Readmission Rates for Heart Failure in a Safety-Net Hospital

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 10/16/2017 and 05/30/2019, 115 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission (p=0.88) while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit (p=0.72). The Intervention:UC cost ratio was 0.33 (0.13-0.79)95%CI (p<0.01). Among the 69 subjects with baseline HbA1c >7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC, p=0.46) and composite 30-day readmission or ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC, p=0.23). In this subgroup, the Intervention:UC cost ratio was 0.21 (0.08-0.58)95%CI (p=0.002). The DiaTOHC Program is feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with higher HbA1c levels.

Download Full-text

Abstract 16520: Predictors of Thirty Day Readmission in a Vulnerable and Underserved Urban Heart Failure Population

Circulation ◽

10.1161/circ.142.suppl_3.16520 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Alexandra B Steverson ◽

Paul Marano ◽

Caren Chen ◽

Yifei Ma ◽

Rachel Stern ◽

...

Keyword(s):

Heart Failure ◽

Substance Use ◽

San Francisco ◽

Chart Review ◽

Safety Net ◽

Housing Status ◽

Medical Comorbidities ◽

Increased Risk ◽

Safety Net Hospital ◽

Icd 10

Introduction: Heart failure (HF) readmission quality metrics disproportionately impact reimbursement in safety net hospitals. Prior research has demonstrated the effect of medical comorbidities on readmission, however, there is a paucity of data on predictors of readmission in vulnerable and underserved HF patients. We sought to evaluate the effect of demographics, medical and social comorbidities on risk of 30 day readmission in an academic safety net hospital in San Francisco. Methods: We performed a retrospective chart review from 2018 to 2020. Patients were included if treated for HF while on inpatient cardiology or medicine services and were assigned an ICD-10 discharge code for HF. Patients less than 21 years old were excluded. Demographics and comorbidities were obtained through evaluation of ICD-10 discharge codes and chart review. Multivariate modeling was used to determine predictors of 30 day readmission. Results: The study population included 383 patients in which the mean age was 60±13 years and 73% (n=282) were male. 44% (170) were Black, 23% (88) were Latinx, 33% (127) were not housed, 97% (371) had public insurance, and 21% (81) had a diagnosis of mental illness. 46% (177) had CAD, 76% (291) hypertension, and 36% (177) DM. Substance use was common with 30% (114) using methamphetamines, 36% (138) cocaine, 18% (69) opioids, and 35% (135) alcohol. On multi-variate analysis, EF less than 40% (75%, 285) was the only medical comorbidity associated with an increased risk of readmission (OR 1.86, 1.1-3.1, p= 0.018). Social variables associated with increased risk of readmission included identifying as Black (OR 2.26, 1.03-5.0, p= 0.043) or Latinx (OR 3.43, 1.41-7.59, p= 0.006), homelessness (OR 3.02, 1.76-5.18, p=<0.001), and specific substance use: methamphetamine (OR 2.23, 1.39-3.57, p=0.001), cocaine (OR 1.63, 1.03-2.57, p= 0.037), opioids (OR 1.81, 1.05-3.13, p= 0.033), and alcohol (OR 2.26, 1.43-3.58, p= 0.001). Conclusion: Race, housing status and substance use were more strongly associated with readmission risk than medical comorbidities in a population of urban, vulnerable and underserved HF patients. Interventions to improve HF readmission metrics should consider addressing racial and social disparities in similar populations.

Download Full-text

Abstract 16247: Methamphetamine Use Predicts Worse Prognosis in a Safety Net Heart Failure Population

Circulation ◽

10.1161/circ.142.suppl_3.16247 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Anjali B Thakkar ◽

Yifei Ma ◽

Teresa Wang ◽

Alexandra Teng ◽

Rebecca Scherzer ◽

...

Keyword(s):

Heart Failure ◽

Coronary Artery ◽

San Francisco ◽

Cox Regression ◽

Bypass Graft ◽

Safety Net ◽

High Risk Population ◽

Age And Gender ◽

Safety Net Hospital ◽

And Gender

Background: Methamphetamine (MA) use is rising, and overdose deaths have increased by 500% in San Francisco since 2008. MA use is associated with heart failure (HF); yet, cardiovascular (CV) outcomes in this population have not been described. Methods: We performed a retrospective case-control study of HF patients at a safety net hospital in San Francisco. Between January 2001-June 2019, 1771 HF patients with MA use were matched by age and gender to 3542 HF patients without MA use. We examined age and gender-adjusted associations of MA use with likelihood of index HF admission and 30-day readmission (HF and all-cause), and used demographic-adjusted Cox regression model with competing risks to compare hazard rates associated with MA use over the 18-year study period. Results: At time of HF diagnosis, mean age was 52 years and 77% were male. Patients with MA use were significantly more likely than non-MA users to be black (49.1% vs 33.0%), and to have comorbid conditions including HIV (14.5% vs 4.7%), pulmonary hypertension (11.1% vs 7.7%), hypertension (82.0% vs 77.6%), and cocaine use (58.0% vs 14.7%). Despite similar rates of coronary artery disease, myocardial infarction, and diabetes, HF patients with MA use were less likely to have percutaneous coronary intervention (6.1% vs 8.2%) or coronary artery bypass graft (0.8% vs 1.4%), p<0.05 for all. Compared to HF patients without MA use, HF patients with MA use had higher rates of index HF hospitalizations (36.0% vs 21.7%, adjusted odds ratio 2.04, 95% CI 1.80-2.32, p<0.01), 30-day HF readmission (12.2% vs 6.4%, adjusted hazard ratio (aHR) 1.87, 95% CI 1.31-2.67, p<0.01) and 30-day all cause readmission (20.9% vs 14.3%, aHR 1.46, 95% CI 1.14-1.88, p<0.01). Exposure to MA was associated with higher likelihood of death during the study period, regardless of hospitalizations (22.4% vs 15.1%, aHR=1.17, 95% CI 1.03-1.33, p<0.01). Conclusions: In our study, HF patients with MA use were more likely to be admitted for an index HF admission; subsequently, they were also more likely to be readmitted within 30 days. Regardless of hospitalization risk, individuals with MA use had higher likelihood of death. Further study to understand the clinical and socioeconomic factors driving worse outcomes in this high-risk population is needed.

Download Full-text

Abstract 18: Patient-administered Home Inotrope Therapy: A Proof of Concept

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.18 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Wally A Omar ◽

Chris Mathew ◽

Kavita Bhavan ◽

Sandeep R Das ◽

Jose A Joglar

Keyword(s):

Heart Failure ◽

Infusion Pump ◽

Cost Savings ◽

Safety Net ◽

Therapy Program ◽

Advanced Therapies ◽

Safety Net Hospital ◽

End Stage ◽

The Cost ◽

To Receive

Background: Palliative use of continuous IV inotrope therapy has shown to improve quality of life and reduce hospital readmissions for patients with end-stage heart failure (HF) who are otherwise ineligible to receive advanced therapies. Administration of home inotrope therapy generally requires a hospice or home-health agency, placing this option out of reach for patients who lack funding. As such, underinsured patients are relegated to the difficult choice of either remaining in the hospital to receive IV inotropes, or going home without the therapy for as long as their symptoms allow. To address this issue at our large county safety-net hospital, we developed and implemented a patient self-administered home inotrope therapy program. Methods: A multidisciplinary team of physicians, pharmacists, nurses, and social workers was assembled to pilot the program. Eligible patients were provided with a peripherally inserted central venous catheter (PICC) and a portable infusion pump. They were then instructed on proper use of the pump, medication administration, medication bag changes, and IV line care using a nursing teach-back technique. After proper understanding was demonstrated, patients were discharged home with weekly follow up in heart failure clinic for PICC-care and medication exchanges. Results: During the initial 12 months of the program, 5 patients were deemed eligible for enrollment. Total hospitalized days for these patients was 277 (mean = 55.4 days) in the one year prior to enrollment and 12 (mean = 2.4 days) while enrolled for a cumulative period of 288 days (Figure 1). One patient was able to secure funding for advanced therapies, two patients died while enrolled, and two patients are currently enrolled and alive. Discussion: A self-administered home IV inotrope therapy program is a feasible alternative for palliation in unfunded patients with end-stage HF who are otherwise not candidates for advanced therapies, allowing for more days at home in the end of life. Thus far, the cost impact of the program has been mitigated by the cost savings for inpatient hospitalizations. Studies to assess patient-centered outcomes, and overall cost savings are ongoing.

Download Full-text

Multidisciplinary Team Utilizing Pharmacists in Multimodal, Bundled Care Reduce Chronic Obstructive Pulmonary Disease Hospital Readmission Rates

Journal of Pharmacy Practice ◽

10.1177/0897190019889440 ◽

2019 ◽

pp. 089719001988944 ◽

Cited By ~ 2

Author(s):

Anthony J. Gentene ◽

Maria Rose Guido ◽

Brittany Woolf ◽

Amber Dalhover ◽

Timmi Anne Boesken ◽

...

Keyword(s):

Chronic Obstructive Pulmonary Disease ◽

Pulmonary Disease ◽

Multidisciplinary Team ◽

Safety Net ◽

The United States ◽

Care Bundle ◽

Chronic Obstructive ◽

Readmission Rates ◽

Obstructive Pulmonary Disease ◽

Safety Net Hospital

Background: Chronic obstructive pulmonary disease (COPD) is a major contributor of morbidity and mortality in the United States resulting in high hospitalization and readmission rates. For health systems, identifying an effective strategy to reduce COPD readmissions has remained difficult. Multiple COPD care bundles have been developed with varying degrees of success. Bundles that were multidisciplinary and included pharmacists were successful in reducing readmissions. Objective: To describe and assess a multidisciplinary, 5-element, COPD care bundle that was implemented in an academic, urban safety-net hospital to reduce COPD readmissions and the role of pharmacists in bundle implementation. Methods: A multidisciplinary team collaborated to develop a 5-element COPD care bundle that met unmet patient needs. The bundle elements included the following, with pharmacy responsible for the first two: optimization of COPD inhalers, 30-day supply of insurance-compatible inhalers, individualized patient inhaler teaching, provision of standardized discharge instructions, and scheduling of a 15-day discharge follow-up appointment. Bundle was implemented with multiple Plan-Do-Study-Act (PDSA) cycles to develop intra- and interdepartment processes. Results: Prior to bundle implementation, the health system COPD readmission rates were 22.7%. Reliable implementation of the bundle reduced readmissions to 14.7% over a 6-month period. Pharmacy adherence to completion of the bundle was over 95% over 2 years of bundle use. Conclusion: Pharmacists have a crucial role in hospital-based transitions of care to reduce COPD readmissions.

Download Full-text

Abstract 15128: Clinical Outcomes in Heart Failure Patients With Concurrent Cocaine Use

Circulation ◽

10.1161/circ.142.suppl_3.15128 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jonah D Garry ◽

Anjali Thakkar ◽

Yifei Ma ◽

Rebecca Scherzer ◽

Priscilla Hsue

Keyword(s):

Heart Failure ◽

San Francisco ◽

Hospital Readmissions ◽

Safety Net ◽

Chronic Obstructive ◽

Day Hospital ◽

Cocaine Use ◽

Significant Difference ◽

Safety Net Hospital ◽

The Impact

Background: While cocaine use is associated with heart failure (HF) with reduced ejection fraction, the impact of cocaine use on HF outcomes including 30-day hospital readmission and survival has not been well described. Accordingly, this study evaluated the impact of cocaine use on 30-day hospital readmissions (heart failure and all cause) and mortality. Methods: We performed a case control study of HF patients with an index HF hospitalization at an academic safety net hospital in San Francisco between 2001-2019. 746 HF patients with history of cocaine use were matched to 746 HF patients without cocaine use, based on age, gender, and date of index hospitalization. We compared clinical characteristics, readmission rates, and mortality between these two groups. Results: Average age was 53 years and 79% were male. HF patients with cocaine use were more likely to be African American (69.6% vs. 29.8%, p<0.01), have hypertension, liver disease and concurrent use of methamphetamines and opioids. Rates of coronary artery disease, diabetes, chronic kidney disease, HIV, and chronic obstructive pulmonary disease were similar between the groups. There was no significant difference in prescription of guideline directed medical therapies at discharge. Within 30 days of index HF hospitalization, HF patients with cocaine use were more likely to attend follow up (91.8% vs 86.9%, p<0.01), but were more likely to be readmitted for HF (12.1% vs 7.4%, OR 1.75, p<0.01) or other causes (22.4% vs 14.7%, OR 1.67, p<0.01). Over the study period, cocaine use was associated with greater likelihood of death (27.9% vs 20.1%, p<0.01). Conclusions: HF patients with comorbid cocaine use were found to have higher likelihood of readmission or death following index HF hospitalization compared to HF patients without cocaine use. As cocaine use continues to grow it is critical to understand the mechanisms underlying cocaine induced cardiovascular pathophysiology, and to identify factors affecting readmission and mortality in this high risk group.

Download Full-text