Congestive Heart Failure Hospital Readmissions: Preventable or Inevitable? A Literary Review

ABSTRACT: Approximately 2 million Americans aged 65 and over reside in a long-term care facility and suffer from some form of cardiovascular disease, the most common and prominent disease state among this population. Congestive heart failure (CHF), a serious cardiovascular disorder that arises as a result of cardiovascular disease, accounts for approximately 17% of hospitalizations and more than 250,000 deaths per year.Ongoing changes to the United States healthcare system and recent impositions of financial penalties on hospital systems by the Centers for Medicare and Medicaid Services (CMS) for 30-day hospital readmissions, has sparked a renewed interest in the development of evidenced-based strategies to reduce hospital readmissions in patients with CHF from these facilities. This feature examines the prevalence of, and obstacles in, CHF management, and introduces new strategies for improving continuity of care while also reducing associated costs. 

Innovations in medical technology, greater focus on healthier lifestyles and public health initiatives over the years have led to improvements in the quality of people’s lives and contributed to increased lifespan.^1,2 Certainly, this is an appreciable circumstance, however medical advances also mean that more people will live longer. 

In 2010, the number of people aged 65 and older surpassed 40 million^.3 One year later, the first line of baby boomers began turning 65, spurring an unprecedented increase in America’s elderly population.⁴ By 2030, when the last of these boomers turn 65, the US elderly population is projected to top 70 million.⁴ Such substantial growth will create a momentous burden on our already strained healthcare system to manage their chronic diseases and effectively care for this segment of the population.³

Along with longer lifespan, studies indicate that approximately 2 million Americans over the age of 65 reside in a skilled nursing facility/long term care (SNF/LTC) facility and suffer from some form of cardiovascular disease.⁵ The exact number of heart failure patients specifically who reside in an SNF/LTC facility is currently unknown, however. 

 Literature related to cardiovascular disease indicates that more than three-quarters of the 5 million Americans who suffer from heart failure are over the age of 65 and congestive heart failure (CHF) is a highly common reason for hospital admission. Management of their care is significantly more complex, as they typically suffer from multiple comorbidities, have functional limitations, cognitive impairments and consume a plethora of medications, increasing their risk for CHF development and the potential for hospital admission or readmission.⁵ 

To complicate matters, the patient and family’s healthcare preferences and the differences in clinical provider practices amplify the challenge of effectively managing and preventing exacerbations of these chronic illnesses.⁵ Furthermore, there are currently no evidence-based practice guidelines, nor substantiated scientific corroboration, available to help navigate care management for this complex segment of the population.⁵

Cardiovascular Disease/Congestive Heart Failure Prominence

Approximately 5.7 million people have heart failure in the United States with less than 1% occurring in people age 50 years and younger.⁶ Out of the 6.6% of Americans that reported having cardiovascular disease, 2% of those were CHF patients.⁷ According to the CDC,⁸ 75% of hospital admissions for CHF are patients that are aged 65 years and older. The CDC also reports that the proportion of patients diagnosed with CHF under age 65 has significantly increased from 23% in the year 2000 to 29% in 2010.⁸  The rate of CHF hospitalizations per 10,000 has not changed significantly, but there is an upward trend in hospitalization of patients under 65 years of age.⁸ From 2000 to 2010, the rate of hospitalizations for males under age 65 increased significantly while the rate for females aged 65 and over decreased.⁸ In the United States, 550,000 new cases are reported annually and CHF is the cause of greater than 250,000 deaths per year.⁶ The CDC reports that the data has not changed between the years 2000 to 2010 and the number and rate of hospitalizations for CHF patients averaged out at approximately 1 million admissions and readmissions per year.⁸

Incidence of 30-day Readmissions

Although the rate of hospitalizations for patients under age 65 significantly increased between 2000 and 2010, there is a higher rate of this age group discharging to their homes, while patients age 65 and over are being discharged to a SNF/LTC facility.⁸ Hospital readmissions in patients discharged to their homes could possibly be attributed to poor self-care management of their CHF as well as nonadherence to lifestyle modifications and medication regimen.⁷ Not only are patients discharged to an SNF/LTC facility persistently being readmitted into the hospital especially within 30 days of discharge,⁹ they are frequently readmitted due to failure of the facility’s healthcare providers to continue the recommended treatment regimen or follow-up.¹⁰ 

Between 2000 and 2006, the rate of SNF/LTC facility readmissions to the hospital grew by 29%.⁹ By the year 2006, 23.5% of all hospital discharges to a SNF/LTC facility returned directly to the hospital in less than 30 days, costing the Medicare program approximately $4.34 billion in 1 year.⁹ Certain readmissions for conditions such as pneumonia, syncope, stroke or chronic obstructive pulmonary disease (COPD) from an SNF/LTC facility may be unavoidable as research has shown that many of these diseases could have been better managed initially to avoid hospital readmission.⁹ Mentioned among the hospital diagnoses as cause for readmission are CHF,  respiratory infection, urinary tract infection, sepsis, and electrolyte imbalance which account for 78% of the 30 day readmissions from SNF/LTC facilities.¹¹ Randomized control trials of SNF/LTC facilities with a designated program focused on, and applied interventions for, CHF readmission prevention and reduction have proven to reduce 30-day
readmissions rates by 20% to 40%.⁹

Causes of Hospital Readmission

Hospitalizations are common in the age range of 65 and over.¹² Several studies have found that many of these hospitalizations are inappropriate, avoidable, or related to conditions that could be treated outside of the hospital setting. One such study found that in many situations, nursing home residents experiencing an acute change in condition could be cared for safely and effectively within a skilled nursing facility.¹² This study also found that the training of the healthcare professionals in geriatrics and LTC was not up to capacity to safely evaluate and manage the acute changes in a condition a clinically complex nursing home resident may be experiencing.¹²  

Accurate diagnosis of heart failure is important to ensure proper treatment. Signs and symptoms of heart failure in the older population are often overlooked due to their physical limitations or unreliable history due to dementia. Symptoms are often nonspecific to heart failure, such as venous insufficiency, obesity, and COPD and can be a sign of other common diseases in the older population.¹³

Several factors contribute to the cause of hospital readmissions in heart failure patients. These factors are (1) disease-centered (2) physician-centered (3)
patient-centered and (4) community resource availability.¹⁴

Disease-centered is the repeat hospitalization of heart failure patients that may be secondary to the progression of an underlying cardiovascular disease or may be the result of noncardiovascular co-morbidities. Progression of these cardiovascular comorbidities includes heart failure, coronary artery disease, and valvular disorders. Comorbidities affecting readmission include diabetes mellitus, hypertension, arrhythmias, infections, pneumonia, COPD, cellulitis, cerebrovascular accident, renal dysfunction, peripheral artery disease, and sleep disorders.¹⁴ 

Physician centered factors include risk management, early detection and treatment of hypertension, diabetes mellitus, coronary artery disease, dyslipidemia, metabolic syndrome and cardiotoxin exposure. In addition, appropriate medication therapy and dosing of angiotnsin-converting enzyme ACE inhibitors, beta-blockers, diuretics, hydralazine, nitrates, spironolactone and digoxin along with monitoring of cardiac devices such as implantablecardioverter defibrillator, cardiac resynchroniation therapy, and implantable hemodynamic monitors. Furthermore, arranging specialized cardiac care, appropriate timing of discharge, discharge planning, post discharge care and communication between the hospital physician and outside physician are key.¹⁴ Jacobs¹⁰ found that patients with heart failure who were discharged to SNFs were frequently readmitted to the hospital due to the lack of adequate continuity of care at the time of discharge. There were transcription errors, no customized or standardized communication with the SNF, daily monitoring of weights were not ordered, and no parameters on contacting the physician if the patient experienced a weight gain of 3 lb per day or 5 lb per week were established. The patient was not ordered a 2-g sodium-restricted diet and they were often not prescribed a diuretic.¹⁰

Patient centered factors affecting readmissions include poor compliance with fluid restrictions, medical and dietary regimens, poor follow-up after discharge, and poor understanding of the disease itself.¹⁴ Patients with chronic conditions, including CHF, were found to only adhere to 50% to 60% of the medications they were prescribed.
Exercise regimens were not performed by 41% to 58% of heart failure patients and compliance with a sodium restricted diet varied from 50% to 88%. Additionally, approximately 20% of patients did not follow up on their referrals to specialists as ordered.¹⁵  

A study compared the readmission rates of patients who receive multidisciplinary education regarding their disease process, dietary recommendations, and physical therapy consultations with a group of patients who did not receive this education and found that hospital readmission rates were 4 times higher in the group of patients who did not receive multidisciplinary educational support requiring nearly 50% more skilled nursing visits and more than twice as many home health aide visits.⁵

Community resource availability factors include the lack of available resources or access to them, multidisciplinary teams, follow-up or home services, and lack of social support options for patients. It is crucial that heart failure be identified early, then monitored and treated appropriately. Evidence indicates multidisciplinary heart failure management is effective in reducing rehospitalizations.¹⁴ While all of these contributory factors intersect with each other, there is no statistical evidence to support that 1 factor contributed more significantly than another, therefore they are not mutually exclusive.

Financial Implications

Heart failure is a syndrome associated with high mortality and frequent hospital admissions. CHF has created a significant economic burden that researchers are predicting will only increase due to the aging population.¹ According to the CDC, heart failure costs the nation an estimated $32 billion each year. This total includes the cost of healthcare services, medications used to treat heart failure, and missed days of work.² In the United States, the estimated annual cost of heart failure in 2010 was estimated at $39.2 billion or 2% of total US healthcare budget.¹ On an individual perspective, the diagnosis of heart failure is associated with an annual cost of $8500 per patient according to data provided by the National Heart and Lung Institute. The annual cost of heart failure is steadily increasing as predicted.¹ In the United States, the estimated annual cost for heart failure rose from $24.3 billion in 2003 to $39.2 billion in 2010.¹

Hospitalizations are expensive: Approximately three quarters of the total cost for treatment of heart failure is connected with hospital admissions, inpatient treatment, and nursing home patient care.¹ There is some contention that the shorter intervals of inpatient treatment could result in an increased risk for early readmission.¹ Results from a US registry revealed that approximately one-third of patients still have signs and symptoms of congestion upon discharge, thus increasing their risk for rehospitalization.⁵

Prevention Strategies/Education

SNF/LTC patients interact with an array of individuals including physicians, nurse practitioners, nurses, nursing assistants, social workers, and physical, occupational and speech therapists on a daily basis.¹⁶ Those who have frequent direct contact with these patients are essential to early detection of CHF, thus allowing for prompt interventions to prevent rehospitalization.¹⁷ Studies have shown that the care of SNF/LTC patients by those who are trained to recognize early signs and symptoms of CHF are also the ones who normally assess the patients on a regular basis.¹⁸ However, these patients interact with various other staff members on a daily basis who may not be as well-versed in CHF symptom recognition such as nursing assistants or therapists. Educating and providing teaching tools to auxiliary staff may offer additional opportunities for early intervention and prevent rehospitalizations.¹⁷

Implementation of early intervention methods has demonstrated reductions in CHF hospitalizations. A 2011 study published in the Journal of the American Geriatrics Societyevaluated the Interventions to Reduce Acute Care Transfers II (INTERACT II) program, which encompasses a set of tools and strategies that can be utilized by all SNF/LTC staff to assess changes in the patient’s status.¹⁶ These tools are incorporated in a Stop and Watch early warning system that is simplistically designed and can be easily applied by any of the healthcare team members. In the study, the authors found that: 

•The 25 nursing homes that completed the program experienced a 17% reduction in hospitalization rates compared with the same six-month period in the previous year. 

•Of the 25 nursing homes, 17 were characterized as “moderately or highly engaged” in the initiative. This group had a 24% reduction in hospitalizations, compared with a 6% reduction in the group of 8 facilities rated as “minimally or not engaged” and a 3% reduction in a comparison group of 11 nursing homes. 

•The average cost of the 6-month intervention was $7700 per nursing home. 

•The authors estimate that the projected Medicare savings in a 100-bed nursing home could be about $125,000 per year. 

A heart failure mnemonic was developed to assist with heart failure early identification and interventions, reduce hospitalizations, and improve outcomes particularly in the elderly.⁵ DEFEAT-HF which stands for Diagnosis, determine Etiology, Fluid volume and Ejection Action and Therapy, coincides with the national guideline for management of heart failure in LTC settings.¹⁹ Its intent is to provide an easy reference to help guide and individualize treatment options for succinct resolution. While there are currently no statistical studies to support the success, or failure, of this tool, its use allows clinicians the ability to rapidly assess these patients and employ the appropriate diagnostics and subsequent treatment.  

Another early intervention method, focused on a 6-month nurse case management quality improvement program, revealed a significant reduction in hospital readmissions. This program was developed to enhance continuity of care, improve communications, and foster partnerships between the discharging facility and the SNF/LTC facility. These strategies focus on the patient’s discharge and subsequent monitoring needs in order to lessen the rate of CHF hospital readmissions from the SNF/LTC facility. The study illustrates a 38.68% reduction in hospital readmissions, from 50% prior-to-program implementation to 11.32% post-program implementation.²⁰ Additionally, the reduction in readmissions also resulted in a cost savings of $16,748 over the 6-month period.²⁰ 

Conclusion

The fundamental basis for successful CHF hospital readmission prevention involves strategies that encompass staff’s continuity of care derived from discharge instructions provided upon admission to the SNF/LTC facility, as well as vigilant monitoring by the physicians, nurse practitioners, nurses, and other staff members, along with educational commitments to employ judicious policies, and implementation of various tools and programs that are readily available to all staff providing care for, or interacting with these patients. Establishing such foundational criteria can enhance early CHF symptom recognition and precipitate appropriate interventions,^5,16,17 thus reducing costs.

However, while the medical professionals plan and implement a variety of strategies to effectively manage CHF and its complications, there is a level of responsibility placed upon the patient to adhere to these recommendations. Since the studies show that only half of diagnosed patients actually conform to their clinician’s plan of care,¹⁸ the other 50% of patients will undoubtedly develop a congestive heart failure exacerbation at some point and consequently require hospital readmission. Such readmissions are not only a result of plan of care non-compliance but may also be partially attributed to a patient’s right to choose, cost factors and/or access to care. Given this information we would conclude that hospital readmissions for CHF appear to be inevitable.  

Nevertheless, as clinicians we should not become defeated by these statistics. Ongoing support to these patients is essential with continued focus on prevention strategies, understanding risk factors, and patient preferences. Sustained fostering of adherence to medication, dietary, and lifestyle modifications may allow the patient to recognize that without conformity to an amenable plan of care their quality of life will continue to deteriorate. 

Roberta O’Brien, APRN, FNP-C, obtained her MSN as a family nurse practitioner in 2014 from the University of Cincinnati. She currently practices in both Ohio and Kentucky as an NFP-C caring for the elderly. She will expand her career into the field of wound care beginning in May 2015. 

Angela Paima, APRN, FNP-C, is a licensed and certified nurse family practitioner in Ohio where she is employed at a rural family practice. Additionally, she serves as an adjunct clinical faculty member at Central Ohio Technical College in Newark, OH.

Naomi Abaga, MSN, BSN, RN, Naomi earned her BS in nursing from Towson University and her MSN from University of Cincinnati. She has 6 years of experience in critical care nursing and now begins her career in advanced practice nursing as a family nurse practitioner.  

References:

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2.Heart failure fact sheet. Centers for Disease Control and Prevention Web site. www.cdc.gov/DHDSP/data_statistics/fact_sheets/docs/fs_heart_failure.pdf 2012.  Published December 3, 2013. Accessed May 20, 2014.

3. The state of aging and health in America 2013. Centers for Disease Control and Prevention Web site. www.cdc.gov/features/agingandhealth/state_of_aging_and_health_in_america_2013.pdf.  Published July 9, 2013. Accessed May 20, 2014.

4. United States Census. Fueled by aging baby boomers, nation's older population to nearly double in the next 20 years, Census Bureau Reports. May 6, 2014 www.census.gov/newsroom/press-releases/2014/cb14-84.html. Accessed June 1, 2014.

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7.Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics – 2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e220. 

8.Hospitalization for congestive heart failure: United States 2000-2010. Centers for Disease Control and Preventions Web site. www.cdc.gov/nchs/data/databriefs/db108.pdf. Published October 2012. Accessed March 15, 2014.

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11. Hospital readmissions reduction program. Centers for Medicare and Medicaid Services Web site. www.medicare.gov/hospitalcompare/data/30-day-measures.html.  Accessed May 10, 2014.

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13. Daamen M, Hamers J, Gorgels A, et al. The prevalence and management of heart failure in Dutch nursing homes:  design of a multi-centre cross-sectional study. BMC Geriatr.  2012;12:29.  

14. Zaya M, Phan A, Schwarz ER. The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure. Heart Fail Rev. 2012;17(3):345-353. 

15. Sparks R. Improved patient compliance reduces readmissions. Healthcare Finance News.  November 14, 2011. www.healthcarefinancenews.com/ blog/improved-patient-compliance-reduces-readmissions.  Accessed December 3, 2014.

16. Ouslander J, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes:  evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745-753. 

17. Boxer R, Dolansky M, Frantz M, et al.  The Bridge Project: improving Heart Failure care  in Skilled Nursing Facilities. J Am Med Dir Assoc. 2012:13(1):83.e1-e7. 

18. Ouslander J, Berenson R. Reducing unnecessary hospitalizations of nursing home residents. NEJM. 2011;365(13):1165-1167. 

19. Heart failure in the long term care setting.  National Guideline Clearinghouse. Agency for Healthcare Research and Quality Web site. Published May 2014. www.guideline.gov/content.aspx?id=32492.  Accessed December 5, 2014.   

20. Jung M, Yeh A, Pressler S.  Heart failure and skilled nursing facilities: review of the literature. J Card Fail. 2012;18(11):854-871.