Is Inadequate Follow Up Related to Early Hospital Readmissions In Patients with CHF ? Mudasir Chisti PGYIII Aravind Herle MD

Rationale & Background Heart Failure is the most common Medicare diagnosis related group. Patients with CHF are frequently readmitted to the hospital following exacerbation of their symptoms. The 3-6 month readmission rates have been reported to be as high as 30-50%.

Rationale & Background One-fifth of Medicare beneficiaries are rehospitalized within 30 days. Nearly 90% of these readmissions are unplanned and potentially preventable. Translates into $17 billion or nearly 20% of Medicare’s hospital payments.

Medicare contemplates profiling hospitals based on readmision rates with complimentary changes in payment rates. Hospitals with high risk-adjusted rates of rehospitalization to receive lower average per case payments. Identifying factors associated with readmissions is therefore important.

Studies suggest that care coordination is important in preventing readmissions. Early physician follow up post discharge may have potential to reduce readmissions. Data on follow up patterns following hospitalisation for CHF & its relationship to readmissions is limited.

STUDY: Primary Objective: To determine if lack of early Follow Up is associated with 30 Day Readmissions in CHF patients. Secondary Objectives: To determine readmission rates for CHF. To identify other risk factors for 30 day readmissions.

Study Design: Case Control Study based on Retrospective Chart review. Single centre based in SBMH. Proper IRB approval obtained for chart review and phone survey 5 month period Nov 2010 through March 2011.

Inclusion Criteria : Primary discharge diagnosis of CHF exacerbation on index admission. Cases: CHF patients readmitted within 30 days of discharge for all causes Controls: CHF patients not readmitted within 30 days of discharge. Early Follow Up defined as F/U occuring <=7 days following discharge from the hospital.

Exclusion criteria: Death during or following index admission Discharge to hospice after index admission Missing clinical data Lack of follow up data

Total Charts Reviewed =255 CHF charts= 226 Non CHF charts =29 CHF Charts Excluded: 21 (met exclusion criteria) Hospice =15 Expired =2 AMA= 1 Missing data =3 CHF charts included =205

CHF Charts analysed= day Readmissions/Cases= 52 No 30 day Readmission/Controls= day Readmission Rate=52/226 or 23% Clinical data was available and compared for 205 patients Follow up data was available and compared for 180 patients including patients discharged to Rehab

Analysis of Clinical Data Variables compared Demogaphic: Age,race & sex. Heart Failure Variables: LVEF, prior CHF,LOS Treatment Variables: Cardiology consultation,Meds at discharge Comorbidities Lab variables: BNP,Na,K,BUN,Cr Discharge Planning Variables : CHF Teaching, DC instructions, Instructions on follow up, appointment scheduled before discharge or not. Disposition : Discharge to Rehab/NH or home.

Variables compared using Fischer’s Exact test Significance defined as p-value< 0.05

Demographic Variables Group 30 Day Readmits N=52 No30 Day Readmission N= 15395% C.IP ValueResult Mean Age to Not sig Sex M 26F 26M=68F= Not sig Race W 50B 2W=151B= Not sig Afib Yes/No Y=26N=26Y=99N= Not sig LVEF <40 Y=26N=26Y=55N=92NA= Not sig Prior CHF Y=44N=8Y=117N= Not sig Mean LOS to Not sig Cardiology consult Y=49N=3Y=141N= Not sig

Group 30 Day Readmits N=52 No30 Day Readmission N=153OR95% C.IP ValueResult Meds on Discharge to Sig Diuretics Y=46N=6Y=145N= Not sig Beta blocker Y=46N=6Y=134N=191Not sig ACE/ARB Y=21 (40.38%) N=31 (59.62%) Y=99 (64.7%) N=54 (35.3%)0.0032Very sig Spirinolactone Y=5N=47Y=22N= Not sig Statins Y=31N=21Y=89N= Not sig Digoxin Y=13N=39Y=42N= Not sig

Group 30 Day Readmits N=52 No30 Day Readmission N=15395% C.IP ValueResult CAD Y=33N=19Y=99N= Not sig Chronic Lung disease Y=20N=32Y=69N= Not sig HTN Y=50N=2Y=143N= Not sig Diabetes Mellitus Y=25N=27Y=72N=811Not sig CKD Y=36 (69.23%)N=16esrd=4 Y=57 (37.25%)N=96esrd= Ext sig Stroke/TIA Y=11N=41Y=18N= Not sig Dementia Y=9N=43Y=10N= Sig

Group30 Day Readmits No30 Day Readmission95% C.IP ValueResult BNP Mean to Sig Na on admission to Not sig K on admission to Sig BUN on admission to Very Sig Cr at admission to Very Sig

Group 30 Day Readmits N=52 No30 Day Readmission N=15395% C.IP ValueResult CHF teaching Y/NY=47N=5Y=127N= Not sig Current Smoker Y/NY=3N=49Y=18N= Not sig Alcohol Yes/noY=2N=50Y=9N= Not sig Rehab/SNF/N H Y/N Y=22 (42.3%)N=30 Y=28 (18.3%)N= Very Sig Home w/wo servicesY=30Y=125 Follow up scheduledY=7N=45Y=13N= Not sig Instructions Follow upY=50N=2Y=145N=81Not sig

Comments Statistically significant differences were noted in the clinical variables between the two groups including : Greater percentage of readmitted patients had CKD % compared to 37.25% among patients not readmitted. Lesser percentage of readmitted patients had been discharged on ACE/ARB % compared 64.7% among those not readmitted. Greater percentage of readmitted patients had been discharged to Rehab upon index admission -42.3% vs 18.3%

Reasons for Readmission : ReasonsTotal Readmissions N=52 Cardiac : % Recurrent CHF % Hypotension2 Chest Pain4 Tachyarrythmia2 Bradycardia3 Infections: % Infections not PNA6 PNA4 Others: % Renal failure5 9.6% AMS2 Fall1 CVA1 Bleeding Complication1 Resp Failure/OSA1

Follow Up Data Analysis: Data obatined via phone survey Available on 180 patients : 130 as outpatient physician follow up 50 Reahab/NH patients – follow up counted as occuring within 1 week of discharge from hospital. Analysis done both including as well as excluding data on Rahab/NH patients.

Follow Up Data Excluding Rehab Patients N=130 OP F/U Interval30 Day Readmits N=30No Readmission N=100 Mean <=7 Days Days Days19 >21 days217 No F/U before Readmission 5

Follow Up Data Excluding Rehab Patients OP Follow Up Interval 30 Day Readmits N=30 No Readmission N=100OR Readmission Ratep valueResult Mean Not sig <=7 days %0.6454Not sig >7 days %0.6454Not sig 8-14 days154525%0.6795Not sig <=14 days227423%1Not sig >14 days %

F/U Interval >7 d was associated with higher Readmision Rate 24.47% vs 19.4% but the difference was not statistically significant. F/U interval 8-14 days had highest readmission rates 25% but again not statistically significant.

Follow Up Data Including Rehab Patients N=180 OP F/U Interval30 Day Readmits N=52No Readmission N=128 <=7 Days Days Days19 >21 days217 No F/U before Readmission 5

Follow Up Data Including Rehab Patients N=180 OP Follow Up Interval 30 Day Readmits N=52 No Readmission N=128OR Readmission Ratep valueResult Mean Not sig <=7 days %0.1904Not sig >7 days %0.1904Not sig 8-14 days154525%0.4869Not sig <=14 days %0.5318Not sig >14 days %

Comments F/U Interval <7d was associated with higher Readmission Rates 33.72% vs 24.47% when Rehab/NH patients were included,but it was not statistically significant.

Conclusions Recurrent CHF is a major reason for early readmissions. Among patients discharged home, lack of F/U within 7 days was not significantly associated with readmissions in our study population. Study identifies high risk groups particularly patients requiring Rehab upon discharge. Further studies need focus on this group to elucidate this relationship and explore interventions that may reduces such readmissions.

Statistically significant association also between presence of CKD, lack of ACE/ARB upon discharge from hospital. Improving adherence to ACE/ARB may prove helpful.

Limitations Retrospective study design. Single centre. Relatively smaller sample size for follow up data. Potential Recall Bias in follow up data. Confounders

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