Strategies to Reduce Heart Failure Readmissions

Chronic Heart Failure (CHF) is the most common discharge diagnosis within Medicare beneficiaries and the most renowned cause as far as hospital readmissions in the United States (U.S.) are concerned ( Feltner, et.al, 2014) . It is also fundamental to note that HF today represents one of the most expensive conditions and accounts for close to $39 billion annually considering healthcare expenses (Bradley et al., 2014a). This is a condition that is characterized by sporadic exacerbations that many at times require hospitalization that alternates within periods of medical stability. CHF care manages symptoms within the outpatient settings to prevent hospitalization given the fact that such episodes are expensive and connected with high mortality and morbidity (Arnold et al., 2013). Recent changes to healthcare reimbursement impose monetary fines in cases where patients with CHF are readmitted within a month considering that readmissions can be avoided ( Feltner, et.al, 2014) . Hospital readmissions can be avoided with an elevated adherence to diet and medication, enhanced social support alongside more significant access to the facilitation of medical care ( Bilchick et al., 2019). 

The most appropriate approaches to offer a better quality of care to CHF patients to avert hospitalization is not guaranteed; nonetheless, significant aspects for high-quality care can be identified and used to all CHF programs. Patients with CHF are today faced with managing a progressive and complex medical issue that makes the problem of hospital readmission challenging. With the high morbidity, costs, mortality, and penalties connected with CHF readmissions, providers of healthcare are today seeking efficient and reproducible interventions to reduce hospital readmissions (Bradley et al., 2014). Therefore it is fundamental to incorporate strategies that are aimed to reduce the readmission rate of CHF patients. This is essential because the degrees of mortality will be reduced on an industrial scale. Such approaches will save costs among many other things given the fact that readmission of patients is one of the most expensive medical condition in the healthcare industry today. 

About 5.8 million adults in America are today living with the condition of CHF. There are projections that the prevalence of the disease will go up from 46 percent by 2030 ( Bilchick et al., 2019). This will, therefore, mean that over 10 million people in the country will be diagnosed with a chronic condition. CHF represents one of the primary diagnoses for hospitalization with an approximated 1 million people discharged in 2017 ( Bilchick et al., 2019). The general cost of CHF for 2017 stood at $40 million (( Bilchick et al., 2019) . From 2015 to 2017, the median hazard-standardization 30-day readmission rate was recorded as 24.3 percent ( Bilchick et al., 2019). Readmissions get precise attention for scholars and researchers alike given the fact that they are considered a correctable source of the low quality of care. The people fear that the condition further leads to high expenses of care. It should be noted that the Affordable Care Act provided financial charges for excessive readmissions for medical facilities that today stands at 3 percent of a hospital’s payments ( Bilchick et al., 2019). 

In the past, there were no approaches to limit patients to get readmitted again and this considerably created a problem as far as costs were concerned. There should be programs tailored towards reducing CHF rates of readmission. Even though a 30-day CHF rate of readmission is an increasing emphasis for improving quality, inpatient involvements for precisely averting and decreasing readmissions are today not agreed upon. On the same note, the 30-day duration for readmissions is possibly an arbitrary time for observation. This duration can provide a multitude of external elements to the quality of inpatient care influences the risk of readmission (Howie-Esquivel et al., 2015). Nonetheless, the objective for health systems should work towards reducing all avoidable admissions whether directory hospitalization and repeat admission. This paper will, therefore, synthesize five sources on strategies to reduce heart failure readmissions. 

PICO Question 

In older patients with CHF directly discharged home from the hospital, does a precise discharge education results in reducing readmission within 30 days as compared to the patients with the hospital's standard discharge planning care? I came up with this question after critically assessing the results of a 30-day readmission pilot program I conducted on medical facilities within the region. 

Conceptual Model and Framework 

The theoretical model guiding evidence-based practice (EBP) project is the Ace Star Model. This will work towards discovering the strategies by searching for new knowledge. The model will use a rigorous systematic review procedure of many studies to formulate a statement of evidence, and this is considered unique to the process of EBP. This, therefore, means that the model will translate the strategies identified to ensure the readmission rates are concerned. After the procedure have been identified, they will be integrated into the healthcare practice to influence organizational and individual change programs. It is fundamental to note that the process will indicate the percentage of improvement for the outcome measure as far as strategies to reduce readmission of patients with chronic heart failure is concerned (Howie-Esquivel et al., 2015. Since this outcome is required to happen within 30 days, the Ace Star Model is necessary to produce considerable measures that will be translated into practical strategies to handle the issue of CHF readmission of patients. 

Method 

Systematic Search 

A detailed MEDPUB research to understand the strategies that have to be put in place to reduce patients with chronic heart failure being readmitted was conducted. The major search words, in this case, were chronic heart failure alongside readmissions. It is fundamental to understand that the search restricted to the source, meaning sources, not below five years of 2019. Studies were included if they touched on the topic of chronic failure and rates of readmissions mostly within the United States. Articles containing information on the standards of mortality attributed to chronic heart failure were also considered to provide a reference for the research. The documents were checked for effectiveness, and zero duplicates were found (Ziaeian & Fonarow, 2016). All the reviewed articles were therefore deemed eligible and were therefore used to provide information to complete the research on heart failure readmissions. 

Review of Evidence 

The article by Ruppar et al. (2016) addresses the medical adherence interventions that can be put in place to enhance mortality of heart failure alongside the rates of readmission. This systematic review calculated the readmission and mortality rates from the data collected. The two elements were amalgamated using random effects approach meta-assessments approaches, given the fact that diversions in true-between side impacts were anticipated from variation as far as study populations and interventions were concerned. In general, the study found out that medication adherence approaches significantly reduced the death rates among patients with CHF. Such interventions further diminish the odds for rates of hospital readmission. Also, the article found out that heterogeneity was significantly on the low since moderator assessment did not detect dissimilarities from familiar sources of possible study prejudice. It can, therefore, be indicated that this study has strength in its own right. The article uses indicative figures on the rates of death and readmission. It is fundamental to note that the authors of this piece incorporated the right forms of studies with an appropriate design of research, applied the standardized criterion to evaluate (Ruppar et al., 2016) . They further used heterogeneity testing to combine information for meta-analysis effectively. On the same note, the results of this article are presented precisely, forcefully expressed and therefore indicate a considerably secure and statistically significant connection between death rates and the relationship with chronic heart failure. The benefit of the intervention as shown in this study outweighed any harm. There are concerns regarding this research incorporate the involvement of solely high-income nations, therefore restricting generalizability to other regions . 

The article by Bilchick and colleagues that was published in 2019 contains information regarding enhancing heart failure outcomes and costs of readmission using the hospital-to-home intervention programs. It is fundamental to note that the authors of this article conducted a retrospective cohort research of the hospital-to-home (H2H) program. This is a rapid follow-up project for patients with recent HF rates of admission at the University of Virginia healthy System. The primary objective of this study was to ascertain whether the applied program had a considerable effect on HF-connected outcomes and measures. A month after the preliminary CHF hospitalization was lower as far as H2H programs are concerned (Bilchick et al., 2019). Besides, there was a decrease in the days of readmission within this time frame, and the rates of the same were discovered to be higher as compared to the staffing expenses within the healthcare institution. It can, therefore, be indicated that this article provides the considerably correct information as far as reducing heart failure readmissions in medical facilities is concerned. The authors of this piece substantiated the information using figures and statistics from sources considered reliable. Some of the sites the authors used to find information on chronic heart failure are the Center for Disease and Control (CDC) and the World Health Organization (WHO). Also, strength is the fact that the article incorporates the H2H program that scholars and other medical care experts have found useful and have using for years to solve problems of this nature (Bilchick et al., 2019). This is a level 3 paper. 

The third article is that of Bradley et al. (2014). This scholarly piece is prospective study evaluates the hospital strategies to uptake and reduce unplanned rates of readmission for patients suffering from heart failure problems. The authors, in this case, to assess critically the connections between the changes in hospital 30-day program for patients with strategies ranging from 12 to 18 months by using a national sample of hospitals. It conducted a study of medical facilities by use of a web-based survey between November 2010 and May 2011. The last analytic sample, in this case, incorporated 478 hospitals (Bradley et al., 2014b). The authors also used the H2H program that was explained earlier in this article. The article discovered that medical facilities that used the approach of often discharging their patients with a follow-up assessment recorded impressive figures of decreases ion the rates of readmission. A strength of this article is that it addresses a precise question while using a specific population, intervention, and outcome. The authors, in this case, included the correct types of research with practical study design and used a standardized criterion for evaluation. All relevant investigations about the incident were involved by locating databases, reaching out to medical experts and professionals alongside critically reviewing the references and source materials. Results were precise and effectively presented (Bradley et al., 2014b). Nonetheless, the article did not a chance for further research even though the topic of chronic heart failure is considerably broad and requires more information. Further, the report did not offer suggestions on what should be done for future scholars delving into this subject. This is a level 3 paper. 

In their article, Feltner et al. (2014) also researched readmission rates for patients with chronic heart failure. They conducted a systematic review and meta-analysis on the transnational care interventions and approaches that should be put in place to prevent readmissions for people troubled with issues of heart failure. The primary purpose of this research was to examine the efficacy, comparative effectiveness alongside harms of transnational care approaches for HF patients. Understudy selection, the authors selected randomized controlled trials within six months. It is worth noting that a single reviewer extracted the information while another checked accuracy. On the same note, two reviewers evaluated bias risk and graded strength of proof. One of the limitations identified in this study is that limited trials reported a 30-day rate of readmission (Feltner et al., 2014). 

Similarly, usual care was heterogeneous and a few times not adequately described. The authors concluded that home visiting programs reduced all-cause mortality alongside readmission. Such interventions should. Therefore, Strengths of this piece incorporate addressing a focused research question that emphasizes on a precise population and consequently produced the required outcomes. Similarly, exposure as far as the topic is concerned was effectively computed, and the result of death rates and readmission to the hospital was effectively provided. A more significant part of the essential confounding elements and aspects were included and critically explained (Feltner et al., 2014) A case in point is that this article utilized facts and figures from government sources. For instance, health statics reports provided fundamental statics that ensured completion of this piece. However, some of the details the authors provided are difficult to comprehend for individuals outside the medical field. Starting students and healthcare practitioners rank this piece highly. This is a level 1 paper. 

The fifth article assesses the impact of nurse post-discharge telephone calls on 30-day rates of readmission in the hospital. This piece by Harrison and others was published in 2014. The authors provide information regarding several care transition interventions and propose that post-discharge phone calls are effective in reducing adverse events while additionally decreasing costs of returning to the medical facilities. It should be noted that the actual connection between post-discharge telephone calls and the rates of readmission in the contemporary world is not specified (Harrison et al., 2014). The situation is mainly because of the multi-faceted nature of a majority of care transition interventions. It should be noted that the key objective of this article was to understand the impact of attaining a post-discharge telephone call on monthly readmission and within the population. 

The approach used to make this successful is prospective observational research. The participants were sick people discharged home from a medical facility between November and May. The authors used logistic regression-aligned clinical and patient covariates alongside propensity scores to represent the possibility of being called to ascertain the connection that exists between risk for readmission and receiving calls. It was discovered that patients who received invitations and completed the intervention provided little likelihood to be readmitted as compared to those that did not (Harrison et al., 2014). A significant strength as far as this article is concerned is that it offers comprehensive information regarding how phone calls by medical practitioners and patients. On the same note, the report provided clear outcomes and measures to be used to attain the stated results. This is despite the fact the authors did not offer recommendations and suggestions on different methods that can also be incorporated in case of the patients living in remote areas and without access to phone communication (Harrison et al., 2014). 

Synthesis 

Feltner et al. (2014) utilized a predefined criterion that is founded on the topic. This study nonetheless cannot be rated as having a bias since information provided aligns with the research. This is even though a more significant part of the involved trials contains methodological constrictions projecting some risk of bias. It should be noted that some of the tests did not adequately describe approaches applied while assessing rates of readmission and models for handling missing information varied. In connection to this Harrison et al. (2014) studied a large population and did not consider language, the ability to respond to phone calls, insurance alongside socioeconomic status. Nonetheless, this is a retrospective observational study and therefore can only illustrate connections between readmissions and post-discharge phone calls. In their article, Ruppar et al. (2016) scored well since they identified the scope of their study. They minimized bias by applying numerous analyses. Trained research was independently coded in different databases. But, intervention descriptions varied considerably in detail. The study had many interventions to improve the condition. Information regarding dose was poorly indicated in all the cases. 

Bradley et al. (2014) provided a sample from national-wide medical institutions to provide a full illustration of the baseline traits as far as the participants were concerned. It should also be noted that many participants in this study responded. But the hospital sample is attained from a sample group that took part in initiatives aimed at reducing readmissions, which essentially means that outcomes in other medical facilities might be different. This could, therefore, lead to bias on the most appropriate strategies to mitigate the rates of readmission of patients with heart failure. Finally, Bilchick et al. (2019) effectively emphasized on data analysis in the form of costs, demographics and comorbid situations were also attained from a vast database that is considered accurate and valid. Baseline traits in this research were considerably similar. But, the study did not conduct the intention to treat. This means that the H2H program who failed to show up ensured that the researchers found difficulties in this case. Finally, some patients might have been admitted to other medical facilities within the region. 

Co nclusions 

This paper, therefore, synthesized five sources on approaches to reduce heart failure readmissions. The research provides valuable information on the topic alongside suggesting ways that can be used to reduce the problem that for many years has been affecting the American economy. It is fundamental to note that there are high costs connected with this problem. Some of the strategies this paper suggests that should be put in place to handle the problem are the 30-day rate of readmission program and involving pharmacists in the process. A synthesis of the five sources revealed that the problem heart failure readmission is on the decline in the United States is this attributed to the fines and penalties that were put in place by the government. Medical facilities in lower socioeconomic regions are disadvantaged and therefore at higher risk of being fined by the government. 

Recommendations 

Various medical treatments are known to enhance outcomes alongside reducing the danger of readmissions patients with CHF. Such therapies are often not effectively utilized in select patients. Approaches that offer support discharge, improved communication alongside new and close outpatient follow-up are connected with lower risks of readmissions. The 30-day rate of readmission is a valuable quality metric as far as inpatient care for HF patients is concerned (Harrison et al., 2014). Health system approaches to enhance patient outcomes while further reducing the burden of hospitalization for CHF necessitate further research. It is fundamental to note the four significant elements within this concept can offer a ground to a new study of the situation. A CHF disease management strategy that incorporates education and teaching necessitates follow-up, appointments, and consultation services alongside follow-up calls can be appropriate. 

Such a system might work towards reducing the rates of readmission. The same will assist launch further studies to offer a possible solution to the issue in hospital readmissions (Harrison et al., 2014). On the same note, to reduce readmissions, there is the reason for the early detection of patients with HF. Medical practitioners should be involved quickly to allow for faster determinations of patients with CHF. It is worth noting that specialist involvement further speeds up the development of care plans. Before being discharged from the hospital, a follow-up appointment must be established with a provider with the support of a pharmacist. Other strategies that can work in this case are optimization and use of evidence-based drugs alongside therapies, handling HF causes, treating comorbidities together with enhancing management of care (Harrison et al., 2014). 

References 

Arnold, S., Bailey, H., Bates, G., Bell, V., Brumbelow, R., Chunn, M., ... & Duke, J. (2013). 

Improvement Strategies to Reduce 30-Day Heart Failure Readmissions.  Heart & Lung: 

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Bilchick, K., Moss, T., Welch, T., Levy, W., Stukenborg, G., Lawlor, B. T., … Mazimba, S. (2019). Improving Heart Failure Readmission Costs and Outcomes With a Hospital-to-Home Readmission Intervention Program. American Journal of Medical Quality , 34(2), 127–135. https://doi.org/10.1177/1062860618788436 

Bradley, E. H., Sipsma, H., Horwitz, L. I., Ndumele, C. D., Brewster, A. L., Curry, L. A., & Krumholz, H. M. (2014a). Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study. Journal of general internal medicine, 30(5), 605–611. https://doi:10.1007/s11606-014-3105-5 

Bradley, E. H., Curry, L. A., & Krumholz, H. M. (2014b). Strategies to reduce heart failure readmissions.  JAMA ,  311 (11), 1160-1160. Retrieved https://www.researchgate.net/publication/260916388_Strategies_to_Reduce_Heart_Failure_Readmissions 

Butler, J., & Kalogeropoulos, A. (2012). Hospital strategies to reduce heart failure readmissions: where is the evidence?. Journal of the American College of Cardiology . Volume 60, Issue 7, August 2012 DOI:  10.1016/j.jacc.2012.03.066 

Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z.-J., Sueta, C. A., Coker-Schwimmer, E. J. L., … Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.  Annals Of Internal Medicine , 160(11), 774–784. https://doi-org.proxy.library.nyu.edu/10.7326/M14-0083 

Harrison, J. D., Auerbach, A. D., Quinn, K., Kynoch, E., & Mourad, M. (2014). Assessing the impact of nurse post-discharge telephone calls on 30-day hospital readmission rates. Journal Of General Internal Medicine, 29(11), 1519–1525. https://doi-org.proxy.library.nyu.edu/10.1007/s11606-014-2954-2 

Howie-Esquivel, J., Carroll, M., Brinker, E., Kao, H., Pantilat, S., Rago, K. and De Marco, T., 2015. A strategy to reduce heart failure readmissions and inpatient costs.  Cardiology research ,  6 (1), p.201. Retrieved https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5295554/ 

Ruppar, T. M., Cooper, P. S., Mehr, D. R., Delgado, J. M., & Dunbar-Jacob, J. M. (2016). Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials.  Journal of The American Heart Association , 5(6). https://doi-org.proxy.library.nyu.edu/10.1161/JAHA.115.002606 

Ziaeian, B., & Fonarow, G. C. (2016). The prevention of hospital readmissions in heart failure.  Progress in cardiovascular diseases ,  58 (4), 379-385. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783289/