A group of nurses and clinicians at the University of California, San Francisco (UCSF) have created a strategy that hospitals may be able to apply toward solving one of health care’s most serious and costly issues: heart failure (HF) rehospitalization.
A Public Health Quandary
The number of Americans living with HF is approaching 6 million, with approximately 670,000 new cases diagnosed annually, according to the American Heart Association. It is the leading cause of hospitalization — accounting for about 1 million admissions each year — and rehospitalization among Medicare beneficiaries. The complexity, fluidity and highly individualized nature of HF care make it notoriously difficult to manage, according to one expert.
“HF severe enough to require hospitalization, particularly more than once, is advanced disease,” says Lynne Warner Stevenson, MD, Director of the Heart Failure Program and Professor of Medicine at the Center for Advanced Heart Disease in the Heart and Vascular Center at Brigham and Women’s Hospital in Boston. “It is a higher level of disease than most of our therapies have been developed to treat.
“Heart failure is a dynamic disease that changes from day to day, so changes in daily salt and fluid intake, food intake, exercise, and other activities change the patient’s physiology such that the ‘right’ doses of medications, particularly the medications that help prevent or treat fluid retention, differ from day to day,” Dr. Stevenson continues. “Care needs to be individualized for each patient, as there are few ‘average’ patients who do best on ‘average’ doses of medication. We have been trying to [manage HF] with a one-size-fits-all approach to the medication regimen.”
“Most patients do not appreciate how severe [heart failure] is in terms of both the intensity of required therapy and limitation of survival. It has been called the ‘cancer of cardiology,’ although the prognosis is worse than for most cancers.”
— Lynne Warner Stevenson, MD, Director of the Heart Failure Program and Professor of Medicine at the Center for Advanced Heart Disease in the Heart and Vascular Center at Brigham and Women’s Hospital in Boston
Hospitals have been incentivized to reduce HF readmissions since Medicare’s implementation of penalties for excessive rehospitalizations in 2012, but the task remains daunting.
“Data show that about one in four HF patients is readmitted by the 30-day mark and one in two by the six-month mark,” says Akshay Suvas Desai, MD, MPH, Director of Heart Failure Disease Management in the Advanced Heart Disease Section of the Cardiovascular Division at Brigham and Women’s Hospital and Assistant Professor at Harvard Medical School. “Broadly speaking, [drivers of HF readmissions] include medical factors, chiefly incomplete treatment of congestion; patient factors, including willingness to adhere to therapy and dietary recommendations, such as sodium and fluid restrictions; physician factors that have to do with how quickly we see patients [after discharge]; system factors that have to do with resources and coordination of care across the continuum; and social factors that are environmental and have to do with patients’ access to care and limitations.”
Reducing Readmissions through Education
According to Dr. Desai, the primary obstacle to reducing HF rehospitalizations is a paucity of information about what prevention strategies are effective. He notes that the literature suggests pre-discharge patient education, prompt post-discharge contact with an ancillary provider and timely follow-up with a clinician are keys to preventing rehospitalization. A recent UCSF study published in Cardiology Research underscores these points and may provide a reproducible, cost-effective model for hospitals.
A team of providers at UCSF created TEACH-HF, an intervention that includes four components: inpatient Teaching and patient Education from two nurse coordinators, follow-up Appointments within seven days of hospital discharge, Consultation for additional medical and support services, and Home follow-up phone calls within seven days of discharge. To educate patients about HF, the nurse coordinators use teach-back, a method that asks patients to convey information they learn from the coordinators back to the providers to improve comprehension. The researchers implemented TEACH-HF in 2009.
The UCSF team designed the TEACH-HF intervention based on proven transition-of-care models and tools developed by the Institute for Healthcare Improvement, according to Teresa De Marco, MD, FACC, Professor of Medicine and Surgery, Director of the Advanced Heart Failure Therapies Program, Director of the Adult Pulmonary Hypertension Comprehensive Care Center, and Medical Director of Heart Transplantation at UCSF. Dr. De Marco was involved in the TEACH-HF study.
“It was clear from the beginning that there would be no one factor that would be successful [in reducing HF readmissions]; rather, a comprehensive program had to be developed utilizing components that were realistic within our medical system ...,” she says. “All components [of TEACH-HF] are interrelated and essential to achieve success. In-depth interviews of patients and caregivers carried out by the dedicated HF nurses to assess health literacy, cognition and likely barriers to successful outcomes so as to design an effective individualized plan within the overall TEACH-HF intervention were subjectively deemed to be highly valuable. The teach-back method in hospital and with outpatient reinforcement was subjectively deemed by the nurses to facilitate patient and caregiver education.”
Dr. De Marco and co-investigators tested the efficacy of TEACH-HF by comparing readmission rates and inpatient costs for a group of patients who received the intervention from 2010 to 2012 with those of a cohort who received care from 2007 to 2008, before the program was instituted. Patients who received TEACH-HF had a 30-day readmission rate of 12 percent; non-TEACH-HF patients had a 19 percent 30-day readmission rate. Nineteen percent of TEACH-HF patients were rehospitalized within 90 days, compared with 30 percent of pre-TEACH-HF patients. Non-TEACH-HF patients were 1.5 times more likely to be readmitted than patients who received the intervention. TEACH-HF saved 649 bed days in two years and $640,000 per year in operating costs.
“TEACH-HF can be effective in reducing readmission for HF patients,” Dr. De Marco says. “The personnel costs of providing this comprehensive disease management program can be offset by reducing CMS penalties and savings in hospital bed days ... . At our institution, the program paid for itself. [Hospitals may wish to] consider instituting a similar program within the context of their unique HF patient population and resources.”