Reduce readmissions with education, follow-up and advanced therapies
Approximately 5.1 million Americans are affected by heart failure, and 2.5 million of these patients are women.1
Women are typically older when heart failure develops, and the cause is most often linked to hypertension, diabetes, valvular disease or coronary artery disease; it is less likely to be from a previous heart attack.2
For women older than 65, heart failure is the leading reason for hospitalization.3 The good news is that, in general, women with heart failure survive longer than men.2
Of the more than 1 million people who are hospitalized with heart failure each year, 250,000 are readmitted within 30 days of discharge.4 While it’s easy to maintain control in the confines of the hospital, when at home, some patients don’t make the best choices.
One of the patients treated in our heart failure setting, a 43-year-old woman with viral cardiomyopathy and an ejection fraction of 14%, presented to clinic for her consult with four-pillow orthopnea, shortness of breath at rest, and markedly swollen legs. When asked about her dietary habits, she reported eating a jar of pepperoncinis daily and drinking the fluid from the jar! She thought this was a healthy snack. She was more than 20 pounds fluid overloaded and was admitted to the hospital.
Repeated admissions exert a great financial burden on the healthcare system, making effective management at home a top priority for healthcare providers. The admission of 1 million patients annually accounts for more than $17 billion in Medicare expenditures.5
Heart failure is expensive to treat, and multiple co-morbidities make it difficult to treat as well. Research shows repeat exacerbations contribute to disease progression.2 Effective management in the outpatient setting is fast becoming a top priority to prevent readmissions and improve quality of life for patients.
Healthcare professionals are in a prime position to help identify barriers to care that may increase readmission risk. Ensuring each patient is discharged from the hospital with a follow-up appointment in place, thoroughly reviewing medications to make sure any changes to the regimen are understood, and assessing the patient’s ability to pay for necessary medications can greatly reduce readmission risk.
Some hospitals have nurse navigator programs in which a nurse practitioner or nurse makes a home visit within a week of discharge, then follows up with the patient by phone over the next 3 weeks. Utilization of home health services and nurse navigators places more “eyes” on the patient and provides another point of contact for the patient to help recognize early symptoms of exacerbation.
All of this helps ensure early intervention should problems arise. Providing education about community resources, reportable signs and symptoms, medication effects and precautions, and caregiver support is another way to help keep patients out of the hospital.
Advances in Therapy
In the area of treatment for heart failure, a new advancement is cardiac resynchronization therapy (CRT). Certain types of pacemakers have an extra lead that delivers electrical impulses to the myocardium to synchronize ventricle activity. These devices can improve the symptoms of heart failure, help patients live longer, and improve quality of life.1-7
CRT is indicated for patients who meet New York Heart Association (NYHA) criteria class III or IV and have an ejection fraction of 35% or less and a QRS interval of greater than 120 milliseconds. CRT therapy is also indicated for patients who meet NYHA class II criteria and have an ejection fraction of 30% or less, left bundle branch block, and a QRS interval of more than 130 milliseconds. The third type of patient who is an appropriate candidate for CRT meets NYHA class I through III criteria with an ejection fraction of 50% or less and atrioventricular block.
Clinical studies have demonstrated that CRT therapy reduces mortality and heart failure admissions.6 However, even though CRT therapy is indicated for a wide range of patients, 60% of eligible patients are not receiving CRT devices.7
AdaptivCRT is a technology application for resynchronization therapy. It allows treating providers to customize therapy for each patient. AdaptivCRT is a dynamic pacing algorithm that adapts to the patient’s physiologic needs during activity and monitors conduction status, enhancing response to synchronization by providing pacing when needed, improving response rate and clinical outcomes.8 A recent study showed AdaptivCRT reduced a patient’s odds of being readmitted to a hospital by nearly 60% when compared to echocardiogram-optimized CRT.9
In our heart failure practice, we see patients improve and have better outcomes after CRT therapy. Better cardiac output can increase renal perfusion, making diuretics more effective and reducing water weight.10 Fatigue and shortness of breath have improved, as well as ability to exercise and overall quality of life.
Become an Advocate
Nurses are in a unique position to advocate for patients, improve outcomes, and reduce readmissions. By keeping up-to-date on the latest research and attending conferences, nurses can keep abreast of the latest innovations and therapies for heart failure.
Patients often turn to nurses for questions or clarification about the treatment plan. A knowledgeable provider inspires confidence and trust.
It is also important that nurses encourage women with heart failure not to downplay any symptoms they may be experiencing; this often happens when the patient is a caregiver to her spouse or other family member. Helping the patient identify resources may allay her anxiety and facilitate her receiving the care she needs.
Given today’s command to rely on evidence-based practice, there is no excuse for disparities in healthcare, such as that between the number of patients who qualify for CRT therapy and those who receive it. If this intervention were more widely used, many more patients could have the opportunity to reduce symptoms, have fewer readmissions and achieve better overall outcomes.
Don’t let your patient be one of the 60%. Encourage women to participate in research. Nurses can educate patients about options and the latest advancements that may benefit them.
1. Go AS, et al. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245.
2. Jain P, et al. Current medical treatment for the exacerbation of chronic heart failure resulting in hospitalization. Am Heart J. 2003;145(Suppl 2):S3-S17.
3. Heart Failure in Women. https://my.clevelandclinic.org/services/heart/disorders/heart-failure-what-is/heart-failure-women
4. Six steps could cut heart failure readmission. http://newsroom.heart.org/news/six-steps-could-cut-heart-failure-readmissions
5 Rosamond W, et al. Heart disease and stroke statistics-2008 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25-e146.
6. Cleland JG, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.
7. Fonarow GC, et al. Heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Circ Heart Fail. 2008;1(2):98-106.
8. Martin DO, et al. Investigation of a novel algorithm for synchronized left-ventricular pacing and ambulatory optimization of cardiac resynchronization therapy. Heart Rhythm. 2012;9(11):1807-1814.
9. Starling RC, et al. Impact of a novel adaptive optimization algorithm on 30-day readmissions: evidence from the adaptive CRT trial. JACC Heart Fail. 2015;3(7):565-572.
10. Boerrigter G, et al. Cardiac resynchronization therapy improves renal function in human heart failure with reduced glomerular filtration rate. J Card Fail. 2008;14(7):539-546.