Approaches to Decrease CHF Readmits

The February 8, 2016 issue of JAMA Internal Medicine had an opinion article that reviewed telemonitoring as one potential approach to decrease readmissions.  The article gives background that we are no three years into the Hospital Readmissions Reduction Program and CMS still reports that the CHF readmission rate is still near 22%.

The authors commented on a meta analysis of telemonitoring studies and found that no evidence that the telemonitoring decreased readmissions.  In fact in some of the higher grade studies, they found negative results.

In the Beat-HF study, the researchers found only 55.8% of the people in the study completed the study and identified “treatment burden” issues including changing drug regimens, arranging multiple medical appointments, and financial costs.  They advocate that future studies should use existing technology and methodology that patients are comfortable and familiar with.

The authors also postulated that future studies need to address the treatment burdens and the toxicities of hospitalization including sleep disruption, high ambient light, painful procedures, frequently missed meals, immobility, uncertain schedules, exposure to sick patients, and witnessed traumatic events.  They also have to deal with persistence of symptoms after discharge.

In the Beat-HF study, 40% of patients report no improvement at one week post discharge of dyspnea, anxiety, pain, and fatigue and wonder how the emergency department can assist.

It is interesting as we look at the preliminary results of Medic Ambulance’s Community Paramedicine/Mobile Integrated Healthcare project that perhaps we have found solutions to some of the “treatment burden” issues that have plagued the tele monitoring programs and are making our program successful .  Hopefully, we will be able to report on some of our early findings by mid 2016.

So the good news is that without other interventions it appears that telemedicine is not the sole answer to decreasing CHF readmissions

the problem is we still have a lot of work to do

We need to know what services are effective in decreasing admissions and what are the qualifications necessary to provide those services?   This is what I believe is being overlooked. What services are decreasing readmissions and improving compliance? Dietary counseling and getting them food? Getting the patient their medications? Scheduling and getting them to their appointments? Explaining them the discharge instructions? Holding their hand and letting them know someone cares?

Clearly it’s not just having the doctor on a camera.


The associated Beat-HF article gives great background on the problem of heart failure readmissions

Heart failure (HF) is a prevalent condition in the United States, affecting 5.8 million patients,1 and is associated with high hospitalization and readmission rates, mortality, and cost of care.1– 6 For patients with HF, discontinuities and lack of post–acute care monitoring can increase overall health care resource use through readmissions or worsened morbidity.7,8 Persistently high readmission rates for patients with HF suggest that further improvements to existing care transition approaches are needed,1,9 as evidenced by the readmission-related financial penalties of approximately $428 million affecting 2610 hospitals in the third year of the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program.10

Interventions to improve the care transition process have been shown to reduce readmissions while potentially improving morbidity and mortality in randomized clinical trials (RCTs),11– 14 particularly for patients with HF.15 However, many of these interventions were tested in single centers with limited numbers of patients. Moreover, sustainability of research-derived care transition approaches is difficult, with many requiring intensive in-person interactions that are not always acceptable to patients16,17 and incurring costs to health professional organizations that may not be favorable under current health care financing arrangements.18 Telehealth technology, including mobile health and remote patient monitoring technologies, potentially provides more cost-effective solutions to the problems of financial viability and home visit acceptability by substituting for in-person interactions. However, its effectiveness to date (particularly in patients with HF) has been mixed. The largest RCT in the United States to date in this area, Telemonitoring to Improve Heart Failure Outcomes, did not show any significant benefit from its telehealth approach,19 perhaps because of the type of technology used, low adherence rates, lack of patient engagement before discharge, or handling of values that exceeded threshold variables.19,20 Another large RCT in Europe with high adherence rates and improved technology also showed no significant benefit.21However, systematic reviews that include these studies continue to suggest significant reductions in mortality, morbidity, and HF-related hospitalizations.22

Gheorghiade  M, Vaduganathan  M, Fonarow  GC, Bonow  RO.  Rehospitalization for heart failure: problems and perspectives. J Am Coll Cardiol. 2013;61(4):391-403.
PubMed   |  Link to Article
Thom  T, Haase  N, Rosamond  W,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics: 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee [published corrections appear in Circulation. 2006;113(14):e696 and 2006;114(23):e630]. Circulation. 2006;113(6):e85-e151. doi:10.1161/CIRCULATIONAHA.105.171600.
PubMed   |  Link to Article
Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program [published correction appears in N Engl J Med. 2011;364(16):1582]. N Engl J Med. 2009;360(14):1418-1428.
PubMed   |  Link to Article
Centers for Medicare & Medicaid Services. Hospital Compare. Accessed September 28, 2015.
Krumholz  HM, Merrill  AR, Schone  EM,  et al.  Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2(5):407-413.
PubMed   |  Link to Article
Ong  MK, Mangione  CM, Romano  PS,  et al.  Looking forward, looking back: assessing variations in hospital resource use and outcomes for elderly patients with heart failure. Circ Cardiovasc Qual Outcomes. 2009;2(6):548-557.
PubMed   |  Link to Article
Nielsen  GA, Bartely  A, Coleman  E,  et al. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients With Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; 2008.
Amoah  B, Boutwell  A, Schall  M, Sevin  C, Shapiro  E, Taylor  J. Getting Started Guide: Improving Care for Patients With Heart Failure: Focus on Ambulatory Care. Cambridge, MA: Institute for Healthcare Improvement; 2008.
Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation.2013 Measures Updates and Specifications Report: Hospital-Level 30-Day Risk-Standardized Readmission Measures for Acute Myocardial Infarction, Heart Failure, and Pneumonia (Version 6.0). New Haven, CT. March 2013.
Rau  J. Medicare fines 2,610 hospitals in third round of readmission penalties. Kaiser Health News. Published October 2, 2014. Accessed November 26, 2015.
Naylor  MD, Brooten  D, Campbell  R,  et al.  Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620.
PubMed   |  Link to Article
Naylor  MD, Brooten  DA, Campbell  RL, Maislin  G, McCauley  KM, Schwartz  JS.  Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-684.
PubMed   |  Link to Article
Coleman  EA, Parry  C, Chalmers  S, Min  SJ.  The Care Transitions Intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828.
PubMed   |  Link to Article
Jack  BW, Chetty  VK, Anthony  D,  et al.  A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
PubMed   |  Link to Article
Feltner  C, Jones  CD, Cené  CW,  et al.  Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774-784.
PubMed   |  Link to Article
Voss  R, Gardner  R, Baier  R, Butterfield  K, Lehrman  S, Gravenstein  S.  The Care Transitions Intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232-1237.
PubMed   |  Link to Article
Katz  MH.  Interventions to decrease hospital readmission rates: who saves? who pays? Arch Intern Med. 2011;171(14):1230-1231.
PubMed   |  Link to Article

Source: The Network Reader