Factors Affecting Heart Failure Readmission Rates in VA Patients

If readmitted within the study period, data collection included the date of first nonelective hospital readmission for HF, BP, heart rate, weight, serum digoxin level, serum creatinine, serum potassium, and whether the patient was on a target dose of HF recommended medications (if LVEF < 40% and no contraindication). Heart failure recommended medications for which target doses are established include ACE-I/ARB and ß-blockers. For this study, target doses of ACE-Is were captopril 50 mg 3 times daily, enalapril 10 mg twice daily, fosinopril 40 mg daily, lisinopril 20 mg daily, ramipril 10 mg daily, and trandolapril 4 mg daily. Target doses for ARBs were candesartan 32 mg daily, losartan 50 mg daily, and valsartan 160 mg twice daily. ß-blocker target doses were bisoprolol 10 mg daily, carvedilol 25 mg twice daily (50 mg twice daily if patients’ weight was > 85 kg), and metoprolol succinate 200 mg daily.^5,6 A statistical analysis was not performed on the data.

RESULTS

A total of 137 patient charts were reviewed, and 109 patients were included in the study. Patients were excluded if they transferred to or from an outside hospital (n = 8), had no follow-up at JBVAMC (n = 8), left the hospital against medical advice (n = 4), were electively admitted (n = 4), were not treated for HF (n = 3), or only had comfort measures documented in the chart (n = 1). The patients included were predominantly male (99%) and African American (78%) and had a mean age of 70 years. The majority of the patients had a prior diagnosis of HF (87%) and a history of systolic HF (58%). Most patients were previously prescribed an ACE-I/ARB (83%) and a ß-blocker (76%) at the time of admission (Table 1).

Six patients were readmitted within 30 days of the index hospitalization, whereas 103 patients were readmitted after 30 days or not at all. With respect to secondary endpoints, there were 21 patients readmitted within 90 days of the index hospitalization, whereas 88 patients were readmitted after 90 days or not at all. Additionally, 6 patients were readmitted ≥ 2 times within 6 months of the index hospitalization, whereas 103 patients were readmitted < 2 times within 6 months.

Baseline characteristics seemed similar across the study groups, except a greater percentage of patients readmitted within 30 days of the index HF hospitalization had a prior history of systolic HF and were hospitalized for HF 30 days prior to the index hospitalization (Table 2). In addition, patients readmitted within 30 days tended to receive a shorter duration of oral diuretic therapy after discontinuation of IV diuretics (mean 0.2 days vs 1.1 days). Patients in this group with an LVEF < 40% were less likely to be discharged on an ACE-I/ARB (75% vs 95%) and a ß-blocker (50% vs 85%) than were the patients who were readmitted after 30 days or not at all. These trends continued for patients readmitted within 90 days of the index hospitalization and for those readmitted after 90 days or not at all. The mean length of stay for the index HF hospitalization was about 5 days and was comparable among all study groups.

From the evaluation of postdischarge characteristics, no patients readmitted within 30 days had a follow-up appointment scheduled with the CHF clinic. In comparison with patients readmitted after 30 days or not at all, more patients had follow-up at an urgent care clinic (33% vs 6%) or no follow-up appointment scheduled at the time of discharge (17% vs 2%). Half of all the patients with a scheduled follow-up missed their appointment. Additionally, medication adherence was lower (33% vs 80%), and none of the patients were enrolled in the CHF-PharmD clinic (0% vs 5%). A similar trend continued for the secondary endpoint groups (Table 3). Last, none of the study patients had an outpatient dietitian consultation.

On readmission, the majority of patients readmitted within 30 days were not on a target dose of an ACE-I/ARB (75%), and none were on a target dose of a ß-blocker. The same trend continued for the secondary endpoint groups. None of the study patients had a serum digoxin level > 0.9 ng/mL. However, serum digoxin level was not measured in all readmitted patients prescribed digoxin (Table 4).

In regard to other secondary endpoints, 6 patients (5.5%) were readmitted for HF within 30 days of the index HF hospitalization. The average number of readmissions per patient in 6 months was < 1, mean time to readmission was 85 days (n = 33), and mean time to death was 88 days (n = 5) when applicable.