Is Inadequate Follow Up Related to Early Hospital Readmissions In Patients with CHF ?

Mudasir Chisti PGYIII

Aravind Herle MD

Rationale & Background

Heart Failure is the most common Medicare diagnosis related group .

Patients with CHF are frequently readmitted to the hospital following exacerbation of their symptoms.

The 3-6 month readmission rates have been reported to be as high as 30-50%.

Rationale & Background

One-fifth of Medicare beneficiaries are rehospitalized within 30 days.

Nearly 90% of these readmissions are unplanned and potentially preventable.

Translates into $17 billion or nearly 20% of Medicare’s hospital payments.

Medicare contemplates profiling hospitals based on readmision rates with complimentary changes in payment rates.

Hospitals with high risk-adjusted rates of rehospitalization to receive lower average per case payments.

Identifying factors associated with readmissions is therefore important.

Studies suggest that care coordination is important in preventing readmissions.

Early physician follow up post discharge may have potential to reduce readmissions.

Data on follow up patterns following hospitalisation for CHF & its relationship to readmissions is limited.

STUDY:

Primary Objective: To determine if lack of early Follow Up is

associated with 30 Day Readmissions in CHF patients.

Secondary Objectives: To determine readmission rates for CHF.To identify other risk factors for 30 day

readmissions.

Study Design:Case Control Study based on

Retrospective Chart review.Single centre based in SBMH.Proper IRB approval obtained for chart

review and phone survey5 month period Nov 2010 through March

2011.

Inclusion Criteria :Primary discharge diagnosis of CHF

exacerbation on index admission.Cases: CHF patients readmitted within 30

days of discharge for all causes Controls: CHF patients not readmitted

within 30 days of discharge.Early Follow Up defined as F/U occuring

<=7 days following discharge from the hospital.

Exclusion criteria:Death during or following index

admissionDischarge to hospice after index

admissionMissing clinical data Lack of follow up data

Total Charts Reviewed =255 CHF charts= 226 Non CHF charts =29CHF Charts Excluded: 21 (met exclusion

criteria) Hospice =15 Expired =2 AMA= 1 Missing data =3 CHF charts included =205

CHF Charts analysed=20530 day Readmissions/Cases= 52No 30 day Readmission/Controls=15330 day Readmission Rate=52/226 or 23%Clinical data was available and compared

for 205 patientsFollow up data was available and

compared for 180 patients including patients discharged to Rehab

Analysis of Clinical Data

Variables comparedDemogaphic: Age,race & sex.Heart Failure Variables: LVEF, prior CHF ,LOSTreatment Variables: Cardiology

consultation ,Meds at discharge ComorbiditiesLab variables: BNP,Na,K,BUN,CrDischarge Planning Variables : CHF Teaching, DC

instructions, Instructions on follow up, appointment scheduled before discharge or not.

Disposition : Discharge to Rehab/NH or home.

Variables compared using Fischer’s Exact test

Significance defined as p-value< 0.05

Demographic Variables

Group30 Day Readmits N=52

No30 Day Readmission N= 153 95% C.I P Value Result

Mean Age 80.08 77.8-1.22 to 5.78 0.2009Not sig

Sex M 26 F 26 M=68 F=85 0.5219Not sig

Race W 50 B 2 W=151 B=2 0.2669 Not sig

Afib Yes/No Y=26 N=26 Y=99 N=54 0.071Not sig

LVEF <40 Y=26 N=26 Y=55 N=92 NA=6 0.1395Not sig

Prior CHF Y=44 N=8 Y=117 N=36 0.2463Not sig

Mean LOS 5.54 5.46

-1.19 to 1.34 0.9075Not sig

Cardiology consult Y=49 N=3 Y=141 N=12 0.7649Not sig

Group30 Day Readmits N=52

No30 Day Readmission N=153 OR 95% C.I P Value Result

Meds on Discharge 12.66 11.44

0.01 to 2.43 0.0476Sig

Diuretics Y=46 N=6 Y=145 N=8 0.1984Not sig

Beta blocker Y=46 N=6 Y=134 N=19 1Not sig

ACE/ARBY=21 (40.38%)

N=31 (59.62%)

Y=99 (64.7%)

N=54 (35.3%) 0.0032Very sig

Spirinolactone Y=5 N=47 Y=22 N=131 0.4806Not sig

Statins Y=31 N=21 Y=89 N=64 0.8723Not sig

Digoxin Y=13 N=39 Y=42 N=111 0.8566Not sig

Group

30 Day Readmits N=52

No30 Day Readmission N=153 95% C.I P Value Result

CAD Y=33 N=19 Y=99 N=54 0.8685Not sig

Chronic Lung disease Y=20 N=32 Y=69 N=84 0.4232Not sig

HTN Y=50 N=2 Y=143 N=10 0.7342Not sig

Diabetes Mellitus Y=25 N=27 Y=72 N=81 1Not sig

CKD Y=36 (69.23%) N=16 esrd=4

Y=57 (37.25%) N=96 esrd=5 0.0001Ext sig

Stroke/TIA Y=11 N=41 Y=18 N=135 0.1084Not sig

Dementia Y=9 N=43 Y=10 N=143 0.0279Sig

Group 30 Day ReadmitsNo30 Day Readmission 95% C.I P Value Result

BNP Mean 1183.92 893.7218.94 to 561.47 0.0361Sig

Na on admission 137.4 136.76

-0.74 to 2.03 0.3582Not sig

K on admission 4.502 4.293

0.007 to 0.410 0.0431Sig

BUN on admission 34.44 26.82

1.91 to 13.34 0.0092Very Sig

Cr at admission 2.058 1.432

0.227 to 1.024 0.0022Very Sig

Group30 Day Readmits N=52

No30 Day Readmission N=153 95% C.I P Value Result

CHF teaching Y/N Y=47 N=5 Y=127 N=26 0.2641Not sig

Current Smoker Y/N Y=3 N=49 Y=18 N=135 0.2938Not sig

Alcohol Yes/no Y=2 N=50 Y=9 N=144 0.7329Not sig

Rehab/SNF/NH Y/N

Y=22 (42.3%) N=30

Y=28 (18.3%) N=125 0.0012Very Sig

Home w/wo services Y=30 Y=125

Follow up scheduled Y=7 N=45 Y=13 N=140 0.2908Not sig

Instructions Follow up Y=50 N=2 Y=145 N=8 1Not sig

CommentsStatistically significant differences were noted in the

clinical variables between the two groups including :

Greater percentage of readmitted patients had CKD -69.23 % compared to 37.25% among patients not readmitted .

Lesser percentage of readmitted patients had been discharged on ACE/ARB -40.38% compared 64.7% among those not readmitted .

Greater percentage of readmitted patients had been discharged to Rehab upon index admission -42.3% vs 18.3%

Reasons for Readmission:Reasons Total Readmissions

N=52

Cardiac : 31 59.61%

Recurrent CHF 20

38.46%

Hypotension 2

Chest Pain 4

Tachyarrythmia 2

Bradycardia 3

Infections: 10 19.23 %

Infections not PNA 6

PNA 4

Others: 11 21.15%

Renal failure 5 9.6%

AMS 2

Fall 1

CVA 1

Bleeding Complication 1

Resp Failure/OSA 1

Follow Up Data Analysis:Data obatined via phone surveyAvailable on 180 patients : 130 as outpatient physician follow up 50 Reahab/NH patients – follow up

counted as occuring within 1 week of discharge from hospital.

Analysis done both including as well as excluding data on Rahab/NH patients.

Follow Up Data Excluding Rehab Patients N=130

OP F/U Interval 30 Day Readmits N=30 No Readmission N=100

Mean 11 14.5

<=7 Days 7 29

8-14 Days 15 45

15-21 Days 1 9

>21 days 2 17

No F/U before Readmission

5

Follow Up Data Excluding Rehab Patients

OP Follow Up Interval

30 Day Readmits N=30

No Readmission N=100 OR

Readmission Rate p value Result

Mean 11 14.5 0.2102Not sig

<=7 days 7 29 0.745 19.40% 0.6454Not sig

>7 days 23 71 24.47% 0.6454Not sig

8-14 days 15 45 25% 0.6795Not sig

<=14 days 22 74 23% 1Not sig

>14 days 8 26 23.52%

F/U Interval >7 d was associated with higher Readmision Rate 24.47% vs 19.4% but the difference was not statistically significant.

F/U interval 8-14 days had highest readmission rates 25% but again not statistically significant.

Follow Up Data Including Rehab Patients N=180

OP F/U Interval 30 Day Readmits N=52 No Readmission N=128

<=7 Days 29 57

8-14 Days 15 45

15-21 Days 1 9

>21 days 2 17

No F/U before Readmission

5

Follow Up Data Including Rehab Patients N=180OP Follow Up Interval

30 Day Readmits N=52

No Readmission N=128 OR

Readmission Rate p value Result

Mean 11 14.5 0.2102Not sig

<=7 days 29 57 1.57 33.72% 0.1904Not sig

>7 days 23 71 24.47% 0.1904Not sig

8-14 days 15 45 25% 0.4869Not sig

<=14 days 44 102 30.13% 0.5318Not sig

>14 days 8 26 23.52%

CommentsF/U Interval <7d was associated with

higher Readmission Rates 33.72% vs 24.47% when Rehab/NH patients were included,but it was not statistically significant.

ConclusionsRecurrent CHF is a major reason for early

readmissions.

Among patients discharged home , lack of F/U within 7 days was not significantly associated with readmissions in our study population.

Study identifies high risk groups particularly patients requiring Rehab upon discharge. Further studies need focus on this group to elucidate this relationship and explore interventions that may reduces such readmissions.

Statistically significant association also between presence of CKD , lack of ACE/ARB upon discharge from hospital .

Improving adherence to ACE/ARB may prove helpful.

LimitationsRetrospective study design.Single centre.Relatively smaller sample size for follow

up data.Potential Recall Bias in follow up data.Confounders

Questions?