The Current State of Heart Failure Readmission

Context of Readmissions

In hospital care settings, Heart Failure (HF) treatment and management are among the leading causes of in-patient admissions, conferring one of the single largest economically expensive and resource-intensive pathologies faced in modern healthcare. Of this economic burden, patient readmission makes up the most significant proportion of the costs associated with patient management, and despite readmission reduction policies, 30-day and six-month readmissions are increasing. 

Many factors that determine the increased incidence of readmission are the same factors associated with HF worsening pathophysiology. e.g., comorbidities, cardiovascular disease and frailty. However, post-discharge, patients readmitted for HF are likely to present case-specific factors such as reduced ejection fraction, higher QRS, poor medication adherence history, or undetected congestion. 

There is evidence suggesting that while hospitals with high volumes of HF patients have more success in treating patients, readmission rates remain high and are sometimes higher in these specialised settings. This implies that current surgical and medical interventions for HF events are not necessarily aligned with the factors that affect readmission rates following discharge. Therefore, in reducing readmissions, it is essential to look toward other factors such as patient education, follow-up care, and home monitoring targeted at the cascade of events that lead to readmission, such as intracardiac pressure. 

Patients readmitted to the hospital for HF issues usually present measurable risk factors. Many of these are risk factors that can be monitored before rehospitalisation and can be used as metrics to determine the intensity of in-patient treatment and as the focus of post-discharge follow-up programs. Self-care and lifestyle are substantial contributing factors to rehospitalisations for HF patients, and similarly, there is evidence to support the cascade of heart failure and targeted interventions aimed at the stages before clinical signs and congestion symptoms. These include Intrathoracic impedance changes, Autonomic adaptation markers and Intracardiac pressure monitoring  (IPCM) technologies, yet these require additional clinical validation and simplified system-wide deployment. 

Knowing this, however, it is possible to tailor patient education and treatment strategies toward reducing readmissions effectively. Given that the population is steadily ageing within the developed world, and the healthcare system needs to be prepared to take the strain, the time for these new approaches has never been more pressing.

Adamson PB. (graph adapted from) Pathophysiology of the transition from chronic compensated and acute decompensated heart failure: new insights from continuous monitoring devices. Curr Heart Fail Rep. 2009;6(4):287-92

Pathophysiology of acute decompensated heart failure – Curr Heart Fail Rep. 2009;6(4):287-92

Readmission Statistics and its importance? 

Hospital admissions and readmissions result from worsening status or new-onset heart failure and are preceded by other clinical signs or symptoms and accompanying biomarkers and critical vital measures.  Readmission statistics have therefore been used as an unbiased surrogate marker of the longitudinal success of heart failure services for several decades, based on the idea that they reflect the efficacy of treatment during initial admission. 

It is important to note that readmissions in some cases are unavoidable or necessary for interventions, and a hospital must balance reduction practices against the needs of those high-risk patients to receive care only obtainable through prompt and successful readmission. Therefore, we must appraise readmission statistics against the expected, or desired level of in-patient intervents for the baseline population whilst managing quality of life measures and effective resource utilisation through decreasing and optimising the cost and duration of stay. 

Rehospitalisation rates in chronic heart failure (CHF) patients within six months have been reported as high as 50% and within 30 days at 21%. Over recent years have increased in both categories. Of all hospital readmissions, more than 27% of total readmissions are attributed to CHF patients and constitute at least 2% of total hospital admissions. Daily readmission risk is highest on the third day after discharge and reduced to half by the 38th day.

Measures to reduce readmissions today

Patients enrolled in readmission reduction programs participate in an increased follow-up appointment frequency schedule, improving adherence to the follow-up treatment plan. Commitment to the maximum tolerated and optimised treatment plan can reduce estimated short-term readmissions by half in the follow-up patient group. Despite this,  it has recently been observed that although there is a reduction in short-term readmission rates with a reduced length of in-hospital stay through these programmes and other state-of-the-art technologies, 30-day mortality and 30-day readmission rates have continued to increase or plateau globally. 

Compounding this readmission picture, the number of comorbidities for a patient with heart failure also increases on average. This trend results in a rise in initial hospital admissions and a higher risk of readmission. Despite readmission reduction programs and current technologies succeeding in some select sub-cases, studies and population statistics show that they are not necessarily effective at reducing mortality or combined readmission outcomes.  

Heart failure readmissions are associated with adverse patient outcomes and high financial costs. Reducing readmissions is an attempt to increase the standard of living for HF patients, improve their quality of care, and reduce healthcare costs. Therefore a metric of success is to reduce readmission.

Hospitalisations are a marker of patient care, the severity of disease, and quality of life. The cost of readmissions makes them another factor for consideration. Some HF conditions need to be eradicated. Making it too difficult for a patient to get readmitted will lose care for high-risk patients. 

As part of a cost-saving strategy, admission avoidance can be generally considered an improvement to the quality of life. Therefore, reducing rehospitalisations makes sense as a success metric with these methods to a certain degree. 

The most significant improvement in quality of life for heart failure patients can be realised when admission avoidance plans are combined with emerging AI-powered technologies that effectively manage and guide patient treatment. Effective QOL improvement could accomplish this through emerging IPCM devices to uncover critical vital signs and pressure markers when function and pressure information is combined to deliver optimal medical and pharmacological therapy personalised to each patient. Non-invasive AI devices providing these parameters will likely have a pivotal effect on the clinical workflow of heart failure care and management.