Rapid Heart-Failure Readmission Program Curbs Costs, Not Just Mortality

Patrice Wendling

April 14, 2016

CHICAGO, IL — Rapid follow-up and support for recently discharged heart-failure patients reduces costs more than threefold at 30 days and more than twofold at 1 year, a cost analysis shows[1].

The average cost per patient fell from $21,743 with usual care to $5767 with use of the Hospital-to-Home (H2H) program at 30 days and from $105,018 to $51,343, respectively, at 1 year (P<0.0001).

"The cost for running the program is roughly two and a half nurse practitioners, and clearly from the data, those costs are offset," senior author Dr Sula Mazimba (University of Virginia [UVA], Charlottesville) told heartwire from Medscape.

The university's H2H program is modelled after the similarly named American College of Cardiology H2H initiative, which seeks to have a follow-up appointment scheduled or cardiac rehabilitation referral made within 7 days of hospital discharge for all HF and AMI patients. The goal is to improve transitions to home and reduce federal penalties associated with high readmissions that are pervasive in HF patients.

Patients referred to the H2H program at the UVA Medical Center are typically seen in the dedicated HF clinic within 3 to 4 days of discharge. During the 1-hour follow-up visit, the nurse practitioner who specializes in cardiac care reviews all medications; HF signs for the patient to look for, such as weight gain and shortness of breath; and self-care behaviors including diet and exercise and ensures that patients have refills, phone numbers, and contact information. After that, visits are set up when needed depending on clinical stability while the patient is waiting to be seen by their primary cardiologist, he said.

Early follow-up allows for fine-tuning medications, including those forgotten at home, but is often necessary on a very fundamental level because research suggests that almost 30% to 40% of patients with an HF diagnosis don't have adequate information about HF, Mazimba said.

What makes the H2H program so successful is getting patient buy-in, agreed lead author Dr Timothy Welch (UVA, Charlottesville).

"It's getting patients to understand why they're on the medications they're on and having that opportunity to sit with a provider and talk about heart failure, their concerns, their fears. They're full of questions, even with an in-patient hospital admission," he told heartwire .

When "See You Soon" Is a Good Thing

The investigators reviewed 4910 HF admissions at UVA from January 2011 through December 2014, of which 614 (12.5%) patients were enrolled in the H2H program. H2H patients were younger than those receiving usual care (64.6 years vs 68.4 years) but had a higher median Charlson Comorbidity Index (4.16 vs 3.5) and were more likely to have systolic HF (71.2% vs 44.6%).

Mean costs, defined as the total cost of hospitalization without physician charges, were higher without H2H at 30 days, 180 days, and 365 days after the first survived hospitalization (P<0.0001, 0.09, and 0.07, respectively) and significantly higher without H2H after all subsequent admissions at all three time points (P<0.0001), according to data reported in a poster at the American College of Cardiology 2016 Scientific Sessions.

In multivariate analysis, H2H enrollment, Charlson scores, and age were significantly associated with 30-day and 1-year costs (P<0.0001) after adjustment for other comorbid conditions including type of HF and survival following initial hospitalization.

"Coming back to the hospital is the expensive part, not just the hospital or ICU stay, but readmissions are going to get the hospital penalized if there are too many, and by spending a little extra time we can keep the patients home and healthy," Welch said.

All-cause mortality rates after first hospitalization were significantly lower with H2H vs usual care at 30 days (P=0.01) and numerically lower at 1 year (P=0.06).

H2H reduced all-cause mortality after all hospitalizations compared with usual care at 30 days (1.63% vs 4.66%; P<0.001) and 1 year (10.59% vs 14.29%; P=0 .01).

To increase uptake of H2H, the hospital began using a nurse navigator in October 2013 to discuss the H2H program with HF patients before discharge. H2H enrollment has increased from 265 patients in the year prior to the nurse navigator to 429 patients in 2014, Mazimba said.

The authors note that limitations of the study are its single-center, observational design, use of coding data to identify risk factors and outcomes, and that admissions to other hospitals were not captured.

Mazimba and Welch report no relevant financial relationships.

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