Heart Failure: Moving Beyond 30-Day Readmission Rates

Ileana L. Piña, MD, MPH


April 01, 2014

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Hello. I am Dr. Ileana Piña, Associate Chief of Cardiology at Montefiore Einstein Vascular and Cardiac Center in the Bronx, New York.

We have spoken many times about the 30-day readmission rate for heart failure and in 2014, hospitals that exceed the national average by a certain number of percentages will now be returning 3% back to Medicare. Last year, it was 2% and the year before that, it was 1%.

Hospitals are spending a lot of resources and a lot of money to place patients in some kind of system that will reduce the 30-day readmission rate. But it has given us another concern. Do you focus only on the 30-day readmission rate, or do you focus on the totality of the care? As we touch on this topic today, I want to take a different view, and that is the 40,000-foot view for the patient.

It is not just at 30 days, but what happened to that patient when he or she came into the hospital? Were the appropriate drugs given and the inappropriate drugs discontinued? Or were patients given drugs that ultimately worsened their heart failure? If you think about it, those 30-day readmission rates are not just because of heart failure. As a matter of fact, only 40% are due to exacerbation of the heart failure. These patients can take many turns -- it can be anemia, renal dysfunction, or dehydration from excessive diuresis.

Rather than spending all that money just on the 30-day readmission rate, I believe that hospitals should focus on the totality of heart failure care and the importance of team care, which many hospitals have not yet adopted. The new healthcare law impresses me for 2 reasons. It stresses the importance of team care, particularly in these chronic conditions, and it stresses patient-centeredness. What does a patient really want, and what does the patient really need?

Let me have you think about another transition point. Do we really think that 48 hours of intravenous nitroglycerin, nitroprusside, milrinone, dobutamine, dopamine, or even a drug such as saralasin is really going to change what happens at 5 days, 30 days, or 60 days, if we don't have patients on the right drug? When do you start the chronic therapy?

I have been doing heart failure trials for many years, and I can't remember a trial that found that after you finish the early treatment, you put the patient on chronic oral therapy for X number of days. I have never seen that. And yet, when we send the patients home, don't we want to send them on chronic therapy and don't we want to up-titrate that chronic therapy?

Because, let's face it, we don't have any new drugs. We haven't had any "pow-wow, wonderful" trials of heart failure in the last few years. Even in our heart failure with preserved ejection fraction (HFpEF) world, TOPCAT[1] was not a slam-dunk, so we don't even have good guidelines for the HFpEF patient.

What a concept. Why don't we start using the drugs that we know work? And when is that transition going to be made? I believe that we still have room to do some clinical trials to take the patient from that acute point to the chronic point. Is it at 48 hours? Perhaps. Maybe it is 72 hours. Maybe it is on the day of discharge.

I don't think that any of us knows, and everyone practices differently. I know that I start chronic oral therapy very early in the hospital, as soon as I stabilize the patient. I don't wait until I have totally diuresed the patient and have them euvolemic before I start angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or even beta-blockers.

So as we look forward, it isn't just the 30-day readmission rate. The patient journey begins in the home when they are feeling poorly, continues into the emergency department, and then into the hospital, wherever they happen to be, and continues on to the next stage. Each of these points are transitions, and every single transition needs to be looked at carefully.

We have been doing it with the guidelines[2] now, for many years, and have gathered a lot of important data. We continue to strongly support "get with the guidelines," and we now have a 30-day form that you can fill out to track these patients. We need to learn from our own practice what is working and what is not working, and maybe those resources that have been expended without knowledge of what is really going on -- without process-mapping each system -- may in fact be wasted.

I leave you with those thoughts. This is Ileana Piña.


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