11/9/2018

1

Seeing Faces on Readmissionsand Unmet Metrics

• Who is getting readmitted after heart failure hospitalizations?

• Who with HFrEF is discharged without guideline-based medications?

Positive Impact of Recent Metrics

•Hospital focus on readmissions:• Attention and engagement of hospital staff previously focused on length of stay

• Focus on medication reconciliation and prescriptions• Support for HF management infrastructure - ?maintenance

•Get with the Guidelines program • Identification of GDMT as a key value for patient care• Education and engagement of hospital staff for discharges• Focus on medication reconciliation and prescriptions• Resources and feedback to improve individual provider performance

11/9/2018

2

Metrics for ReadmissionAdjusted for Severity

• 6,302,380 Medicare episodes at 3259 HRPP hospitals and 1115 control hospitals • (AMI, heart failure, pneumonia)

Hospital  Incentives PRE‐HRPP POST‐HRPP

Control 1115 hosps 2.50 2.99

HRPP  3259 hosps 2.50 3.47

Ibrahim et alJAMA Int Med2018: 178: 83‐5

UNADJUSTED ADJUSTED FOR CO‐MORB

Average # Co‐Morbidities 

( especially renal disease , HTN, electrolyte disorders)

What Are Our Re-Admissions To Target?

HF Both Admits Index non card

Index non‐card terminal+HF Readmit non‐CardioRenal

HF orCardiorenalBoth Admits

IndexNon‐HF

Index hospTerminalNon‐CardWith HF 

ReadmitNonCardio‐Renal

Munoz et al…VUMC Readmits2016 to early 2018

11/9/2018

3

Near Refractory

PLAD

Others left Wet

Other

Persistently LimitedAdherence = 

Types of Patients Readmitted  WITH HEART FAILURE

Average 6 readmissionsIn preceding 12 months

Munoz D, Choma N et alVanderbilt Heart and Vascular Institute

• History: HFrEF non-ischemic 2 hospitalizations in past 3 years for congestion, once after elective gall bladder surgery at another hospital, once shortly after Thanksgiving trip during which she did not take Lasix given long flights

• When not in hospital: Shows up to most appointments, generally knows what foods/fluids to avoid; water aerobic class 3x/week

• Her words: “I can usually tell when I start holding onto extra fluid. When my weight goes up, I double my Lasix and get better, sometimes it’s not enough.”

Typical single hosp: heart failure

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4

• Lost touch with family, rents a room in group home.

• Comorbidities: DM, COPD, OSA , morbid obesity

• Hospital history: HfpreservedEF 8 admissions in past 18 months for volume overload, usually 15-20 lbs more than when he last left hospital. Easy to diurese in the hospital. Orders fast food delivery to his room.

• When not in hospital: Rarely shows up to appointments, does not answer RN calls or open door to home health. Not sure of medications. Eats “what I can take home with me”

• His words: “I don’t know why these doctors can’t just get me better.”

Familiar face: heart failure

• Family Information: Married, 5 grandchildren

• Medical history: HFrEF first MI 25 years ago, HTN, DM, eGFR 25 cm, torsemide dose 200 bid

• The past year: 6 hospitalizations at VUMC for shortness of breath and GI symptoms. RV failure with RAP=PCW 18 on last cath. During last stay, needed short course of IV inotrope

• When not in hospital: Shows up to all of his appointments with his wife, communicates well/frequently with medical team, fills prescriptions on time.

• His words: “I realize my disease is getting worse, but I want to see my grandchildren graduate from college and keep my wife company.”

Late‐stage, advanced heart failure

11/9/2018

5

Seeing Faces on Readmissionsand Unmet Metrics

• Who is getting readmitted after heart failure hospitalizations?

• Who with HFrEF is discharged without guideline-based medications?

SCAMP =Standardized Care and Management Plan

All quality improvement is local.

Encourage and standardized quality care established by guidelinesDocument and understand deviations 

226 discharges from HF inpatient service132 from academic hospital

94 from community hospital with dedicated HF management program

Gilstrap,Stevenson,Small,Parambi,Hamershock.Greenberg,Carr,Ghazinouri,Rathman,Han,Mehra,Desai.J Am Heart Assoc 2018;118: 1‐11. 

11/9/2018

6

Guidelines Reflect the Needfor Individualized Care

11/9/2018

7

Reasons for Lower Doseor No Beta Blockers

at Discharge

Gilstrap et alJ Am Heart Assoc 2018;7, 1‐8

Inotropic TherapyHYPOTENSION

HF Program inAcademic Hosp

Expert HF ProgramIn Community Hosp

37% of HFrEF patients dischargedOn lower doses or no beta blockers 

Reasons for Lower Doseor No ACEI/ARB

at Discharge

Gilstrap et alJ Am Heart Assoc 2018;7, 1‐8

28% not on at admission or discharge18% stopped or lower dose52% initiated or maintained2% changed from ACEI to ARB

HF Program inAcademic Hosp

Expert HF ProgramIn Community Hosp

47% of HFrEF discharged on lower dosesOr no ACEI/ARB inhibition

11/9/2018

8

Guideline Adherence and Readmissions

CONGESTED

CONGESTED

Better with ACEI/ARBTherapy or Patient?

Conception of the Changing Gap After Getting With the Guidelines

Propensity to Match or MismatchPatients and Therapies ? European J Heart Failure 2017;20: 355-358.

Good to goWith Guidelines

??? BeyondGuidelines

11/9/2018

9

Recommended Food for BirdsLooks like a bird,Flies like a bird,

But not every birdcan take the same food.