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

A Supportive Heart Failure Care Program to Reduce Hospital Readmissions

In the United States, heart failure (HF) is the leading reason for hospital readmissions, with 27% of Medicare recipients with HF being readmitted within 30 days The purpose of this quality improvement project was to decrease HF readmissions during their first 30 days of care with our home health agency. The Supportive Heart Failure Care education program was based on the results of a population assessment and included establishment of agency-wide best practices, nursing education sessions, and implementation of best practices focused on evidence-based self-management. After implementation of this project, the hospital readmission rate decreased from 32% to 21%. The nurses who completed the education sessions (N = 35) showed an increase in knowledge of 4.1% from pre-test scores. However, chart audits showed varying levels of documented practice in alignment with best practices. Although results of this project showed a small improvement in nurse knowledge and varied changes to documented practice, the overall project goal of decreasing hospital readmissions was achieved. Understanding individual and systems-level barriers to translating education to practice is needed to better meet the needs of home health nurses and the HF patients they serve.

Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study

OBJECTIVE

Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality.

METHODS

This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities.

RESULTS

Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years.

CONCLUSION

One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.

Combining Physiology-Based Modeling and Evolutionary Algorithms for Personalized, Noninvasive Cardiovascular Assessment Based on Electrocardiography and Ballistocardiography

Purpose: This study proposes a novel approach to obtain personalized estimates of cardiovascular parameters by combining (i) electrocardiography and ballistocardiography for noninvasive cardiovascular monitoring, (ii) a physiology-based mathematical model for predicting personalized cardiovascular variables, and (iii) an evolutionary algorithm (EA) for searching optimal model parameters.

Methods: Electrocardiogram (ECG), ballistocardiogram (BCG), and a total of six blood pressure measurements are recorded on three healthy subjects. The R peaks in the ECG are used to segment the BCG signal into single BCG curves for each heart beat. The time distance between R peaks is used as an input for a validated physiology-based mathematical model that predicts distributions of pressures and volumes in the cardiovascular system, along with the associated BCG curve. An EA is designed to search the generation of parameter values of the cardiovascular model that optimizes the match between model-predicted and experimentally-measured BCG curves. The physiological relevance of the optimal EA solution is evaluated a posteriori by comparing the model-predicted blood pressure with a cuff placed on the arm of the subjects to measure the blood pressure.

Results: The proposed approach successfully captures amplitudes and timings of the most prominent peak and valley in the BCG curve, also known as the J peak and K valley. The values of cardiovascular parameters pertaining to ventricular function can be estimated by the EA in a consistent manner when the search is performed over five different BCG curves corresponding to five different heart-beats of the same subject. Notably, the blood pressure predicted by the physiology-based model with the personalized parameter values provided by the EA search exhibits a very good agreement with the cuff-based blood pressure measurement.

Conclusion: The combination of EA with physiology-based modeling proved capable of providing personalized estimates of cardiovascular parameters and physiological variables of great interest, such as blood pressure. This novel approach opens the possibility for developing quantitative devices for noninvasive cardiovascular monitoring based on BCG sensing.

Nurse-led ambulatory care supported by non-invasive haemodynamic assessment after acute heart failure decompensation

Heart failure (HF) is characterized by frequent decompensation and an unpredictable trajectory. To prevent early hospital readmission, coordinated discharge planning and individual therapeutic approach are recommended.

Aims

We aimed to assess the effect of 1 month of ambulatory care, led by nurses and supported by non‐invasive haemodynamic assessment, on the functional status, well‐being, and haemodynamic status of patients post‐acute HF decompensation.

Methods and results

This study had a multicentre, prospective, and observational design and included patients with at least one hospitalization due to acute HF decompensation within 6 months prior to enrolment. The 1 month ambulatory care included three visits led by a nurse when the haemodynamic state of each patient was assessed non‐invasively by impedance cardiography, including thoracic fluid content assessment. The pharmacotherapy was modified basing on haemodynamic assessment. Sixty eight of 73 recruited patients (median age = 67 years; median left ventricular ejection fraction = 30%) finished 1 month follow‐up. A significant improvement was observed in both the patients' functional status as defined by New York Heart Association class (P = 0.013) and sense of well‐being as evaluated by a visual analogue score (P = 0.002). The detailed patients' assessment on subsequent visits resulted in changes of pharmacotherapy in a significant percentage of patients (Visit 2 = 39% and Visit 3 = 44%).

Conclusions

The proposed model of nurse‐led ambulatory care for patients after acute HF decompensation, with consequent assessment of the haemodynamic profile, resulted in: (i) improvement in the functional status, (ii) improvement in the well‐being, and (iii) high rate of pharmacotherapy modifications.

Representativeness of the PIONEER-HF Clinical Trial Population in Patients Hospitalized With Heart Failure and Reduced Ejection Fraction

Background:

In PIONEER-HF (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-pro BNP in Patients Stabilized From an Acute Heart Failure Episode), the in-hospital initiation of sacubitril/valsartan in patients hospitalized for acute decompensated heart failure (ADHF) was well-tolerated and led to improved outcomes. We aim to determine the representativeness of the PIONEER-HF trial among patients hospitalized for ADHF using real-world data.

Methods:

The study population was derived from all patients discharged alive for ADHF in the Get With The Guidelines—HF registry from 2006 to 2018 with HF with reduced ejection fraction (HFrEF; all HFrEF with ADHF). We then determined the proportion of patients meeting PIONEER-HF eligibility criteria (PIONEER-HF eligible) and those meeting a set of limited eligibility criteria (actionable cohort). Rates of HF readmissions and all-cause mortality were then compared between the all HFrEF with ADHF, PIONEER-HF eligible, and actionable cohorts using linked Medicare claims data.

Results:

A total of 99 767 patients with HFrEF in Get With The Guidelines—HF were hospitalized for ADHF. PIONEER-HF inclusion criteria were met by 71 633 (71.8%) patients, and both inclusion and exclusion criteria were met by 20 704 (20.8%) patients. Further, 68 739 (68.9%) patients met the criteria for the actionable cohort. Among the Centers for Medicare and Medicaid—linked patients, the HF rehospitalization rate at 1 year was 35.1% (95% CI, 34.5–35.8) for all HFrEF with ADHF patients, 32.6% (95% CI, 31.3–33.9) for the PIONEER-HF eligible cohort, and 33.1% (95% CI, 32.3–33.9) for the actionable cohort. The 1-year all-cause mortality was 36.7% (95% CI, 36.1–7.4) for all HFrEF with ADHF patients, 31.6% (95% CI, 30.3–32.9) for the PIONEER-HF eligible cohort, and 32.2% (95% CI, 31.4–33.0) for the actionable cohort.

Conclusions:

Patient characteristics and clinical outcomes for patients eligible for PIONEER-HF only modestly differ when compared with those encountered in routine practice, suggesting that the in-hospital initiation of sacubitril/valsartan should be routinely considered for patients with HFrEF hospitalized for ADHF.

Emergency department visits of older adults within 30 days of discharge: analysis from the pharmacotherapy perspective

OBJECTIVE

To analyze, from the pharmacotherapy perspective, the factors associated to visits of older adults to the emergency department within 30 days after discharge.

METHODS

A cross-sectional study carried out in a general public hospital with older adults. Emergency department visit was defined as the stay of the older adult in this service for up to 24 hours. The complexity of drug therapy was determined using the Medication Regimen Complexity Index. Potentially inappropriate drugs for use in older adults were classified according to the American Geriatric Society/Beers criteria of 2015. The outcome investigated was the frequency of visits to the emergency department within 30 days of discharge. Multivariate logistic regression was performed to identify the factors associated with the emergency department visit.

RESULTS

A total of 255 elderly in the study, and 67 (26.3%) visited emergency department within 30 days of discharge. Polypharmacy and potentially inappropriate medications for older adults did not present a statistically significant association. The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with emergency department visits (OR=2.3; 95%CI: 1.04-4.94; p=0.048; and OR=2.1; 95%CI: 1.11-4.02; p=0.011), respectively. Furthermore, the diagnosis of diabetes mellitus and chronic kidney disease were protection factors for the outcome (OR=0.4; 95%CI: 0.20-0.73; p=0.004; and OR=0.3; 95%CI: 0.13-0.86; p=0.023).

CONCLUSION

The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with the occurrence of an emergency department visit within 30 days of discharge.

[Pulmonary artery pressure sensor for ambulatory assessment of ventricular filling pressure in advanced heart failure : What should be considered for the follow-up care?]

BACKGROUND

Patients with advanced heart failure suffer from frequent hospitalizations. Noninvasive hemodynamic telemonitoring for assessment of pulmonary filling pressure has been shown to reduce hospitalizations. In this article, our experience with possible control intervals and the standardization of the follow-up care of hemodynamic telemonitoring is reported.

METHODS

A literature search and our own experience in the follow-up care concerning the implantable pulmonary artery pressure sensor for noninvasive hemodynamic telemonitoring in patients with advanced heart failure are presented.

RESULTS

For standardized follow-up care of heart failure patients with hemodynamic monitoring a specialized team consisting of a heart failure nurse and heart failure physician is essential. These teams should ideally work based on a unique standard operating procedure (SOP) to ensure standardized control intervals and a standardized approach to classical hemodynamic changes. However, all therapeutic recommendations have to be prescribed by a physician and must be modified if individually appropriate.

CONCLUSION

Optimized follow-up care for hemodynamically guided heart failure management requires the implementation of novel structures in the German health care system in order to transfer the clinical benefit from clinical trials into daily routine.