1. Heart Failure Disease Management Within the North Florida/South Georgia VHS Richard S. Schofield MD Lynnette Boyer ARNP Cardiology Section North Florida/South Georgia VHS

2. Epidemiology of Heart Failure in the United States 5 million patients 1 ; estimated 10 million in 2037 2 Incidence: about 660,000 new cases each year 1 Leading cause for inpatient hospitalization in the U.S. Costs $37 billion to the U.S. health care system annually 3 Sudden cardiac death is 6 to 9 times higher than in the non-heart failure population 1 199120012037 3.5 5 10.0 Patients in US (millions) Year 1. American Heart Association. 2008 Heart and Stroke Statistical Update. 2. Croft JB et al. J Am Geriatr Soc. 1997;45:270–275. 3. National Heart, Lung, and Blood Institute. Congestive Heart Failure Data Fact Sheet. Available at: http://www.nhlbi.nih.gov/health/public/heart/other/CHF.htm.

3. Heart Failure Hospitalizations HF hospitalizations are increasing for both men and women CDC/NCHS: hospital discharges include patients both living and dead. American Heart Association. 2002 Heart and Stroke Statistical Update. 2001. Annual Discharges 0 100,000 200,000 300,000 400,000 500,000 600,000 '79'81'83'85'87'89'91'93'95'97 Women Men Year '99

4. Rates of Hospital Readmission for CHF Patients in the Medicare Program 0 10 20 30 40 50 60 Within 2 Days Within 1 Month Within 6 Months Patients Readmitted (%) 2% 20% 50% Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3–S9.

5. Preventable Causes of CHF Readmissions Are Present in >50% of Cases 29% 34% 29% 37% 40% 37% 1= Medical Noncompliance 2= Diet Noncompliance 3= Inadequate Discharge Planning 4= Inadequate F/U 5= Failed Social Support 6= Failure to Seek Medical Attention Vinson JM et al. J Am Ger Soc, 1990

6. Heart Failure Within the Veterans Administration Leading discharge diagnosis in the VA Up to 20% readmission rate within 14 days Avg. 1.42 hospital stays,14 inpatient days/year > 20 outpatient visits/year Approximately $2.5 billion in cost annually > 60% mortality at 5 years 1. VA QUERI CHF fact sheet, 2003 2. Med Care 1997;35:768 3. Am J Med Qual 1999;14:45 4. Med Care 2000;38:I-26

7. VA Data - 14 day Outpatient Encounters Following HF Discharge (1999-2005) CHF QUERI 2007

8. VA Heart Failure Practice Survey 2008: Physician Resources % of VAs VA Heart Failure QUERI Presentation, 6/29/09

9. NF/SG VA Heart Failure Team Concept The Heart Failure Team was created in response to a need for better utilization of inpatient beds (FIX Committee Initiative) The team was designed to target the most high risk cohort of HF patients, and to reduce admissions We attempt to screen all inpatient HF admissions HF disease management offered to all eligible patients Combines inpatient, outpatient, and home telehealth/case management strategies Outcomes are tracked for quality improvement

10. Unique Aspects of this HF Team Integrates multiple aspects of HF disease management Entry into the program is triggered by a HF admission, therefore targets the highest risk pts Early post-discharge clinic follow-up Care coordination/home telehealth management is available for appropriate patients Patient outcomes are tracked in a HF database with potential for automatic download of data from CPRS HF-specific quality of life is measured Directed by HF-specialty trained cardiologist

11. Identify potential inpatient HF admissions daily (M-F) from medical admissions pull list Confirm likely HF admissions from brief CPRS chart review Submit an electronic consult Complete inpatient consult Optimize HF therapy Discharge planning/HF education Explain HF Team concept Provide scale and BP cuff Return to HF outpatient clinic within 7-14 days 6 months of HF clinic for stable pts Long term HF clinic for complex pts Enroll in the HF Team HF Care Coordination and Home Telehealth management for appropriate patients

12. Patient Characteristics Age (years)70.9 ± 13 Baseline LVEF (%)33.5 ± 13.9% NYHA Class III or IV (%)72% Ischemic cardiomyopathy (% )52% Males (%)100% Body Mass Index30.7 ± 7 Creatinine (mg/dl)1.5 ± 0.6 NT-proBNP level (pg/ml)7,597 ± 7,511 Clinical Characteristics of the First 137 Patients Screened

13. * Only 7% of all patients screened were enrolled in a telehealth program Enrollment Breakdown of the First 137 Patients Screened

14. Sociodemographic Characteristics Distance (miles) Residence Location Education Level RangeMeanRuralUrbanCollege No College 0 – 27944.173%27%39%61% Sociodemographic Characteristics of the First 137 Patients Screened

15. Heart Failure-Specific Quality of Life Data on 52 Patients: Comparison with Non-Veterans with HF

16. Heart Failure-Specific Quality of Life Data on 52 Patients: Comparison with Non-Veterans with HF

17. Medication Usage in the First 137 Patients Screened

18. Low Usage of Spironolactone and Digoxin Among the First 137 Patients Screened

19. 6-Month Outcomes of the Heart Failure Team: 30-day HF Readmission Rate for Primary Dx of HF 64% relative reduction compared to historical control data

20. HF Disease Management Program for NF/SG VHS, Fiscal YTD Through 7/31/09 (10 Month Data) (3.5%) (5.0%)

21. Barriers to Implementation Travel cost reduces pt willingness to come for frequent clinic visits Clinic space is limited at our facility Broad inclusion of all-comers with HF has revealed a large proportion of patients with diastolic HF, right HF, morbid obesity, and renal failure; these patients will not likely respond well to standard HF therapy or to HF disease management Large proportion of very elderly (80+) pts Large proportion of pts with multiple co-morbidities Limited availability of ICU beds and lack of an IMC unit limits our access to more complex inpatient therapies such as diuretic infusions, inotropes, hemodynamic monitoring (Swan-Ganz catheterization), etc Our home telehealth program needs to be expanded

22. Limitations This is a retrospective, observational assessment of data accumulated from clinical chart review of patient data, and placed into a clinical HF database The number of patients reviewed thus far is small Unclear whether short term reductions in hospitalizations can be sustained over time No data on mortality No data on HF subsets (diastolic, right HF, CKD) These clinical data do not necessarily correlate with other datasets within the VHA which are derived from discharge codes, therefore results seen may not precisely match with 30 day readmission rates measured from coded data

23. Conclusions In this preliminary analysis, our new HF team led to a dramatic reduction in HF 30-day readmission rates compared to historical control data and to observational data within the program Several barriers to fuller implementation of the program have been identified, and will be addressed over time This program may offer important insights into the optimal management of high risk patients with HF in the Veterans Health System