Heart failure readmissions: a losing battle or an opportunity for improvement?

ABSTRACT

Despite great strides in diagnosis and management of heart failure (HF), this chronic illness continues to be a worldwide epidemic with approximately 23 million people afflicted across the globe. In the US, over 6.5 million carry a HF diagnosis with almost 90% of all HF deaths occurring in patients over the age of 70. Since one in five Americans are expected to be older than 65 years by 2050, almost 1,000,000 new HF cases are expected to be diagnosed every year. The staggering nature of these numbers only pales in comparison to current dismal HF survival statistics. The unavoidable natural history of HF continues to be characterized by the occurrence of repetitive hospital admissions. Not only are hospital readmissions demarcated as one of the most important risk factors associated with mortality; but also, a well-recognized trigger for additional hospital readmissions. Even when HF treatment guidelines have been recently updated; the mere fact that four HF societies have issued individual recommendations without reaching a common unifying consensus statement adds to the complexity of HF patient management. The purpose of this Editorial not only to fuel more interest on this topic but also to spark the notion that we have a potential catastrophe in our hands and is the responsibility of all health-care professionals to attend to this vital issue.

KEYWORDS:

• Heart failure with reduced ejection fraction
• heart failure with preserved ejection fraction
• hospitalizations
• readmissions
• health costs
• morbidity and mortality

Despite great strides in diagnosis and management of heart failure (HF), this chronic illness continues to be a worldwide epidemic with approximately 23 million people afflicted across the globe [1]. In the US, over 6.5 million carry a HF diagnosis with almost 90% of all HF deaths occurring in patients over the age of 70 [2]. Since one in five Americans are expected to be older than 65 years by 2050 [3], almost 1,000,000 new HF cases are expected to be diagnosed every year [4].

The staggering nature of these numbers only pales in comparison to current dismal HF survival statistics. The unavoidable natural history of HF continues to be characterized by the occurrence of repetitive hospital admissions. Not only are hospital readmissions demarcated as one of the most important risk factors associated with mortality; but also, a well-recognized trigger for additional hospital readmissions [5].

Even when HF treatment guidelines have been recently updated [6–8]; the mere fact that four HF societies have issued individual recommendations without reaching a common unifying consensus statement adds to the complexity of HF patient management.

Aside from these trivialities, the fact that up to a quarter of HF patients continue to be readmitted within 30 days while 50% of these HF patients are readmitted within 6 months is astonishing [9,10]. Moreover, up to 75% of all these early readmissions could be preventable, prompting great concern to the health-care industry that continues pressing for new policy and practice reforms [11–13].

Although several medical and social elements have been shown to lead to HF readmissions [14,15], the elderly HF patient population has not only been afflicted with a greater number of comorbidities but also with less awareness of their disease, ultimately hindering proper follow-up and compliance with recommended therapy [16–18]. To mitigate these difficulties, several approaches have been studied including the use of system-based practices that utilize a multidisciplinary team collaboration, enhance patient education, optimization of the transition between hospital and the outpatient setting, and improved palliative care options [19,20].

Complementary to all these efforts, risk stratification efforts and implementation of precision medicine are also needed to individualize HF management beyond the use of standard HF therapies. With that in mind, efforts must be taken to develop acute care setting decision tools so that patients can be safely triaged and identified in the Emergency Department. In a recent study, the STRATIFY decision tool was used as a model to identify patients with acute HF in the ED who were considered to be at low risk for 30-day adverse events in order to be discharged and followed with routine ambulatory management [21]. Although further verification of this model is needed, the basis of this approach might help pave the way for new disposition strategies to ameliorate HF readmissions [21].

Even when all these efforts are meant to have a significant impact among the whole population of HF patients, we cannot lose track that approximately 50% of HF patients have a reduced ejection fraction (HFrEF) and that is where most of the emphasis has been devoted. However, less emphasis has been given to the other 50% of HF patients, those with preserved ejection fraction (HFpEF) [22].

Recent data analysis utilizing a cohort of 19,477 Medicare beneficiaries who were admitted with HF and discharged alive between 2007 and 2011 were studied. Authors interestingly noted that admission’s length of stay of HFpEF patients was comparable to that of HFrEF patients with a nearly identical 30-day readmission rate [23]. In contrast, 30-day mortality was 10% lower in HFpEF when compared to HFrEF patients [23].

Furthermore, data from Goyal and associates analyzed between 2007 and 2013 revealed that HF diagnoses were less common among patients readmitted with HFpEF than among patients with HFrEF [24]. These findings prompted the authors to speculate that interventions should be aimed at paying greater attention to non-cardiovascular comorbidities and interventions rather than to target HFpEF and HFrEF separately [24].

Data from Rushton and Associates regarding non-cardiovascular comorbidity, severity, and prognosis in a non-selected HF population revealed that even though much of the evidence has centered on the impact that renal dysfunction has on HF outcomes; other clinical entities such as diabetes mellitus, chronic obstructive pulmonary diseases, anemia, arthritis, dementia, cancer, other lung disease, and liver disease increase the likelihood of hospital admissions and are associated with higher mortality. This data certainly prompts further investigation to examine the interplay existing between HF and comorbid severity to fully determine the life course outcomes from the time of diagnosis to death [25].

It appears then that we have just started to realize the complexity of the problem without yet knowing how to approach all the numerous intangibles before we can make any significant headway in treating HF as well as reducing hospital readmissions.

Amid from the clinical complexity of HF and associated comorbidities are the financial implications of treating HF. In an attempt of improving healthcare for Americans by linking payment to the quality of hospital care rendered, Medicare introduced the Hospital Readmissions Reduction Program (HRRP). This value-based purchasing program reduces payments to hospitals that experience an excess in readmissions for certain predetermine chronic conditions [26].

In terms of HF, data from Wadhera showed that among Medicare beneficiaries, HRRP was significantly associated with an increase in 30-day post-discharge mortality after hospitalization for HF [27]. Furthermore, among fee-for-service Medicare beneficiaries discharged after HF hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality [28]. Obviously, given the study design of these reports additional data is certainly needed to determine if such regulatory focus on readmissions equates to good clinical care and to examine if financial concerns in some way or form might interfere with medical care.

In order to plan an effective intervention to address these challenges, short- and long-term goals are needed to strive in the right direction moving forward. To this end, perhaps we ought to redefine our current approach to classify HF. Specifically, solely basing our full diagnostic and therapeutic approach on LVEF must be one of the first items on our agenda to be revisited. Our current knowledge of two-dimensional based LVEF measurements are flawed with many limitations [29]. Rather, LV performance should take into consideration the intricate relationship known to exist between LV and left atrium as well as between LV and right ventricle, given that a significant number of these patients have elevated pulmonary artery systolic pressures. Also, in this analysis better interpretation of LV filling characteristic as well as measures of left atrial pressures should be incorporated. Finally, the presence and extent of myocardial fibrosis known to increase the risk of arrhythmia, reduce myocardial perfusion and cause left ventricular dysfunction should be taken into consideration [30]. Particularly when this information should be extremely useful not only to guide therapeutic interventions but also valuable in identifying potential patients that could be less likely to respond to medical therapy given the proven fact that HFpEF patients have quite abnormal myocardial longitudinal strain values simply because of increasing LV wall thickness [31].

Aside from all these technicalities and redefining LV values, the majority of the excellent and adequate care to patients with HF is mainly provided by general internists or cardiologists, without subspecialized HF training [32].

The sad true reality is that it never be would be sufficient HF specialists able to provide primary care for the ever-growing number of Americans carrying a HF diagnosis [32]. In fact, the ACCF/AHA Heart Failure and Transplant Committees as well as the Heart Failure Society of America have reported that current HF centers approximately employ 2.65 physician full-time equivalents (FTEs), 2.21 nonphysician practitioner FTEs (nurse practitioner or physician assistant), and 2.61 nurse coordinator FTEs annually, all of whom provide care to approximately 1,641 outpatients annually [33].

However, on a more positive note, for the rest of us not being HF specialists, multiple learning opportunities exist to receive continued education regarding HF management such as those provided by the Heart Failure Society of America, practice improvement modules offered by the American Board of Internal Medicine and the American College of Physicians [32].

Therefore, although at plain sight the problem with HF might appear to be a losing proposition; I am convinced that we can all pull together and make this situation, a true opportunity for improvement.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. A peer reviewer on the manuscript is PI of grants from the Intermountain Foundry innovation program, the Intermountain Research and Medication Foundation, AstraZeneca, GlaxoSmithKline, and CareCentra related to risk scores for readmission and other clinical outcomes. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript was not funded.