-discharge, follow-up practices, monitoring patients’ vitals and behaviours, and reducing hospital readmission rates. This is a significant part of follow-up care for discharged heart failure patients. Implantable Intracardiac Pressure Monitoring (ICPM) devices can monitor and record factors, such as changes in pressure indicative of a congestive or pre-congestive state.7
Doctors can use these factors to modify medications or change the care procedures involved in the follow-up program and, importantly, receive reassurances or early warnings about post-discharge complications.8 These technologies are yet to be universally deployed across healthcare settings primarily due to the invasive nature of these devices, which carry procedural risk and a significant cost to fund their use, without thoroughly proven health economic data, on international markets.9
Therefore, home visits are considered a very effective way of monitoring patients’ progress. These visits are opportunities to record a patient’s vitals and more subjective metrics of improvement, such as mindset and attitude, and pick up on areas that need improvements, such as medication compliance and routines. A technological gap needs to be addressed in delivering personalized treatment and monitoring every growing patient population living with heart failure at the point of discharge and through ongoing in-person or virtual check-up visits.10,11,12,13
Ambulatory Interventions
Around half of the recorded hospital readmissions following the index admission for heart failure occur before the first ambulatory visit following discharge. However, when a patient has received an ambulatory visit after discharge, the risk of readmission is vastly reduced.14
When an ambulance is involved, there is an opportunity to improve practices and reduce readmissions. Active intervention for patients inside the ambulance can reduce the need for readmission in patients with lower-risk decompression. Yet, skilled professionals would need to determine those with lower-risk presentation algorithmically. This classification challenge is present in both emergency call-outs and scheduled ambulatory visits. Proper planning for the follow-up care should include effective ambulatory intervention practices, which can reduce the pressure on the triaging in the emergency department. 15,16
Non-invasive ICPM is a rising area in development, addressing the volume of emergency care and ambulatory visits, with patients at risk of acute decompensation and accelerating the time to diagnosis for optimal medical therapy. The most significant measurements are subsets of pulmonary artery pressure measure with actionable data deriving from the mean, systolic, diastolic, pulmonary wedge, cardiac output, ejection fraction and stroke volume.
Technologies are already improving care.
ICMP has been shown to improve the quality and efficiency of care in the heart failure patient workflow, with non-invasive intracardiac pressure monitoring promising decreased economic cost to deploy and the irradiation of risk associated with invasive techniques. With the advent of machine learning technology, there is an opportunity to improve the data acquired from pressure dynamics in acoustic, vibratory and pulse waveforms measured invasively or non-invasively further to enhance the utilization of ICPM through increased accuracy.17,18,19,20