Original article
Early Postdischarge STOP-HF-Clinic Reduces 30-day Readmissions in Old and Frail Patients With Heart FailureUna consulta específica al alta (STOP-HF-Clinic) reduce los reingresos a 30 días de los pacientes ancianos y frágiles con insuficiencia cardiaca

https://doi.org/10.1016/j.rec.2017.01.003Get rights and content

Abstract

Introduction and objectives

Heart failure (HF) is associated with a high rate of readmissions within 30 days postdischarge. Strategies to lower readmission rates generally show modest results. To reduce readmission rates, we developed a STructured multidisciplinary outpatient clinic for Old and frail Postdischarge patients hospitalized for HF (STOP-HF-Clinic).

Methods

This prospective all-comers study enrolled patients discharged from internal medicine or geriatric wards after HF hospitalization. The intervention involved a face-to-face early visit (within 7 days), HF nurse education, treatment titration, and intravenous medication when needed. Thirty-day readmission risk was calculated using the CORE-HF risk score. We also studied the impact of 30-day readmission burden on regional health care by comparing the readmission rate in the STOP-HF-Clinic Referral Area (∼250 000 people) with that of the rest of the Catalan Health Service (CatSalut) (∼7.5 million people) during the pre–STOP-HF-Clinic (2012-2013) and post–STOP-HF-Clinic (2014-2015) time periods.

Results

From February 2014 to June 2016, 518 consecutive patients were included (age, 82 years; Barthel score, 70; Charlson index, 5.6, CORE-HF 30-day readmission risk, 26.5%). The observed all-cause 30-day readmission rate was 13.9% (47.5% relative risk reduction) and the observed HF-related 30-day readmission rate was 7.5%. The CatSalut registry included 65 131 index HF admissions, with 9267 all-cause and 6686 HF-related 30-day readmissions. The 30-day readmission rate was significantly reduced in the STOP-HF-Clinic Referral Area in 2014-2015 compared with 2012-2013 (P < .001), mainly driven by fewer HF-related readmissions.

Conclusions

The STOP-HF-Clinic, an approach that could be promptly implemented elsewhere, is a valuable intervention for reducing the global burden of early readmissions among elder and vulnerable patients with HF.

Resumen

Introducción y objetivos

La insuficiencia cardiaca (IC) se asocia a una alta tasa de reingreso en los 30 días posteriores al alta. Las estrategias para reducir los reingresos han mostrado, en general, resultados moderados. Hemos desarrollado una consulta multidisciplinaria estructurada ambulatoria para pacientes ancianos y frágiles tras el alta de un ingreso por IC (STOP-HF-Clinic), con el objetivo de reducir estas tasas de reingreso.

Métodos

Estudio prospectivo que incluye a todos los pacientes dados de alta de medicina interna o geriatría tras una hospitalización por IC. Intervención: visita presencial temprana (antes de 7 días), educación sobre IC por enfermería, titulación del tratamiento y administración de medicamentos intravenosos cuando fuera necesario. El riesgo de reingreso a 30 días se calculó utilizando la puntuación de riesgo CORE-HF. También se estudió el impacto de la carga de reingresos a 30 días en la atención sanitaria regional comparando la tasa de reingresos en el área de referencia de la STOP-HF-Clinic (∼250.000 personas) con la del resto del Servei Català de la Salut (CatSalut) (∼7,5 millones de personas) durante 2 periodos de tiempo, antes de la STOP-HF-Clinic (2012-2013) y después (2014-2015).

Resultados

De febrero de 2014 a junio de 2016, se incluyó a 518 pacientes consecutivos (media de edad, 82 años; índice de Barthel, 70; índice de Charlson, 5,6; riesgo a 30 días de reingreso según la puntuación CORE-HF, 26,5%). La tasa de reingreso a 30 días por todas las causas observadas fue del 13,9% (reducción del riesgo relativo, el 47,5%), y la tasa de reingreso por IC a 30 días observada fue del 7,5%. El registro del CatSalut incluyó 65.131 ingresos índice por IC, con 9.267 reingresos a 30 días por todas las causas y 6.686 por IC. La tasa de reingresos a 30 días se redujo significativamente en el área de referencia de la STOP-HF-Clinic en 2014-2015 en comparación con 2012-2013 (p < 0,001), a expensas principalmente de la reducción de los reingresos por IC.

Conclusiones

La STOP-HF-Clinic, iniciativa que podría aplicarse sin demora en otros lugares, es una valiosa intervención para reducir la carga total de reingresos prematuros de los pacientes con IC mayores y frágiles.

Section snippets

INTRODUCTION

Heart failure (HF) is the leading cause of hospital readmission in developed countries.1 It is a particular concern for patients ≥ 65 years of age, who comprise approximately 80% of the population with HF.2 The total annual cost of HF in the US is estimated to be $30.7 billion, with about two-thirds attributable to HF-related hospitalizations.3

Rates of rehospitalization within 30 days of discharge can reach 20%–30%.4 Early rehospitalization is attributed to underlying disease exacerbation5 and

Study Population

This prospective single-center study was designed to include the most vulnerable patients admitted for acutely decompensated HF. We performed an all-comers, consecutive study of HF patients discharged from internal medicine and geriatric wards with a primary hospital diagnosis of HF according to the Framingham HF Criteria.16 Our study did not include patients discharged from the cardiology ward (n = 106 during the study time period), who were generally younger (64 ± 12 years), male (76%), of

RESULTS

A total of 518 patients attended the STOP-HF-Clinic from February 2014 to June 2016. These patients’ demographic and clinical characteristics are shown in Table 1. The mean patient age was 82.3 ± 8.3 years, 25% were ≥ 88 years old, and 57.1% were women. Common comorbidities included diabetes, anemia, and renal failure. Hemoglobin levels were < 10 g/dL in 55 patients (10.6%) and < 9 g/dL in 13 patients (2.5%). The median time from discharge to first STOP-HF-Clinic visit was 5 days (Q1-Q3, 3-6

DISCUSSION

The concept that “hospitalization begets further hospitalization” is certainly applicable to HF.21 Because many HF readmissions are considered preventable, novel strategies are needed to reduce rehospitalizations. We have developed a comprehensive patient-centered model: the STOP-HF-Clinic. Our present data show that implementation of the STOP-HF-Clinic intervention was associated with a significant ∼50% reduction in all-cause 30-day readmission, mainly driven by reduced HF-related

Conclusions

The STOP-HF-Clinic included early follow-up, HF nurses tasked with medication reconciliation, education and patient self-care empowerment, staff assigned to follow up on postdischarge test results, immediate availability of intravenous treatments and patient treatment titration, and partnerships with community physicians. This intervention resulted in an ∼50% reduction in the all-cause 30-day readmission rate after an index hospitalization for HF, which was mainly driven by a reduction in

CONFLICTS OF INTEREST

None declared.

WHAT IS KNOWN ABOUT THE TOPIC?

  • –

    Heart failure is associated with a high rate of readmissions within 30 days postdischarge.

  • –

    Old and frail patients are the most vulnerable and prone to require premature readmission after being hospitalized for HF.

  • –

    Strategies to lower these readmission rates have generally shown modest results.

WHAT DOES THIS STUDY ADD?

  • –

    An early postdischarge multidisciplinary approach including face-to-face health literacy, intravenous therapy, and improved primary care transition significantly reduced 30-day readmission

Acknowledgements

We thank the nurses of the STOP-HF-Clinic—Roser Cabanes, Margarita Rodríguez, Carmen Rivas, Nuria Benito, and Alba Ros—for data collection and their invaluable work in the Clinic. This study was funded by the Red de Investigación Cardiovascular - RIC (RD12/0042/0047) and Fondo de Investigación Sanitaria, Instituto de Salud Carlos III (FIS PI14/01682) projects as part of the Plan Nacional de I+D+I and was cofunded by the ISCIII-Subdirección General de Evaluación and the Fondo Europeo de

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    © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.