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The relationship between discharge clinical characteristics and readmission in patients hospitalized with heart failure Kelley M. Anderson, PhD, FNP.

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Presentation on theme: "The relationship between discharge clinical characteristics and readmission in patients hospitalized with heart failure Kelley M. Anderson, PhD, FNP."— Presentation transcript:

1 The relationship between discharge clinical characteristics and readmission in patients hospitalized with heart failure Kelley M. Anderson, PhD, FNP

2 Heart Failure – Incidence and Prevalence  High prevalence, 5.2 million Americans  Only major cardiovascular disorder with increasing incidence  Lifetime risk 1 in 5, 20%, for men and women greater than 40 years  Most common Medicare hospital discharge diagnosis $

3 Heart Failure Burden  Mortality: one year 20%  Morbidity = hospitalizations Incidence of hospitalizations Increase in hospital discharges by 175% between 1979 to 2004 (399,000 to 1,099,000) (AHA, 2007) Re-hospitalizations Medicare Quality Monitoring, 30-day, one year HF readmission 9%, 38%; all cause readmission 25% and 74% (MQMS, 2008)

4 Problem  Patients with heart failure experience hospitalizations  Re-hospitalizations frequent  Limited research on clinical, nursing, characteristics at discharge  Correlation of these characteristics with 60-day heart failure readmissions

5  Discharge Guidelines Exacerbating factors addressed (dyspnea) Near optimal volume status achieved Ambulation before discharge to assess functional capacity Level C = Expert opinion Heart Failure Society of America HFSA Comprehensive Guidelines, 2010

6 Criteria InclusionExclusion  Primary discharge diagnosis of HF  Admission greater than 24 hours  Age greater than or equal to 50 years  Cardiac transplant candidate  Acute coronary event within 30 days  Coronary revascularization within 30 days  Left ventricular assist device  Five or more non-cardiac procedure codes  Mortality within 60 days  Discharged to hospice

7 Methodology Descriptive, correlation design  Setting – two acute care facilities, mid- Atlantic, same hospital system  Sampling – retrospective chart review  Procedure Data extraction of patient characteristics and nursing assessment indicators Standardized forms, then entered into computerized database

8 Sample Characteristics  Final cohort of 134 subjects  55.2% Female, 44.8% Male  Average age years (SD 11.34)  Average length of stay 5.83 days (SD 3.29)  Ethnic Group Caucasian 64.9% Black/African American 15.7% Hispanic 6% Asian 4.5% Other 6.7%, Not stated 2.2%  Marital Status – 40.3% married, 35.8% widowed  93.3% admitted through emergency department  79.1% routine discharge home

9 Co-Morbidities  Hypertension 79.1%  Coronary artery disease 55.2%  Diabetes mellitus 51.5%  Valvular heart disease 50.7%  Rhythm abnormality 57.5%  Renal insufficiency 45.5%  Pulmonary disease 36.6%

10 Results - Indicators of Readmission Assistance with activities of daily living (ADLs) Bathing with assistance Toileting with assistance Crackles Congestion on chest radiograph Assistive devices for ambulation Intake and outputs Dyspnea Ambulation with assistance Effusions on chest radiograph History of previous heart failure Left ventricular ejection fraction (LVEF) Ethnicity 2

11 Factor Readmission 2 Age Gender * 4. ADLs Crackles * 6. Dyspnea 7. Congestion 8. Devices 9.Intake/Output 10. HF history.266* *.241* * * * Ethnicity2.176*-.264* * Correlation Matrix for Key Factors *P<.05 + P<.001

12 Selection of Factors for Model  Theoretical, Prior research, Nursing Sensitive  Key Factors Activities of Daily Living, Crackles, Dyspnea Age, Gender  Factors Not in Model Congestion – missing data, chest x-ray Ambulation devices – correlated ADLs Intake/output records – missing data Did not improve model/amenable to ○ Heart failure history ○ Ethnicity

13 Evaluation of the Model  Omnibus Test of Model Coefficients Chi square , 5 df, significance.000  Hosmer and Lemeshow Test Chi square 6.432, 8 df, significance.599  Model Summary Cox & Snell R Square.339 Nagelkerke R Square.453

14 Classification  78.2% of those who did have a readmission (sensitivity of the prediction)  76.7% of the subjects where the predicted event, readmission, did not occur (specificity)  77.4% of the cohort

15 PredictorΒOdds Ratio95% CI Age β Gender β ADLs β Crackles β 2 Dyspnea β Logistic Regression Evaluation of Readmission (n=115)

16 Generalizability  Evaluation of National Hospital Discharge Survey (NHDS) 2005; Heart Failure, n=10,000+  Acute Decompensated Heart Failure Registry (ADHERE); n=52,047

17 NHDS ADHERE Dissertation (n=8642)(n=52,047)(n=134) _____________________________________________________________________________ Age, years74.38 (SD 13.37)75.2 Median75.25 (SD 11.34) Gender Female 4779 (55.3%)52%74 (55.2%) Male 3863 (44.7%)48%60 (44.8%) Length of Stay5.41 (SD 4.55) 5.83 (SD 3.29) Ethnicity White51.7%73%64.9% African American18.2% 19%15.7% Payment Source Medicare76.3%72%81.3% Type of Admission Emergency69.9%76.1% Urgent17.7%9% Discharge Home64.7%79.1%

18 Co-Morbidities Study DataADHERE n=134n=52,047% ______________________________________________________________________ Hypertension Diabetes mellitus Coronary artery disease Valvular heart disease Cardiac rhythm abnormalities57.5 Atrial Fibrillation Renal Insufficiency Pulmonary Disease36.631

19 Limitations  Controlling all factors  Adequacy of data is determined by documentation  Evaluation of home care after index hospitalization  Generalizability

20 Clinical Practice Implications  Return to Framingham (clinical) criteria  Potentially modifiable patient clinical factors at discharge  Evaluation of discharge readiness  Clinical guidelines of care  Post-discharge management Home health Long-term care facilities Outpatient follow up Hospice

21 Significance & Originality  Improve understanding of patient factors related to readmissions  Exploration of the discharge phase  Heart failure admissions and re- admissions only  Nursing sensitive indicators  Implications for discharge management and follow-up

22 Conclusion  Hospital admission is a marker of clinical instability in patients with heart failure  Heart failure patients have frequent adverse outcomes after hospitalizations, including re-hospitalizations  Novel understanding of clinical characteristics at the time of discharge associated with 60-day heart failure readmissions


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