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At a glance
|Which approach is most likely to reduce hospital readmissions for heart failure?|
In a time when all other industries are trying to become more efficient, hospitals are building bigger waiting rooms. Health-care costs are skyrocketing, and the federal government is stepping in to try to help.1 Everyone knows that the current health-care system does not work, but the jury is still out on what will correct the problems.
From a provider’s point of view, the goal is to take care of the patient in the best way possible and make a living in the process. Although evidence-based medicine has been part of the literature since the 1990s, patients continue to be admitted and readmitted to hospitals at an alarming rate.2-4
The statistics for heart failure (HF), in particular, are staggering. HF is the primary reason for hospital admissions in patients older than age 65 years and accounts for more than 1 million admissions each year. Even more frightening is the overall five-year mortality of >50%.5,6 Research shows that many HF patients who have been hospitalized will be readmitted almost as soon as they are discharged.7 Of the Medicare patients admitted with HF, approximately 27% will be readmitted within 30 days of discharge, costing Medicare about $17.4 billion each year.6
The question now is, how do we turn this around? The only good news is that providers and patients alike are ready for change. Providers are now looking for new ways to treat old problems more effectively and not only deliver evidence-based medicine, but actually break down the barriers and get effective treatment to the patient.
Treatment of HF is based on a multimodal approach and requires the patient and provider to establish a partnership that focuses on preventing exacerbations and improving quality of life. Traditional treatment regimens include identifying risk factors, modifying lifestyle, maximizing pharmacologic therapy and sometimes surgery.8-10
Risk factors include hypertension, coronary artery disease (CAD), diabetes and alcohol consumption (Table 1); many of these are modifiable.8 By far, the most difficult aspect of HF treatment is addressing the lifestyle changes required for any regimen to be successful. Patients may be unwilling to accept the need for them to change their way of life. Some of the required lifestyle changes include losing weight, eating a healthy diet and exercising daily (Table 2).8
Medications necessary to support a failing heart include beta blockers, ACE inhibitors, spironolactone (Aldactone) and loop diuretics (Table 3).8 Patients with more severe symptoms often benefit from inotropes. In some cases, an implantable cardiac defibrillator, cardiac resynchronization therapy or heart transplant is necessary to decrease mortality and improve cardiac function.9,10
Education at hospital discharge, with an emphasis on symptom recognition for potential exacerbation, is vital to turning the tide of readmissions. The patient needs to be taught to watch for signs of increasing fluid retention, including shortness of breath, edema, and weight gain.10 Postdischarge follow-up has been shown to reduce readmission rates significantly.11 Whatever the approach, the goals of treatment are to increase survivability and exercise capacity and to improve quality of life, while decreasing morbidity, disease progression, neurohormonal changes and clinical symptoms.4,5,9,10,12
Impediments to effective therapy
Providers know what to do and what patients need to do, so why is the plan not working for so many? What are the barriers to optimizing care for HF? The problem has three components: the providers, the patients and the cost in our broken health-care system.
Trust must be built between the provider and the patient. Patients need to understand the cause and effect of their disease processes. They need to understand why the provider is asking that they make changes because understanding is the first step toward compliance. Providers must educate their patients in the limited amount of time available, while remaining sensitive to the patients’ needs and sacrifices. Sometimes patients have to give up the few aspects of their lives that bring them pleasure to effect the changes necessary to improve their quality of life.5,6
In addition to taking care of their patients, providers have to be businesspeople. Because of legislative initiatives, providers are now faced with significant cuts in reimbursement, and the potential for skewed numbers caused by noncompliant patients in the “pay for performance” race increases that stress.
This leaves providers with a moral dilemma: whether to continue to treat the noncompliant patient in the hope of making a difference or “fire” the patient for noncompliance.6 Frustration over the patient’s lack of compliance can be a natural response to what is sometimes seen as a personal insult or challenge. Such feelings often lead providers to stop communicating. Providers must be aware of their feelings before they attempt to engage the patient.6
Addressing cost is a much more complicated problem and the component requiring the most innovation. The rising cost of health care and prescription medications, along with wages lost when patients take time off for medical appointments, are adding up.
Patients have plenty of time to think about all these costs as they sit in the reception area, sometimes for hours, waiting for care. They think about the cost of the medications and the medical bills that are piling up. If patients cannot afford insurance, cannot afford to purchase the medications prescribed and cannot afford to come for office visits because they do not have the money for the co-payment, they will not be compliant, no matter how much they may want to be.6 These factors must be addressed to effectively change the current trend of hospital readmissions.
Home care. One alternative to consider is home visits for follow-up of patients discharged from the hospital after treatment for HF. The goal is to provide the initial posthospital follow-up and get patients started on the path to recovery.
ElderWell is a long-term HF disease management program for patients with HF and diabetes treated at Suburban Hospital in Bethesda, Md., an affiliate of Johns Hopkins Medicine.13 Patients are visited at home monthly by registered nurses who coordinate patient care with the providers. During these visits, the cardiac nurse is able to monitor progress, provide HF education and discuss treatment strategies. Suburban Hospital also has a free educational program designed to decrease 30-day HF hospital readmissions.13
Specialized HF clinics. Another alternative is to provide a posthospital HF clinic specifically designed to meet the needs of HF patients. In the Memphis area, the Methodist Teaching Practice’s Heart Failure Clinic, which is affiliated with Methodist University Hospital, provides this service. At this clinic, the goal is to get patients into the clinic within one to two days after discharge to verify that the outpatient treatment plan is being followed.