Transitions of care in heart failure: a scientific statement from the American Heart Association

Structured Telephone Support Intervention: Improved Heart Failure Outcomes

Background

Presently, 6.5 million Americans are living with heart failure (HF). These patients are expected to follow a complex self-management regimen at home. Several demographic and psychosocial factors limit patients with HF in following the prescribed self-management recommendations at home. Poor self-care is associated with increased hospital readmissions. Under the Affordable Care Act, there are financial implications related to hospital readmissions for hospitals and programs such as the Program of All-Inclusive Care for the Elderly (PACE) in Pinellas County, Florida. Previous studies and systematic reviews demonstrated improvement in self-management and quality of life (QoL) in patients with HF with structured telephone support (STS) and SMS text messaging.

Objective

This study aimed to evaluate the effects of STS and SMS on self-care, knowledge, medication adherence, and QoL of patients with HF.

Methods

A prospective quality improvement project using a pre-post design was implemented. Data were collected at baseline, 30 days, and 3 months from 51 patients with HF who were enrolled in PACE in Pinellas County, Florida. All participants received STS and SMS for 30 days. The feasibility and sustained benefit of using STS and SMS was assessed at a 3-month follow-up.

Results

A paired t test was used to compare the mean difference in HF outcomes at the baseline and 30-day follow-up, which demonstrated improved HF self-care maintenance (t₄₉=0.66; P=.01), HF knowledge (t₄₉=0.71; P=.01), medication adherence (t₄₉=0.92; P=.01), and physical and mental health measured using Short-Form-12 (SF-12; t₄₉=0.81; P=.01). The results also demonstrated the sustained benefit with improved HF self-care maintenance, self-care management, self-care confidence, knowledge, medication adherence, and physical and mental health (SF-12) at 3 months with P<.05 for all outcomes. Living status and social support had a strong correlation with HF outcomes. Younger participants (aged less than 65 years) performed extremely well compared with older adults.

Conclusions

STS and SMS were feasible to use among PACE participants with sustained benefits at 3 months. Implementing STS and SMS may serve as viable options to improve HF outcomes. Improving outcomes with HF affects hospital systems and the agencies that monitor and provide care for outpatients and those in independent or assisted-living facilities. Investigating viable options and support for implementation will improve outcomes.

Short term prognosis of heart failure after first hospital admission

BACKGROUND

Death and unexpected readmission are frequent among heart failure patients. We aimed to assess 30-day readmission and mortality rate as well as to identify predictive factors for patients discharged from a first HF related hospital admission.

METHODS AND RESULTS

Retrospective, single-center, cohort study, using administrative data from a tertiary care hospital in Barcelona, Spain. Patients discharged alive from a first HF related admission from 2010 to 2014 were assessed for 30-day death, readmission and adverse outcome rate. A Linear Logistic Regression Model was fitted for each outcome. The set accounted for 3642 patients; 50.1% female and 49.9% male. Mean age was 76 years (SD=12). 30-Days rates were 9.2% for readmission, 5.6% for death and 13.8% for adverse outcome. Admission to an ED within 30 days was strongly linked to readmission (OR=6.97), death (OR=2.31) and adverse outcome (OR=8.55), as well as chronic kidney disease (OR=1.44/1.61/2.86 respectively). Discharge to a Long Stay Care (LSC) facility was linked to lower readmission and adverse event rates (OR=.57 and OR=.15).

CONCLUSION

Pre and post-index discharge use of health care resources is related to adverse outcome rates. Our findings point out the potential benefit for a more tailored approach in the management of HF patients.

Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

Long-term management of chronic heart failure patients in internal medicine

Chronic heart failure (CHF) is one of the main disabilities in elderly patients requiring frequent hospitalizations with high health care costs. We studied the outcome of CHF outpatient management in reducing hospitalization after discharge from a division of Internal Medicine at a large 3rd referral regional Hospital. 147 CHF inpatients (M:F: 63:84; mean age 76 ± 9.6 years) admitted for acute exacerbation of CHF were followed up as outpatients at 1, 6, 12 and 24 months after discharge. At baseline, patients underwent: laboratory tests, ECG, echocardiogram and a dedicated-intensive health care educational program involving also their families. The rate of hospitalization in the same group of patients was compared with data from the previous 24 months, a period when patients had been seen elsewhere without disease management programs. Patients had high prevalence of comorbidities and the majority was in NYHA class III or IV. Hypertension and valvular heart disease were the most common causes for CHF. Systolic function was preserved (LVEF ≥ 50%) in 61.9% of cases. Functional NYHA class improved significantly after 6 months and remained stable at 24 months. There was a significant increase in the use of the renin-angiotensin system blockers, beta-blockers and diuretics compared to admission to the ward. At 24 months, hospital readmissions were decreased by 42% as compared to the previous 24 months. Risk factors for re-hospitalizations were anemia, NYHA class III or IV and previous hospitalizations. Establishing an intensive outpatient management program for CHF patients leads to long-term beneficial effects with improved clinical parameters and decreased hospitalization in the setting of Internal Medicine.

The Three Rs for Preventing Heart Failure Readmission: Review, Reassess, and Reeducate

Despite improvements in heart failure therapies, hospitalization readmission rates remain high. Nationally, increasing attention has been directed toward reducing readmission rates and thus identifying patients with the highest risk for readmission. This article summarizes the evidence related to decreasing readmission for patients with heart failure within 30 days after discharge, focusing on the acute setting. Each patient requires an individualized plan for successful transition from hospital to home and preventing readmission. Nurses must review the patient's current plan of care and adherence to it and look for clues to failure of the plan that could lead to readmission to the hospital. In addition, nurses must reassess the current plan with the patient and family to ensure that the plan continues to meet the patient's needs. Finally, nurses must continually reeducate patients about their plan of care, their plan for self-management, and strategies to prevent hospital readmission for heart failure.

Functional Capacity but Not Early Uptake of Cardiac Rehabilitation Predicts Readmission in Patients With Metabolic Syndrome

BACKGROUND

Phase II cardiac rehabilitation reduces hospital readmissions and cardiovascular disease risk factors and improves functional capacity. Cardiovascular disease risk factors double with patients with metabolic syndrome, a population less likely to adhere to cardiac rehabilitation.

PURPOSE

The aim of this study was to determine relationships between cardiac rehabilitation uptake timing, demographic variables and functional capacity, and readmission in patients with metabolic syndrome.

METHODS

This retrospective, medical records study involved 353 patients with metabolic syndrome who subsequently received cardiac rehabilitation. Logistic regression was used to examine relationships between time from discharge to cardiac rehabilitation uptake and readmission. Unordered categorical factors were compared between readmission groups using Pearson χ tests. Multivariable logistic regression was used to identify predictors of readmission.

RESULTS

Patients readmitted within 30 and 90 days of hospitalization were more often women (P ≤ .018) and nonwhite (P ≤ .002) and had lower functional capacity (P < .001). In multivariable analysis, white race (odds ratio [OR], 0.50 [95% confidence interval (CI), 0.25-0.99]; P = .045) and higher functional capacity (OR, 0.80 [95% CI, 0.68-0.93]; P = .005) were protective against hospital readmission within the first 90 days. Race, sex, and functional capacity remained significant predictors of readmission at 1 year. In multivariable analysis, only race (OR, 0.41 [95% CI, 0.22-0.79]; P = .007) and functional capacity (OR, 0.83 [95% CI, 0.73-0.95]; P = .007) were significant. Early cardiac rehabilitation was not associated with readmission at any time point (P > .05).

CONCLUSIONS

Sex, race, and functional capacity were important predictors of readmission for metabolic syndrome, even when cardiac rehabilitation intake was delayed. Results raise questions about the unique traits of patients with metabolic syndrome and need for novel approaches to improve cardiac rehabilitation utilization and functional capacity in metabolic syndrome.

Heart Failure in Ischemic Stroke

Background and Purpose—

Heart failure (HF) in patients with acute ischemic stroke constitutes the source of various detrimental pathophysiologic mechanisms including prothrombotic and proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. In addition, HF might affect the safety and efficacy of the acute recanalization stroke therapies.

Methods—

Patients treated with intravenous recombinant tissue-type plasminogen activator or mechanical recanalization at a universitary stroke center were included into a prospective registry. Patients received cardiological evaluation, including echocardiography, during acute care. Functional outcome was assessed after 90 days by structured telephone interviews. Safety and efficacy of intravenous thrombolysis and mechanical thrombectomy were investigated among patients with HF and compared with patients with normal cardiac function after propensity score matching.

Results—

One thousand two hundred nine patients were included. HF was present in 378 patients (31%) and an independent predictor of unfavorable functional outcome. Recanalization rates were equal among patients with HF after intravenous thrombolysis and after mechanical recanalization or combined treatment. The rate of secondary intracranial hemorrhage was not different (7% versus 8%; P =0.909 after thrombolysis and 15% versus 20%, P =0.364 after mechanical recanalization or combined therapy). Early mortality within 48 hours after admission was equal (<1.5% in both groups).

Conclusions—

In this real-world cohort of patients with stroke, HF was an independent predictor of unfavorable functional long-term outcome, while the safety and efficacy of intravenous thrombolysis and mechanical recanalization appeared unaffected.

A Concept Analysis of Transitions of Care for Population Health

Background

Compelling evidence indicates that gaps in quality, safety, and experiences occur when patients encounter transitions across the care continuum. Differences in the organization of healthcare services as well as disparities in health across the globe, may have a unique impact on processes associated with transitions of care for client populations.

Purpose

Increased attention to the concept of transitions of care has resulted in disparate meanings and lack of clarity about its nature. Therefore, the purpose of this manuscript is to address this knowledge gap by analyzing the concept of transitions of care at the population level.

Methodology

To address the knowledge gap of what constitutes transitions of care at the population level, a concept analysis was done guided by the methodology of Walker and Avant. A comprehensive search of the literature yielded a small but relevant number of publications.

Results

This analysis identified four defining attributes, together with antecedents and consequences of transitions of care at the macro-system level of healthcare. A synthesized definition of transitions of care was developed.

Implications for Practice

This analysis provides conceptual clarity for the concept of transitions of care at the macro-system level of care. It can be used to guide the development of a middle-range theory to inform clinical practice and health policy.

Setting Up a Heart Failure Program in 2018: Moving Towards New Paradigm(s)

PURPOSE OF REVIEW

Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting.

RECENT FINDINGS

Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.

Patient engagement in the development of best practices for transitions from hospital to home: a scoping review

OBJECTIVES

To explore the extent of patient engagement in the development of best practice reports related to transitions from hospital to home.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (MEDLINE, EMBASE, CINAHL, Scopus, Trip Database, DynaMed Plus and Public Health Plus) and multiple provincial regulatory agency and healthcare organisation websites.

ELIGIBILITY CRITERIA

We included best practice reports related to the transition from hospital to a long-term care facility, community dwelling or rehabilitation centre. We included documents disseminated in English between 1947 and 2019.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened for eligibility and one extracted and analysed data using a data extraction tool we developed based on established patient engagement frameworks. Only records actively engaging patients were analysed (n=11). The methodological quality of actively engaging patients was assessed using domain 2 (item 5) of stakeholder involvement from the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

The search yielded 1921 citations of which 23 met the inclusion criteria and were included for narrative synthesis. These were disseminated between 1995 and 2019, with 18 (78%) published after 2010. Most were conducted in North America (USA 43%, Canada 22%), Europe (UK 30%) and Australia (4%). Eleven (48%) actively involved patients, of which only two involved patients across all stages of development. Most involved patients through direct or indirect consultation. The mean AGREE II domain 2 item 5 score (of those that actively engaged patients) was 5.9 out of 7.

CONCLUSIONS

Only half of existing best practice reports related to the transition from hospital to home actively involved patients in report development. However, the extent of patient engagement has been increasing over time. More organisations should strive to engage patients throughout the best practice development process and provide patients with opportunities for shared leadership.

Feasibility and performance of a patient-oriented discharge instruction tool for heart failure

Background

The provision of patient-centred discharge instructions is a pivotal goal for improving quality of care for patients with heart failure (HF) during care transitions. We tested the feasibility and performance of a novel discharge instruction tool co-designed with patients and adapted for HF; the patient-oriented discharge summary (PODS-HF) with the aim of improving communication, comprehension and adherence to discharge instructions.

Methods

An iterative process was used to adapt and implement an existing patient instruction tool for patients with HF (PODS-HF). A mixed methods approach was then used to explore patient experience, feasibility and performance using a pre–post study design among eligible patients admitted for HF over a 6-month period. Outcome measures included: the documentation of patient-centred instructions, a locally derived Average Discharge Score (ADS) based on the inclusion of instructions in nine key areas, patient satisfaction and understanding and adherence to instructions at 72 hours and 30 days determined using follow-up phone calls.

Results

19 patients were enrolled. The ADS increased by 68% with more consistent documentation. Patient satisfaction remained high. Patients provided PODS-HF reported receiving written information about HF related signs and symptoms to watch for (two out of five patients in the usual care group vs seven out of seven patients in the PODS-HF group; p=0.045). Patients also felt more confident to manage their own health and 30-day adherence to diet and exercise instructions improved while reducing the need for unscheduled visits. Quantitative results were supported by themes identified during follow-up calls, namely, the utility of written instructions and the importance of a follow-up call.

Conclusion

PODS-HF is a feasible tool for the delivery of patient-centred discharge instructions for patients with HF. The individual benefits of clarification and reinforcement made during follow-up calls among patients receiving this tool remains to be clarified.

Evaluation of the effectiveness of the healthy heart tracker on heart failure self-care

OBJECTIVE

We evaluated the effectiveness of a newly designed patient education booklet, the Health Heart Tracker (HHT), in promoting Heart Failure Self-Care (HFSC) behaviors compared to usual patient discharge handouts.

METHODS

We conducted a quasi-experimental, comparative two-group study using patients admitted for HF to four intermediate care units. The HHT was instituted on two units; patients on the other units served as control. We analyzed HFSC measured prior to HF discharge education and at two and six weeks post discharge using repeated measures ANOVA.

RESULTS

Eighty-four 84 patients completed the study. The sample was 72.6 (+ 12.9) years old, white (75%), educated, and retired (85.8%). All HFSC behaviors improved significantly over time, but there were no significant time by group interactions in HFSC maintenance, symptom perception, and confidence. A notable increase in HFSC management in the HHT group between baseline and 2 weeks was evident, but not sustained to 6 weeks.

CONCLUSIONS

A focused, singular intervention in the form of a patient education booklet designed specifically to improve HFSC did not significantly improve self-care behaviors over time compared to a control group.

PRACTICE IMPLICATIONS

More work is needed to determine optimal written resources for patients with HF.

Patient experiences using a novel tool to improve care transitions in patients with heart failure: a qualitative analysis

OBJECTIVE

To evaluate the utility of a novel discharge tool adapted for heart failure (HF) on patient experience.

DESIGN

Semistructured interviews assessed the utility of a novel discharge tool adapted for HF; patient-oriented discharge summary (PODS-HF) at 72 hours and 30 days after leaving hospital. Interviews were recorded and transcribed verbatim. Three investigators used directed content analysis to determine themes and subthemes from the narrative data.

SETTING

The cardiology ward of an urban academic institution in Canada.

PARTICIPANTS

13 patients and caregivers completed 24 interviews. Eligible patients were >18 years and admitted with a diagnosis of HF.

RESULTS

Analysis revealed six interconnected themes: (1) Utility of discharge instructions: how patients perceive and use written and verbal instructions. Patients receiving PODS-HF identified value in the patient-centred summarised content. (2) Adherence: strategies used by patients to enhance adherence to medications, diet and lifestyle changes. PODS-HF provides a strong visual reminder, particularly early postdischarge. (3) Adaptation: how patients incorporate changes into 'new norms'. This was more evident by 30 days, and those using PODS-HF had less unscheduled visits and readmissions. (4) Relationships with healthcare providers: patients' perceptions of the roles of family physicians and specialists in follow-up care. (5) Role of family and caregivers: the pivotal role of caregivers in supporting adherence and adaptation. (6) Follow-up phone calls: the utility of follow-up calls, particularly early after discharge as a means of providing clarification, reassurance and education.

CONCLUSION

PODS-HF is a useful tool that increases patients' confidence to self-manage and facilitates adherence by providing relevant written information to reference after discharge.

Variation Among Primary Care Physicians in 30-Day Readmissions

Background

Whether readmission rates vary by primary care physician (PCP) is unknown, although federal policy holds PCPs accountable for reducing readmissions.

Objective

To determine whether 30-day readmission rates vary by PCP.

Design

Retrospective cohort study using marginal models and multilevel logistic regression with 100% of data on Texas Medicare claims from 2008 to 2015.

Setting

Texas.

Participants

Patients discharged alive between 1 January 2008 and 30 November 2015 who had a PCP in the prior year and whose PCP had at least 50 admissions in the study period.

Measurements

Readmission within 30 days of discharge. Follow-up visits with a PCP within 7 days of discharge were also measured.

Results

Between 2012 and 2015, the mean risk-standardized rate of 30-day readmissions was 12.9%. Of 4230 PCPs, 1 had a readmission rate that was significantly higher than the mean and none had a significantly lower rate. The 10th and 90th percentiles of PCP readmission rates were 12.4% and 13.4%, respectively, each only 0.5 percentage point different from the mean. The 99th percentile of PCP readmission rates was 14.0%, 1.1 percentage points higher than the mean. Detecting a 1.1-percentage point difference from the mean adjusted readmission rate would require more than 3500 admissions per PCP per year.

Limitations

Only fee-for-service Medicare patients in a single state were included. The authors could not account for confounders not included in Medicare databases or classify readmissions as avoidable.

Conclusion

Variation in readmission rates among PCPs is very low. Programs holding PCPs accountable for readmissions may prove ineffective.

Primary Funding Source

National Institutes of Health.

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review

BACKGROUND

Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.

AIMS

To investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.

METHODS AND RESULTS

We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0-12 h of didactic training and 58-62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79-98% and a specificity of 70-99%. In image adequacy studies, medical students with 2-9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50-100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.

CONCLUSIONS

Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.

Thirty-day readmission after endovascular or surgical revascularization for chronic mesenteric ischemia: Insights from the Nationwide Readmissions Database

There are limited contemporary data on readmission after revascularization for chronic mesenteric ischemia (CMI). This study aimed to determine the rates, reasons, predictors, and costs of 30-day readmission after endovascular or surgical revascularization for CMI. Patients with CMI discharged after endovascular or surgical revascularization during 2013 to 2014 were identified from the Nationwide Readmissions Database. The rates, reasons, length of stay, and costs of 30-day all-cause, non-elective, readmission were determined using weighted national estimates. Independent predictors of 30-day readmission were determined using hierarchical logistic regression. Among 4671 patients with CMI who underwent mesenteric revascularization, 19.5% were readmitted within 30 days after discharge at a median time of 10 days. More than 25% of readmissions were for cardiovascular or cerebrovascular conditions, most of which were for peripheral or visceral atherosclerosis and congestive heart failure. Independent predictors of 30-day readmission included non-elective index admission, chronic kidney disease (CKD), and discharge to home healthcare or to a skilled nursing facility. Revascularization modality did not independently predict readmission. In a nationwide, retrospective analysis of patients with CMI undergoing revascularization, approximately one in five were readmitted within 30 days. Predictors were largely non-modifiable and included non-elective index admission, CKD, and discharge disposition.

Essential Elements of Early Post Discharge Care of Patients with Heart Failure

PURPOSE OF REVIEW

Heart failure is associated with an enormous burden on both patients and health care systems in the USA. Several national policy initiatives have focused on improving the quality of heart failure care, including reducing readmissions following hospitalization, which are common, costly, and, at least in part, preventable. The transition from inpatient to ambulatory care setting and the immediate post-hospitalization period present an opportunity to further optimize guideline concordant medical therapy, identify reversible issues related to worsening heart failure, and evaluate prognosis. It can also provide opportunities for medication reconciliation and optimization, consideration of device-based therapies, appropriate management of comorbidities, identification of individual barriers to care, and a discussion of goals of care based on prognosis.

RECENT FINDINGS

Recent studies suggest that attention to detail regarding patient comorbidities, barriers to care, optimization of both diuretic and neurohormonal therapies, and assessment of prognosis improve patient outcomes. Despite the fact that the transition period appears to be an optimal time to address these issues in a comprehensive manner, most patients are not referred to programs specializing in this approach post hospital discharge. The objective of this review is to provide an outline for early post discharge care that allows clinicians and other health care providers to care for these heart failure patients in a manner that is both firmly rooted in the guidelines and patient-centered. Data regarding which intervention is most likely to confer benefit to which subset of patients with this disease is lacking and warrants further study.

Readmission and mortality in patients ≥70 years with acute myocardial infarction or heart failure in the Netherlands: a retrospective cohort study of incidences and changes in risk factors over time

Objectives

To determine the risk of first unplanned all-cause readmission and mortality of patients ≥70 years with acute myocardial infarction (AMI) or heart failure (HF) and to explore which effects of baseline risk factors vary over time.

Methods

A retrospective cohort study was performed on hospital and mortality data (2008) from Statistics Netherlands including 5,175 (AMI) and 9,837 (HF) patients. We calculated cumulative weekly incidences for first unplanned all-cause readmission and mortality during 6 months post-discharge and explored patient characteristics associated with these events.

Results

At 6 months, 20.4% and 9.9% (AMI) and 24.6% and 22.4% (HF) of patients had been readmitted or had died, respectively. The highest incidences were found in week 1. An increased risk for 14-day mortality after AMI was observed in patients who lived alone (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.01–2.44) and within 30 and 42 days in patients with a Charlson Comorbidity Index ≥3. In HF patients, increased risks for readmissions within 7, 30 and 42 days were found for a Charlson Comorbidity Index ≥3 and within 42 days for patients with an admission in the previous 6 months (HR 1.42, 95% CI 1.12–1.80). Non-native Dutch HF patients had an increased risk of 14-day mortality (HR 1.74, 95% CI 1.09–2.78).

Conclusion

The risk of unplanned readmission and mortality in older AMI and HF patients was highest in the 1st week post-discharge, and the effect of some risk factors changed over time. Transitional care interventions need to be provided as soon as possible to prevent early readmission and mortality.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1227-4) contains supplementary material, which is available to authorized users.

Determination of Hopelessness and Quality of Life in Patients with Heart Disease: An Example from Eastern Turkey

This descriptive study was undertaken in order to determine hopelessness and quality of life among the patients with heart disease. No sampling was made, and 200 patients who were voluntary and were able to communicate were included in the study. The data of the study were collected using a personal information form that involved questions about patients' descriptive information and their diseases, Beck Hopelessness Scale and SF-36 Quality of Life Scale with a face-to-face interview technique. For the analyses of the data, percentages, means, t test, Kruskal-Wallis and Pearson's correlation analyses were used. It was identified 54% of them was male patients. It was seen that there were significant between income status and general health perceptions, hopelessness; and between health perceptions and vitality, general health perceptions, global quality of life, hopelessness (p < .05). It was also explored that there was a negative correlation between hopelessness levels of the cardiac patients and functioning status, general health perceptions and global quality of life. It was determined that the desperation levels of the patients were above the middle level, and the quality of life was low.

A Randomized Controlled Trial Comparing Telehealth Self-Management to Standard Outpatient Management in Underserved Black and Hispanic Patients Living with Heart Failure

Background: Although the American Heart Association promotes telehealth models to improve care access, there is limited literature on its use in underserved populations. This study is the first to compare utilization and quality of life (QoL) for underserved black and Hispanic heart failure (HF) patients assigned to telehealth self-monitoring (TSM) or comprehensive outpatient management (COM) over 90 days.

Methods: This randomized controlled trial enrolled 104 patients. Outcomes included emergency department (ED) visits, hospitalizations, QoL, depression, and anxiety. Binary outcomes for utilization were analyzed using chi-square or Fisher's exact test. Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations were also used as appropriate.

Results: Of 104 patients, 31% were Hispanic, 69% black, 41% women, and 72% reported incomes of <$10,000/year. Groups did not differ regarding binary ED visits (relative risk [RR] = 1.37, confidence interval [CI] = 0.83–2.27), hospitalization (RR = 0.92, CI = 0.57–1.48), or length of stay in days (TSM = 0.54 vs. COM = 0.91). Number of all-cause hospitalizations was significantly lower for COM (TSM = 0.78 vs. COM = 0.55; p = 0.03). COM patients reported greater anxiety reduction from baseline to 90 days (TSM = 50–28%; COM = 57–13%; p = 0.05).

Conclusions: These findings suggest that TSM is not effective in reducing utilization or improving QoL for underserved patients with HF. Future studies are needed to determine whether TSM can be effective for populations facing health care access issues.

Managing the Economic Challenges in the Treatment of Heart Failure

The economics of heart failure (HF) touches all patients with HF, their families, and the physicians and health systems that care for them. HF is specifically targeted by cost-reduction and care quality initiatives from the Centers for Medicare and Medicaid Services (CMS). The changing quality assessment and payment landscape is, and will continue to be, challenging for hospitals and HF specialists as they provide care for patients with this debilitating disease. Quality-based payment systems with evolving performance metrics are replacing traditional volume-based fee-for-service models. A critical objective of quality-based models is to improve care and reduce cost, but there are few data to support decision-making on how to improve. CMS payment programs and their implications for health systems treating HF were reviewed at a symposium at the Heart Failure Society of America conference in Nashville, Tennessee on September 15, 2018. This article constitutes the proceedings from that symposium.

Factors associated with attendance at primary care appointments after discharge from hospital: a retrospective cohort study

BACKGROUND

Follow-up with a primary care provider within 1-2 weeks of discharge from hospital has been associated with reduced readmissions. We sought to determine appointment attendance with primary care providers postdischarge and identify factors associated with attendance.

METHODS

We conducted a retrospective cohort study involving general medicine patients who had been discharged from hospital between Sept. 1, 2014, and Dec. 30, 2015, from 2 Ontario academic hospitals, and who had been supported by a transitional care specialist and advised to see a primary care provider within 1 week. Attendance was determined by self-report during follow-up by telephone. We used multivariable logistic regression to assess whether patient factors (e.g., comorbidity) or system factors (e.g., booking the appointment before discharge) predicted attendance. We used Cox proportional hazards modelling to assess whether attendance predicted readmission within 30 days.

RESULTS

Of the 214 patients included in our study, 35% (n = 75) attended a primary care appointment within 1 week of discharge; 52% (n = 124) of patients attended an appointment within 2 weeks. After adjusting for age, sex and comorbidity, significant predictors of attendance were booking the appointment before discharge (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.07-4.40), familiarity with the primary care provider (OR 5.43, 95% CI 2.25-14.1) and inclusion of a reminder, callback number and appointment time in the discharge summary (OR 15.3, 95% CI 2.09-326). Predictors of nonattendance were the presence of a home support worker (OR 0.38, 95% CI 0.17-0.80) and a booked specialist appointment before discharge (OR 0.37, 95% CI 0.18-0.73). Attendance was not associated with reduced readmissions (hazard ratio 0.66, 95% CI 0.40-1.09).

INTERPRETATION

Timely follow-up with PCPs postdischarge remains challenging. Efforts to improve attendance should focus on reinforcing need for follow-up and coordinating follow-up before discharge, particularly for those poorly connected with the health care system.

Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population

PURPOSE

The utility of a transitions-of-care (TOC) pharmacist intervention focused on improving the quality and safety of the medication process for high-risk cardiovascular patients was evaluated.

METHODS

A quality-improvement initiative was developed for patients with heart failure or acute coronary syndrome followed longitudinally at a hospital's outpatient cardiovascular clinic. The TOC pharmacist intervention occurred either before a patient's outpatient cardiovascular clinic appointment or during a hospitalization. The major outcome analyzed was the number of unplanned hospital readmissions within 30 days. Additional endpoints evaluated included the time to healthcare utilization, number of medication discrepancies identified, percentage of therapeutic recommendations accepted by a provider, number of medication access issues resolved, patient cost savings, patient satisfaction, and mean time spent on an intervention by the pharmacist per patient encounter.

RESULTS

A total of 118 patients received the TOC pharmacist intervention. A total of 516 medication discrepancies were identified and corrected, with 55.6% of discrepancies involving cardiovascular medications. A total of 244 recommendations for therapeutic optimization were provided, with an 81% provider acceptance rate and a 100% patient satisfaction rate. Fifty-five patients were provided with medication cost savings, and medication-access issues were resolved for 8 patients. A TOC pharmacist spent means of 98 and 73 minutes on patient education and coordination of care during inpatient and ambulatory encounters, respectively. The 30-day hospital readmission rate for patients with heart failure was reduced by 20%.

CONCLUSION

A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high-risk cardiovascular patients at our institution.

Risk assessment of the hospital discharge process of high-risk patients with diabetes

Objectives

Describe the application of a risk assessment to identify failures in the hospital discharge process of a high-risk patient group, liver transplant (LT) recipients with diabetes mellitus (DM) and/or hyperglycaemia who require high-risk medications.

Design

A Failure Modes, Effects and Criticality Analysis (FMECA) of the hospital discharge process of LT recipients with DM and/or hyperglycaemia who required DM education and training before discharge was conducted using information from clinicians, patients and data extraction from the electronic health records (EHR). Failures and their causes were identified and the frequency and characteristics (harm, detectability) of each failure were assigned using a score of low/best (1) to high/worst (10); a Criticality Index (CI=Harm×Frequency) and a Risk Priority Number (RPN=Harm×Frequency×Detection) were also calculated.

Setting

An academic, tertiary care centre in Chicago, Illinois.

Participants

Healthcare providers (N=31) including physicians (n= 6), advanced practice providers (n=12), nurses (n=6), pharmacists (n= 4), staff (n=3) and patients (n=6) and caregivers (n=3) participated in the FMECA; EHR data for LT recipients with DM or hyperglycaemia (N=100) were collected.

Results

Of 78 identified failures, the most critical failures (n=15; RPNs=700, 630, 560; CI=70) were related to variability in delivery of diabetes education and training, care coordination and medication prescribing patterns of providers. Underlying causes included timing of patient education, lack of assessment of patients’ knowledge and industry-level design failures of healthcare products (eg, EHR, insulin pen).

Conclusion

Most identified critical failures are preventable and suggest the need for the design of interventions, informed by the failures identified by this FMECA, to mitigate safety risks and improve outcomes of high-risk patient populations.

Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.

Discharge Processes and 30-Day Readmission Rates of Patients Hospitalized for Heart Failure on General Medicine and Cardiology Services

Given high rates of heart failure (HF) hospitalizations and widespread adoption of the hospitalist model, patients with HF are often cared for on General Medicine (GM) services. Differences in discharge processes and 30-day readmission rates between patients on GM and those on Cardiology during the contemporary hospitalist era are unknown. The present study compared discharge processes and 30-day readmission rates of patients with HF admitted on GM services and those on Cardiology services. We retrospectively studied 926 patients discharged home after HF hospitalization. The primary outcome was 30-day all-cause readmission after discharge from index hospitalization. Although 60% of patients with HF were admitted to Cardiology services, 40% were admitted to GM services. Prevalence of cardiovascular and noncardiovascular co-morbidities were similar between patients admitted to GM services and Cardiology services. Discharge summaries for patients on GM services were less likely to have reassessments of ejection fraction, new study results, weights, discharge vital signs, discharge physical examinations, and scheduled follow-up cardiologist appointments. In a multivariable regression analysis, patients on GM services were more likely to experience 30-day readmissions compared with those on Cardiology services (odds ratio 1.43 95% confidence interval [1.05 to 1.96], p = 0.02). In conclusion, outcomes are better among those admitted to Cardiology services, signaling the need for studies and interventions focusing on noncardiology hospital providers that care for patients with HF.

Improving Care Transitions Across Healthcare Settings Through a Human Factors Approach

After more than two decades of research focused on care transition improvement and intervention development, unfavorable outcome measures associated with care transitions across healthcare settings persist. Readmissions rates remain an important outcome to target for intervention, adverse events associated with care transitions continue to be an issue, and patients are often dissatisfied with the quality of their care. Currently, interventions to improve care transitions are disease specific, require substantial financial investments in training allied healthcare professionals, or focus primarily on hospital-based discharge planning with mixed results. This complex situation requires a method of evaluation that can provide a comprehensive, in-depth, and context-driven investigation of potential risks to safe care transitions across healthcare settings, which can lead to the creation of effective, usable, and sustainable interventions. A systems' approach known as Human Factors and Ergonomics (HFE) evaluates the factors in a system that affect human performance. This article describes how HFE can complement and further strengthen efforts to improve care transitions.

Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes

Interventions focused on ensuring safe transitions for patients from hospital to home can assist in providing continuity of care, preventing readmissions, and reducing duplication of services. Patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) procedure are often frail, elderly, and have multiple co-morbidities. A pilot initiative evaluating transitional care strategies through telephone follow up was implemented in a tertiary centre with the aim to identify gaps and intervene, preventing re-admission and improving patient outcomes. TAVI patients or caregivers were contacted at 3 days and 30 days post discharge by an Advanced Practice Nurse (APN). Telephone follow up centered on best practices for transitional care. Outcomes revealed fluid balance monitoring, medication management, and feelings of anxiety and depression post TAVI were the most frequent areas requiring intervention. Findings from this initiative reinforce the need to establish consistent processes that support elderly patient populations during potentially vulnerable points in the care trajectory.

Home Hospitalization for Acute Decompensated Heart Failure: Opportunities and Strategies for Improved Health Outcomes

IMPORTANCE

Heart failure (HF) is the leading cause of hospitalization among patients over the age of 65 in the United States and developed countries, posing a significant economic burden to the health care systems. More than half of the patients with HF will be readmitted to the hospital within 6 months from discharge, leading not only to increased health care related expenses but also functional decline, iatrogenic injuries and in-hospital infections. With the increasing prevalence of HF, there is a substantial need for innovative delivery care models that can provide hospital level of care at a patient's home.

OBSERVATIONS

Home hospitalization was originally used to safely manage chronically ill patients with general medical (stroke, chronic obstructive pulmonary disease, deep vein thrombosis, community acquired pneumonia) and surgical conditions and was associated with improved patient satisfaction and improvement in activity of daily living status. This had no clear effect on readmission or cost. When hospital at home care model was applied to HF patients it demonstrated increased time to readmission, reduced index costs and improved health related quality of life, with no significant differences in adverse events. Eligible patients should be selected based on multiple factors taking into consideration applicable limitations and comorbidities.

CONCLUSIONS AND RELEVANCE

Providing in-hospital level care to the patient's house presents a reliable alternative, yielding multiple benefits both for the patient, as well as the health care system. Formulating a well-defined model is necessary before wide implementation.

Nursing research in heart failure care: a position statement of the american association of heart failure nurses (AAHFN)

BACKGROUND

Heart Failure (HF) is a public health problem globally affecting approximately 6 million in the United States.

OBJECTIVES

A tailored position statement was developed by the American Association of Heart Failure Nurses (AAHFN) and their Research Consortium to assist researchers, funding institutions and policymakers with improving HF clinical advancements and outcomes.

METHODS

A comprehensive review was conducted using multiple search terms in various combinations to describe gaps in HF nursing science. Based on gaps described in the literature, the AAHFN made recommendations for future areas of research in HF.

RESULTS

Nursing has made positive contributions through disease management interventions, however, quality, rigorous research is needed to improve the lives of patients and families while advancing nursing science.

CONCLUSIONS

Advancing HF science is critical to managing and improving patient outcomes while promoting the nursing profession. Based on this review, the AAHFN is putting forth a call to action for research designs that promote validity, sustainability, and funding of future nursing research.

Linking care of patients with obesity to outpatient weight control clinics following acute hospitalizations

Despite obesity impacting over one-third of US adults, guideline recommendations have not been effectively utilized by health care providers in hospital settings. Initiation of weight loss plans for obese patients during hospitalizations followed by linkage of care to weight control centers may improve compliance with the guidelines. Provider recognition and awareness that obesity is a chronic condition that warrants inpatient counsel and management with appropriate arrangement of postdischarge follow-up care will be critical to guideline implementation.

Long-Term Potassium Monitoring and Dynamics in Heart Failure and Risk of Mortality

BACKGROUND

The prognostic value of long-term potassium monitoring and dynamics in heart failure has not been characterized completely. We sought to determine the association between serum potassium values collected at follow-up with all-cause mortality in a prospective and consecutive cohort of patients discharged from a previous acute heart failure admission.

METHODS

Serum potassium was measured at every physician-patient encounter, including hospital admissions and ambulatory settings. The multivariable-adjusted association of serum potassium with mortality was assessed by using comprehensive state-of-the-art regression methods that can accommodate time-dependent exposure modeling.

RESULTS

The study sample included 2164 patients with a total of 16 116 potassium observations. Mean potassium at discharge was 4.3±0.48 mEq/L. Hypokalemia (<3.5 mEq/L), normokalemia (3.5-5.0 mEq/L), and hyperkalemia (>5 mEq/L) were observed at the index admission in 77 (3.6%), 1965 (90.8%), and 122 (5.6%) patients, respectively. At a median follow-up of 2.8 years (range, 0.03-12.8 years), 1090 patients died (50.4%). On a continuous scale, the multivariable-adjusted association of potassium values and mortality revealed a nonlinear association (U-shaped) with higher risk at both ends of its distribution (omnibus P=0.001). Likewise, the adjusted hazard ratios for hypokalemia and hyperkalemia, normokalemia as reference, were 2.35 (95% confidence interval, 1.40-3.93; P=0.001) and 1.55 (95% confidence interval, 1.11-2.16; P=0.011), respectively (omnibus P=0.0003). Furthermore, dynamic changes in potassium were independently associated with substantial differences in mortality risk. Potassium normalization was independently associated with lower mortality risk (P=0.001).

CONCLUSIONS

Either modeled continuously or categorically, serum potassium levels during long-term monitoring were independently associated with mortality in patients with heart failure. Likewise, persistence of abnormal potassium levels was linked to a higher risk of death in comparison with patients who maintained or returned to normal values.

Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality

AIMS

Hospitalizations for heart failure (HF) are common and are associated with significant morbidity, mortality and cost. However, precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood.

METHODS AND RESULTS

The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) programme were prospectively collected and stratified by ejection fraction (EF). Potential precipitants were collected using a specifically designed case report form and categorized according to the presence of cardiovascular (CV), non-CV and unknown factors. Associations between these factors and subsequent rehospitalization and mortality rates were examined. Of 1668 patients who experienced HF hospitalization, 1152 had reduced EF (≤40%, HFrEF) and 516 had preserved EF (HFpEF). Overall, 54% had CV, 32% had non-CV and 14% had unknown factors thought to have precipitated HF, with similar proportions in the HFrEF and HFpEF groups. The most common precipitants were arrhythmia (15%), other non-CV factors (11%) and respiratory infection (10%). Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors. However, mortality rates were similar among patients with any of the three categories of precipitating factors. Results were similar in HFrEF and HFpEF.

CONCLUSIONS

Among chronic HF patients hospitalized for decompensation, the investigator-reported precipitating factor was not associated with the subsequent mortality rate, but was associated with type of readmission: readmissions for CV reasons were more likely when the index precipitant was CV.

Implementation of a Patient Navigator Program to Reduce 30-day Heart Failure Readmission Rate

With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.

Influence of Sacubitril/Valsartan (LCZ696) on 30-Day Readmission After Heart Failure Hospitalization

BACKGROUND

Patients with heart failure (HF) are at high risk for hospital readmission in the first 30 days following HF hospitalization.

OBJECTIVES

This study sought to determine if treatment with sacubitril/valsartan (LCZ696) reduces rates of hospital readmission at 30-days following HF hospitalization compared with enalapril.

METHODS

We assessed the risk of 30-day readmission for any cause following investigator-reported hospitalizations for HF in the PARADIGM-HF trial, which randomized 8,399 participants with HF and reduced ejection fraction to treatment with LCZ696 or enalapril.

RESULTS

Accounting for multiple hospitalizations per patient, there were 2,383 investigator-reported HF hospitalizations, of which 1,076 (45.2%) occurred in subjects assigned to LCZ696 and 1,307 (54.8%) occurred in subjects assigned to enalapril. Rates of readmission for any cause at 30 days were 17.8% in LCZ696-assigned subjects and 21.0% in enalapril-assigned subjects (odds ratio: 0.74; 95% confidence interval: 0.56 to 0.97; p = 0.031). Rates of readmission for HF at 30-days were also lower in subjects assigned to LCZ696 (9.7% vs. 13.4%; odds ratio: 0.62; 95% confidence interval: 0.45 to 0.87; p = 0.006). The reduction in both all-cause and HF readmissions with LCZ696 was maintained when the time window from discharge was extended to 60 days and in sensitivity analyses restricted to adjudicated HF hospitalizations.

CONCLUSIONS

Compared with enalapril, treatment with LCZ696 reduces 30-day readmissions for any cause following discharge from HF hospitalization.

Design and Rationale of a Randomized Trial of a Care Transition Strategy in Patients With Acute Heart Failure Discharged From the Emergency Department: GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure)

GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure) is a multicenter randomized trial of a patient-centered transitional care intervention in patients with acute heart failure (AHF) who are discharged either directly from the emergency department (ED) or after a brief period of ED-based observation. To optimize care and reduce ED and hospital revisits, there has been significant emphasis on improving transitions at the time of hospital discharge for patients with HF. Such efforts have been almost exclusively directed at hospitalized patients; individuals with AHF who are discharged from the ED or ED-based observation are not included in these transitional care initiatives. Patients with AHF discharged directly from the ED or after a brief period of ED-based observation are randomly assigned to our transition GUIDED-HF strategy or standard ED discharge. Patients in the GUIDED arm receive a tailored discharge plan via the study team, based on their identified barriers to outpatient management and associated guideline-based interventions. This plan includes conducting a home visit soon after ED discharge combined with close outpatient follow-up and subsequent coaching calls to improve postdischarge care and avoid subsequent ED revisits and inpatient admissions. Up to 700 patients at 11 sites will be enrolled over 3 years of the study. GUIDED-HF will test a novel approach to AHF management strategy that includes tailored transitional care for patients discharged from the ED or ED-based observation. If successful, this program may significantly alter the current paradigm of AHF patient care.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02519283.

Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach

Supplemental Digital Content is available in the text.

Background:

Vertical integration is expected to improve communication and coordination between inpatient care and care after discharge. Despite being used across health systems worldwide, evidence about its impact on readmissions is sparse and contradictory.

Objective:

To assess the impact of vertical integration on hospital readmissions.

Research Design, Subjects, and Measures:

Using difference-in-differences we compared readmissions before and after vertical integration in 6 Portuguese hospitals for years 2004–2013. A control group with 6 similar hospitals not integrated was utilized. Considered outcome was 30-day unplanned readmission. We used logistic regression at the admission level and accounted for patients’ risk factors using claims data. Analyses for each hospital and selected conditions were also run.

Results:

Our results suggest that readmissions decreased overall after vertical integration [odds ratio (OR)=0.900; 95% confidence interval (CI), 0.812–0.997]. Hospital analysis indicated that there was no impact for 2 hospitals (OR=0.960; 95% CI, 0.848–1.087 and OR=0.944; 95% CI, 0.857–1.038), and a positive effect in 4 hospitals (greatest effect: OR=0.811; 95% CI, 0.736–0.894). A positive evolution was observed for a limited number of conditions, with better results for diabetes with complications (OR=0.689; 95% CI, 0.525–0.904), but no impact regarding congestive heart failure (OR=1.067; 95% CI, 0.827–1.377).

Conclusions:

Merging acute and primary care providers was associated with reduced readmissions, even though improvements were not found for all institutions or condition-specific groups. There are still challenges to be addressed regarding the success of vertical integration in reducing 30-day hospital readmissions.

Chronic Heart Failure Care Planning: Considerations in Older Patients

In developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.

Medication self-management skills and cognitive impairment in older adults hospitalized for heart failure: A cross-sectional study

Background:

Cognitive impairment is highly prevalent among older adults (aged ≥65 years) hospitalized for heart failure and has been associated with poor outcomes. Poor medication self-management skills have been associated with poor outcomes in this population as well. The presence and extent of an association between cognitive impairment and poor medication self-management skills in this population has not been clearly defined.

Objective:

We assessed the cognition of consecutive older adults hospitalized for heart failure, in relation to their medication self-management skills.

Methods:

We conducted a cross-sectional study of older adults (aged ≥65 years) who were hospitalized for heart failure and were being discharged home. Prior to discharge, we assessed cognition using the Mini-Cog. We also tested patients’ ability to read a pill bottle label, open a pill bottle safety cap, and allocate mock pills to a pill box. Pill allocation performance was assessed quantitatively (counts of errors of omission and commission) and qualitatively (patterns suggestive of knowledge-based mistakes, rule-based mistakes, or skill-based slips).

Results:

Of 55 participants, 22% were found to have cognitive impairment. Patients with cognitive impairment tended to be older as compared to those without cognitive impairment (mean age = 81 vs 76 years, p = NS). Patients with cognitive impairment had a higher prevalence of inability to read pill bottle label (prevalence ratio = 5.8, 95% confidence interval = 3.2–10.5, p = 0.001) and inability to open pill bottle safety cap (prevalence ratio = 3.3, 95% confidence interval = 1.3–8.4, p = 0.03). While most patients (65%) had pill-allocation errors regardless of cognition, those patients with cognitive impairment tended to have more errors of omission (mean number of errors = 48 vs 23, p = 0.006), as well as more knowledge-based mistakes (75% vs 40%, p = 0.03).

Conclusion:

There is an association between cognitive impairment and poor medication self-management skills. Medication taking failures due to poor medication self-management skills may be part of the pathway linking cognitive impairment to poor post-discharge outcomes among patients with heart failure transitioning from hospital to home.