Does Palliative Care consultationreduce 30-day readmission Rates in

patients with Heart Failure?

Andi Chatburn, DO, MAPalliative Care Fellow Grand Rounds

June 24, 2014

No Disclosures

Acknowledgements

• Dr. Lori Olson• Dr. Deon Hayley• Heart Failure Nurse Specialists:–Christy Russell–Audra McDonald– Tammy Brown

Abbreviations

• KUMC = The University of Kansas Medical Center

• PC = Palliative Care• HF = Heart Failure• CV = Cardiovascular• GOC = Goals of Care

Objectives

• Review: – Guidelines used in advanced heart failure

• Discover and describe:– 30-day readmission rates of patients admitted

with Heart Failure at KUMC after Palliative Consult– Characteristics of these patients

WHY? relevance

• CMS: “Readmission after hospitalization is a costly and often preventable event”–Reports 30 day readmit for:• HF, Pneumonia, Acute MI• Seen as a marker of quality• 2003-2004: 20% of Medicare beneficiaries

(2.3 million patients) readmitted within 30 days of hospital discharge

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf Page 7. Accessed 6/11/14

Cost of care

• Jenks: Estimate these cost Medicare $17 billion annually

• Commonwealth: Estimate reducing readmit rates to levels comparable to top performing institutions would save CMS $1.9 billion annually

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf Page 7. Accessed 6/11/14

World bank: 1.351 billion people in China as of 2012

$1,900,000,000 = 1.9 x109

Photo by Greg Barber, Shanghai New Year

Why? effect Local practice

Baseline measurement of HF consult behaviors and demographics, prior to embedding into HF Clinic

Future: Create a trigger for when to consult Palliative Care in patients with Heart Failure

Why?

• Current Hospice Guide: NHPCO 1996 guidelines:– Symptoms of HF at Rest (Class IV)–Optimal Medical Management• BB/ACE/ARB/Diuretic

–EF <20%• Other factors predict morbidity in HF:– READMISSION – Stage D

Stage D

• “Patients with truly refractory HF who might be eligible for specialized, advanced treatment strategies”– Mechanical circulatory support– Procedures to facilitate fluid removal– Continuous inotropic infusions– Cardiac transplantation– Or for End-of-life care, such as hospice– *ICDs are NOT warranted in patients with Stage D HF

ACCF/AHA Practice Guideline. “2009 Focused Update Incorporated iInto the ACC/AHA 2005 guidelines for the Diagnosis and Management of HF in Adults” Circulation March 26, 2009. epub. http://circ.ahajournals.org/content/early/2009/03/26/CIRCULATIONAHA.109.192065

Prognostication in Heart Failure

• Two schools of thought:• HF disease trajectory is unpredictable

• Patients don’t perceive HF as terminal• Patients referred to hospice too late

• HF disease trajectory is predictable• Goals of Care can be discussed in light of typical

HF trajectory

Heart Failure Disease Trajectory

• 20.5% unexpected death• 13.3% steady decline, starting 12 months prior

to actual death.• 29.9% decline starting 6 months prior• 36.3% decline starting 3 months prior

Khierbek, et al. “Trajectory of Illness for Patients with CHF” JPM, 2013 May;16(5):478-84 .

Benefits of PC consultation

• Objective Prognosticator

• Verbalize values + Discuss goals of care

• Consultant matches goals to prognosis • Recommend level of support and setting of

care that fits patient

“Communication to define goals of care for the individual patient and then to design therapy concordant with these

goals is fundamental to patient-centered care.”

Whellan, Goodlin et al. “EOL Care in patients with Heart Failure.” Journal of Cardiac Failure, Feb 2014, Vol. 20, p 121-134.

Hypothesis

• Palliative Care Consultation should

30-day Readmission Rates for patients admitted with Heart

Failure

Benefits of reduced 30-day readmission Rates

–Decrease Side Effects of frequent Re-hospitalization:

• Increased risk of infection• Increased risk of medical bankruptcy• Opportunity cost: time/events

Inclusion Criteria

• Patients admitted to KUMC• Who had a Palliative Care Consult• With Diagnosis of Heart Failure• AND: Had HF exacerbation during same

admission as consult • OR: Had HF exacerbation within 30 days prior

to consult admission

methods

• Database: 1110 Inpatient PC Consults in 2013

• 85 patients with Potential Cardiac Diagnosis

Retrospective Chart Review

• Excluded 15 patients with CV/Pulmonary disease but did not have Heart Failure

• N = 64 HF patients with PC Consults

Database

• Age• Gender• Diagnosis System• Admit Date• Consult Date• Disposition on Discharge

Chart Review

• Date of Discharge• Date of Death VS. HF Clinic Follow Up • Discharge Location and Support Plan • Enrolled in HF RN tracking system?• Goals of Care• Prior 30 day Re-Admission and Dates• Future 30 day Re-Admission and Dates• Admission Diagnosis

2013 Palliative Care consults

Non- Heart Failure Consults

Consults with Heart Failure

5.4%

Exclusion Criteria

•64 Palliative Care consults- patients with HF diagnosis

• Total of 11 patients excluded

• Total Study patients: 53

Excluded patients

–5: re-consult on same patient–2: unknown prior 30 day admit hx• transfer from OSH

–1: unknown post-hospital readmits• Lost to Follow Up

–3: Both Transfer from Outside Hospital and Lost to Follow-up

Demographics

• Age Range 35 to > 85• Average Age: 75.9 years old• Median Age: 76 years old• 10 Patients >85 “Oldest old”• 28 Male• 25 Female

<40 40-49 50-59 60-69 70-79 80-84 >85

1 12

9

20

10 10

Number of Patients Per Decade

Non-Cardiac Multimorbidity

• 4: Renal• 4: Cancer• 3: COPD• 3: Neuro• 3: Infectious Disease (Sepsis)• 2: GI

32%

68%

53 study patients with Heart Failure and Palliative Care Consult

Prior 30 day readmission

No prior 30-day readmission

Prior 30 day readmits

• 17 patients had <30 day readmits prior to consult admission

–5 of the 17 went on to have future <30 day readmissions

•2 are still alive at time of chart review

•3 died

Where are they now?

–5 of the 17 went on to have future <30 day readmissions:

– 2 Alive• 1: At home, refused services• 1: Nursing Home (LTC)

– 3 Died• 1 : home on home hospice• 1 : inpatient hospice• 1 : discharged to SNF, died in Nursing Home

No 30-D Readmit after PC Consult

9 Died• 2 died in hospital on comfort measures• 5 Died on Hospice –2: Inpatient + 2 Home + 1 Travel

• 1 Died at home with Palliative Home Health • 1 Unsure of location of death, likely Nursing

Home

No 30-D Readmit after PC Consult

3 Alive at time of chart review • 1 : Home Health• 2 : SNF vs. LTC

The One that got away

One Patient who didn’t have a 30 day readmission

PRIOR to Palliative Care consult, but did AFTER Palliative Care

Consult.

35 Patients without 30-day readmits

26 Died• 8: hospital (7 at KU)• 6: Inpatient Hospice• 10: Home with Hospice• 1: Home without Hospice • 1: Skilled Nursing, rehab

7 Alive• 4: Home/Nursing Home

with Hospice • 1: Palliative Home Health• 1: Home Health • 1: Home without Hospice

2 Patients: Unknown Status

Died; 38

Alive; 13

Unknown; 2

All HF Patients who had PC Consult in 2013

Conclusions

• HF trajectory is predictable.• Patients with Stage D HF ought have GOC

conversation with provider• Patients >85 admitted with HF ought to have

PC Consult• Patients with HF and prior <30 day

readmission ought to have a GOC conversation with provider

Questions?