Heart failure is the leading cause of hospital admission in patients greater than 65 years, and the 30-day hospital readmission rates after a heart failure hospitalization was approximately 20% in the VA nationally and 34% at the Providence VA Medical Center (PVAMC) in 2009. The PVAMC instituted a pharmacist-led heart failure demonstration clinic for ambulatory follow-up of patients recently discharged with congestive heart failure (CHF) that was associated with the lowering of 30-day readmission rates to 22-23% at PVAMC in 2010-2011. Since a seamless transition of care from inpatient to outpatient services is crucial in preventing rehospitalization in patients with CHF, it is likely that the pharmacist-led interventions would be most effective if started as an inpatient.
Through partnership with hospital clinical leadership, we implemented a hospital-wide inpatient referral of patients admitted with CHF to a multidisciplinary CHF Transition of Care Program (CHF-TCP). The specific aims of this project were:
1)To compare the hospital-wide risk-adjusted 30-day rehospitalization rates for patients with a primary discharge diagnosis of CHF at PVAMC, from before (up to 1 year) vs. during the intervention period (9 months) of the CHF-TCP program;
2)To compare the patient's risk of 30-day rehospitalization after a CHF admission, before vs. after enrollment into the CHF-TCP program.
Commitment from organization leaders (Chiefs of Cardiology, Medicine and Primary Care) mandated all patients admitted with a presumed diagnosis of CHF to be referred as an inpatient to the CHF-TCP for the following interventions: a) Medication reconciliation and b) self-management education prior to discharge; c) Communication of discharge medication treatment plan to the patient's primary care team, and d) clinic visit for medication case management and reconciliation in CHF within 2 weeks post discharge. The main study outcome was the hospital's and the enrolled patient's 30-day rehospitalization rates after a CHF admission, for which risk-adjusted 30-day rehospitalization rates before (up to one-year) and during the implementation of CHF-TCP were compared. A formative evaluation was also performed to assess for fidelity and mechanistic pathways of the interventions through surveys and semi-structured interviews with patients and their personal physicians in both the inpatient and outpatient settings.
The intervention CHF-TCP started in the last week of March 2011. Since inception until February 29th, 2012, the team composed of two RNs and one Pharm D had recorded 82 inpatient encounters and 192 outpatient encounters during this time frame for a total of 67 unique patients.
To evaluate the impact of the CHF-TCP intervention on PVAMC-wide 30-day risk-adjusted rehospitalization rates for CHF, PTF dataset was used to identify patients with an admission or primary discharge diagnosis of CHF in the Providence VAMC.
A total of 167 patients who met criteria during March 1st 2010 to Feb 28th 2011 were used as our control group and 115 patients who met criteria during March 1st 2011 to January 31st, 2012 were our intervention group. Patients who died within 30 days of discharge were excluded from the analysis (20 patients in the control and 17 patients in the intervention groups), resulting in a final analytic sample of 147 patients for the control and 98 patients for the intervention groups. The crude 30-day rehospitalization rate for the control group was 25.9% and it was 26.5% for the intervention group. After adjustment for potential confounding by comorbidity burden and clustering by patients who were included in both the intervention and control groups, the adjusted odds ratio for 30-day rehospitalization was not signficantly different between the groups but trended in favor of the intervention (adjusted odds ratio 0.85, 95% CI 0.44 - 1.65).
Subgroup analysis excluding patients who were discharged to nursing home given systematic differences (15% for the intervention and 4% for the control groups), the adjusted odds ratio for 30-day rehospitalization was 0.78 (95% CI 0.38 - 1.60) for the intervention versus the control group.
Insufficient sample size is available for statistical testing in the comparison of the intervened patient's risk of 30-day rehospitalization after a CHF admission, before vs. after enrollment into the CHF-TCP program. Descriptive analyses showed that the unadjusted 30-day readmission rate for the 67 treated patients by CHF-TCP was 16/67 = 23.9%. Of these subjects, only 13 of them had a CHF hospitalization one year before intervention, which prohibited further meaningful comparison.
Although we were unable to show a statistically significant impact in our study outcomes due to limited sample size, this study displayed important trends on the potential positive impact of a transition of care program in CHF to reduce 30-day readmission rates. Our results also serve as pilot data for the design of studies with objective of broad implementation of CHF-TCP programs across VHA hospitals nationwide.
The current partnerships and collaborations with the hospital leadership and clinical managers to implement this intervention will guarantee its sustainability. Furthermore, the experience and process outcomes generated from this proposal provided evidence and insights about effective implementation of this quality improvement approach and generated a best practice model in CHF for VA-wide implementation.
External Links for this Project
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