1. Kelley M. Anderson, PhD, FNP
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. Heart Failure Society of America HFSA Comprehensive Guidelines, 2010
Discharge Guidelines
Exacerbating factors addressed (dyspnea)
Near optimal volume status achieved
Ambulation before discharge to assess functional capacity
Level C = Expert opinion

6. Criteria Inclusion Exclusion
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. Correlation Matrix for Key Factors1 2 3 4 5
1. Readmission
2 Age
.030
3. Gender
-.123
-.263*
4. ADLs
.433+
.264+
-.147
5. Crackles
.327+
.127
-.062
.254*
6. Dyspnea
7. Congestion
8. Devices
9.Intake/Output
10. HF history
.266*
.514+
.309+
-.349*
.241*
.101
.213
.443+
.073
.113
-.073
-.008
.263
.238
.176*
.325+
.239
.549+
-.099
.086
.165
.146
.269*
-.177
.085
.321
.215*
11. Ethnicity2
-.264*
-.038
-.046
.221*
*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
OTMC – overall indication of model performance over and above the results with no predictors entered into the model; “goodness of fit” test; test of the null
HandL- most reliable test of model fit; interpreted differently; poor fit indicated by significance value less than .05, so to support model want greater than .05
Model Summary – amount of variation in the dependent variable explained by the model; pseudo R square 33.9%-45.3% variability explained by set of variables

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
Hierarchical logistical regression a model was derived which demonstrated the ability to correctly classify

15. Logistic Regression Evaluation of Readmission
Predictor Β
Odds Ratio
95% CI
Age β5
-.043
.958
Gender β4
-.769
.464
ADLs β3
2.33
10.26
Crackles β2
Dyspnea β1
1.69
.579
5.41
1.79

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. Age, years 74.38 (SD 13.37) 75.2 Median 75.25 (SD 11.34) Gender
NHDS ADHERE Dissertation
(n=8642) (n=52,047) (n=134)
_____________________________________________________________________________
Age, years (SD 13.37) Median (SD 11.34)
Gender
Female (55.3%) 52% 74 (55.2%)
Male (44.7%) 48% 60 (44.8%)
Length of Stay 5.41 (SD 4.55) (SD 3.29)
Ethnicity
White 51.7% 73% %
African American 18.2% 19% %
Payment Source
Medicare 76.3% 72% %
Type of Admission
Emergency 69.9% %
Urgent 17.7% %
Discharge Home 64.7% %

18. Co-Morbidities Study Data ADHERE 2006-2007 2002-2003 n=134 n=52,047
n=134 n=52,047
% %
______________________________________________________________________
Hypertension
Diabetes mellitus
Coronary artery disease
Valvular heart disease
Cardiac rhythm abnormalities 57.5
Atrial Fibrillation
Renal Insufficiency
Pulmonary Disease

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
Goal – to improve outcomes by reducing readmissions, avoid exacerbations of illness and maintain health based on empirical data

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