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Practices to Reduce Readmissions?

Prior Edition of the 'Redefining Heart Failure Blog

In the prior edition of the “Redefining Heart Failure” blog series, we explored the context of readmission statistics, an understanding of the drivers of readmissions, and ways to reduce this burden.

If you would like to read it before this part 3 on the factor which increases readmission, you can do so here:

Pt1. https://acorai.com/2022/06/05/the-current-state-of-heart-failure/

Pt2. https://acorai.com/2022/07/03/factors-increasi…readmission-2022

Pt3. https://acorai.com/2022/07/24/how-to-reduce-heart-failure-readmission

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

References

  1. Ma C., Rehospitalisation rates and associated factors within 6 months after hospital discharge for patients with chronic heart failure: A longitudinal observational study. J Clin Nurs. 2019 Jul;28(13-14):2526-2536. doi: 10.1111/jocn.14830. Epub 2019 Mar 13.
    https://onlinelibrary.wiley.com/doi/10.1111/jocn.14830
  2. Tian J, Yan J, Zhang Q, Yang H, Chen X, Han Q, Han R, Ren J, Zhang Y, Han Q. Analysis Of Re-Hospitalizations For Patients With Heart Failure Caused By Coronary Heart Disease: Data Of First Event And Recurrent Event. Ther Clin Risk Manag. 2019 Nov 14;15:1333-1341. doi: 10.2147/TCRM.S218694.
    https://www.dovepress.com/analysis-of-re-hospitalizations-for-patients-with-heart-failure-caused-peer-reviewed-fulltext-article-TCRM
  3. Ahmad Shoaib, Harriette G C Van Spall, Jianhua Wu, J
    ohn G F Cleland, Theresa A McDonagh, Muhammad Rashid, Mohamed O Mohamed, Fozia Z Ahmed, John Deanfield, Mark de Belder, Chris P Gale, Mamas A Mamas, Substantial decline in hospital admissions for heart failure accompanied by increased community mortality during COVID-19 pandemic, European Heart Journal – Quality of Care and Clinical Outcomes, Volume 7, Issue 4, October 2021, Pages 378–387, https://doi.org/10.1093/ehjqcco/qcab040
    https://kclpure.kcl.ac.uk/portal/en/publications/substantial-decline-in-hospital-admissions-for-heart-failure-accompanied-by-increased-community-mortality-during-covid19-pandemic(4326302b-f959-46ad-a3a9-d6b011b28208)/export.html
  4. Hospital Admissions and Readmissions for Heart Failure Are on the Rise, AJN, American Journal of Nursing: May 2021 – Volume 121 – Issue 5 – p 17 doi: 10.1097/01.NAJ.0000751052.45715.a7
    https://journals.lww.com/ajnonline/pages/articleviewer.aspx?year=2021&issue=05000&article=00009&type=Fulltext
  5. Lawson C et al, Trends in 30-day readmissions following hospitalization for heart failure by sex, socioeconomic status and ethnicity, eClinical Medicine, The Lancet, Vol. 38, 101008, 1st August 2021. DOI:https://doi.org/10.1016/j.eclinm.2021.101008
    https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00288-1/fulltext
  6. Parizo JT, Kohsaka S, Sandhu AT, Patel J, Heidenreich PA. Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017. JAMA Cardiol. 2020;5(9):1042–1047. doi:10.1001/jamacardio.2020.202
    https://jamanetwork.com/journals/jamacardiology/fullarticle/2766885
  7. De Rosa R, Piscione F, Schranz D, Citro R, Iesu S, Galasso G. Transcatheter Implantable Devices to Monitoring of Elevated Left Atrial Pressures in Patients with Chronic Heart Failure. Transl Med UniSa. 2018 Mar 31;17:19-21.
    https://www.researchgate.net/publication/326671971_Transcatheter_Implantable_Devices_to_Monitoring_of_Elevated_Left_Atrial_Pressures_in_Patients_with_Chronic_Heart_Failure
  8. William T. Abraham, Leor Perl, Implantable Hemodynamic Monitoring for Heart Failure Patients, Journal of the American College of Cardiology, Volume 70, Issue 3, 2017,Pages 389-398, ISSN 0735-1097, DOI: https://doi.org/10.1016/j.jacc.2017.05.052.
    https://www.jacc.org/doi/abs/10.1016/j.jacc.2017.05.052
  9. Hajduczok, A.G., Muallem, S.N., Nudy, M.S. et al. Remote monitoring for heart failure using implantable devices: a systematic review, meta-analysis, and meta-regression of randomized controlled trials. Heart Fail Rev 27, 1281–1300 (2022). https://doi.org/10.1007/s10741-021-10150-5
    https://pubmed.ncbi.nlm.nih.gov/34559368/
  10. Punchik B, Komarov R, Gavrikov D, Semenov A, Freud T, Kagan E, Goldberg Y, Press Y. Can home care for homebound patients with chronic heart failure reduce hospitalizations and costs? PLoS One. 2017 Jul 28;12(7):e0182148. doi: 10.1371/journal.pone.0182148
    https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0182148
  11. Hospital Admissions and Readmissions for Heart Failure Are on the Rise, AJN, American Journal of Nursing: May 2021 – Volume 121 – Issue 5 – p 17 doi: 10.1097/01.NAJ.0000751052.45715.a7
    https://journals.lww.com/ajnonline/Fulltext/2021/05000/Hospital_Admissions_and_Readmissions_for_Heart.9.aspx
  12. Alebachew Taye Belay et al, Congestive Heart Failure Patients’ Pulse Rate Prog28 Aug 2020ression and Time to Death at Debre Tabor Referral Hospital, Ethiopia, Advances in Public Health, Volume 2021 |Article ID 9550628 | https://doi.org/10.1155/2021/9550628
    https://www.hindawi.com/journals/aph/2021/9550628/
  13. Jack Wilson et al, Systolic Blood Pressure and Longitudinal Progression of Arterial Stiffness: A Quantitative Meta‐Analysis, Journal of the American Heart Association. 2020;9:e017804, 28 Aug 2020, doi: https://doi.org/10.1161/JAHA.120.017804
    https://www.ahajournals.org/doi/10.1161/JAHA.120.017804
  14. Cui, X., Thunström, E., Dahlström, U., Zhou, J., Ge, J., and Fu, M. (2020) Trends in cause-specific readmissions in heart failure with preserved vs. reduced and mid-range ejection fraction. ESC Heart Failure, 7: 2894– 2903. https://doi.org/10.1002/ehf2.12899.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524131/
  15. Leiva O, Bhatt AS, Vaduganathan M. Innovation in Ambulatory Care of Heart Failure in the Era of Coronavirus Disease 2019. Heart Fail Clin. 2020 Oct;16(4):433-440. doi: 10.1016/j.hfc.2020.06.004. Epub 2020 Jun 19.
    https://pubmed.ncbi.nlm.nih.gov/32888638/
  16. Muhammad Shahzeb Khn et al, Trends in prevalence of comorbidities in heart failure clinical trials, European Journal of Heart Failure, Vol. 22, Issue 6, Pages: i-vi, 917-1056, June 2020, https://doi.org/10.1002/ejhf.1818|
    https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.1818
  17. Engels EB, Mafi-Rad M, van Stipdonk AM, Vernooy K, Prinzen FW. Why QRS Duration Should Be Replaced by Better Measures of Electrical Activation to Improve Patient Selection for Cardiac Resynchronization Therapy. J Cardiovasc Transl Res. 2016 Aug;9(4):257-65. Epub 2016 May 26. doi: 10.1007/s12265-016-9693-1.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990608/
  18. Ilke Sipahi et al, QRS Duration Criteria to Select Patients for Cardiac Resynchronization Therapy, Arrhythmia and Electrophysiology, Vol. 6, No. 2, 1 april 2013. DOI: https://doi.org/10.1161/CIRCEP.112.000160
    https://www.ahajournals.org/doi/10.1161/CIRCEP.112.000160
  19. Martinez C, Katholing A, Wallenhorst C, et al Increasing incidence of non-valvular atrial fibrillation in the UK from 2001 to 2013 Heart 2015;101:1748-1754.
    https://heart.bmj.com/content/heartjnl/101/21/1748.full.pdf
  20. Toukhsati SR, Jaarsma T, Babu AS, Driscoll A, Hare DL. Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents. Clin Med Insights Cardiol. 2019 Jun 12;13:1179546819856855. doi: 10.1177/1179546819856855.
    https://journals.sagepub.com/doi/10.1177/1179546819856855
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