The relationship between discharge clinical characteristics and readmission in patients

hospitalized with heart failure

Kelley M. Anderson, PhD, FNP

Heart Failure – Incidence and Prevalence

High prevalence, 5.2 million Americans Only major cardiovascular disorder with

increasing incidence Lifetime risk 1 in 5, 20%, for men and

women greater than 40 years Most common Medicare hospital

discharge diagnosis $

Heart Failure Burden

Mortality: one year 20% Morbidity = hospitalizations

Incidence of hospitalizations Increase in hospital discharges by 175%

between 1979 to 2004 (399,000 to 1,099,000)

(AHA, 2007)

Re-hospitalizations 1992-2001 Medicare Quality Monitoring,

30-day, one year HF readmission 9%, 38%; all cause readmission 25% and 74% (MQMS, 2008)

Problem

Patients with heart failure experience hospitalizations

Re-hospitalizations frequent Limited research on clinical, nursing,

characteristics at discharge Correlation of these characteristics with

60-day heart failure readmissions

Discharge GuidelinesExacerbating factors addressed (dyspnea)Near optimal volume status achievedAmbulation before discharge to assess

functional capacity

Level C = Expert opinion

Heart Failure Society of America HFSA Comprehensive Guidelines, 2010

CriteriaInclusion Exclusion

Primary discharge diagnosis of HF

Admission greater than 24 hours

Age greater than or equal to 50 years

Cardiac transplant candidate

Acute coronary event within 30 days

Coronary revascularization within 30 days

Left ventricular assist device

Five or more non-cardiac procedure codes

Mortality within 60 days Discharged to hospice

MethodologyDescriptive, correlation design

Setting – two acute care facilities, mid-Atlantic, same hospital system

Sampling – retrospective chart review Procedure

Data extraction of patient characteristics and nursing assessment indicators

Standardized forms, then entered into computerized database

Sample Characteristics Final cohort of 134 subjects 55.2% Female, 44.8% Male Average age 75.25 years (SD 11.34) Average length of stay 5.83 days (SD 3.29) Ethnic Group

Caucasian 64.9% Black/African American 15.7% Hispanic 6% Asian 4.5% Other 6.7%, Not stated 2.2%

Marital Status – 40.3% married, 35.8% widowed 93.3% admitted through emergency department 79.1% routine discharge home

Co-Morbidities

Hypertension 79.1% Coronary artery disease 55.2% Diabetes mellitus 51.5% Valvular heart disease 50.7% Rhythm abnormality 57.5% Renal insufficiency 45.5% Pulmonary disease 36.6%

Results - Indicators of Readmission

Assistance with activities of daily living (ADLs)Bathing with assistanceToileting with assistanceCracklesCongestion on chest radiographAssistive devices for ambulationIntake and outputsDyspneaAmbulation with assistanceEffusions on chest radiographHistory of previous heart failureLeft ventricular ejection fraction (LVEF)Ethnicity 2

Factor 1 2 3 4 5 6 7 8 9 10

1. Readmission2 Age .030

3. Gender -.123 -.263*

4. ADLs .433+ .264+ -.147

5. Crackles .327+ .127 -.062 .254*

6. Dyspnea7. Congestion8. Devices9.Intake/Output10. HF history

.266*

.514+

.309+

-.349*.241*

.101

.213

.443+

.073

.113

-.073-.008.263.238.176*

.325+

.239

.549+

-.099.086

.165

.146

.269*-.177.085

.321

.215* -.013 -.148 -.310 -.160-.038 .074 .120 -.255

11. Ethnicity2 .176* -.264* -.038 -.046 .221* .108 .090 -.057 -.046 .012

Correlation Matrix for Key Factors

*P<.05 +P<.001

Selection of Factors for Model Theoretical, Prior research, Nursing Sensitive Key Factors

Activities of Daily Living, Crackles, DyspneaAge, Gender

Factors Not in ModelCongestion – missing data, chest x-ray Ambulation devices – correlated ADLsIntake/output records – missing dataDid not improve model/amenable to

○ Heart failure history○ Ethnicity

Evaluation of the Model

Omnibus Test of Model CoefficientsChi square 47.642, 5 df, significance .000

Hosmer and Lemeshow TestChi square 6.432, 8 df, significance .599

Model SummaryCox & Snell R Square .339Nagelkerke R Square .453

Classification

78.2% of those who did have a readmission (sensitivity of the prediction)

76.7% of the subjects where the

predicted event, readmission, did not occur (specificity)

77.4% of the cohort

Predictor Β Odds Ratio 95% CI

Age β5 -.043 .958 .92-1.00

Gender β4 -.769 .464 .170-1.26

ADLs β3 2.33 10.26 3.70-28.44

Crackles β2

Dyspnea β1

1.69.579

5.411.79

1.87-15.61.572-5.57

Logistic Regression Evaluation of Readmission(n=115)

Generalizability

Evaluation of National Hospital Discharge Survey (NHDS) 2005; Heart Failure, n=10,000+

Acute Decompensated Heart Failure Registry (ADHERE); n=52,047

NHDS ADHERE Dissertation (n=8642) (n=52,047) (n=134)

2005 2002-2003 2006-2007

_____________________________________________________________________________Age, years 74.38 (SD 13.37) 75.2 Median 75.25 (SD 11.34)Gender Female 4779 (55.3%) 52% 74 (55.2%) Male 3863 (44.7%) 48% 60 (44.8%)Length of Stay 5.41 (SD 4.55) 5.83 (SD 3.29)Ethnicity White 51.7% 73% 64.9% African American 18.2% 19% 15.7%Payment Source Medicare 76.3% 72% 81.3%Type of Admission Emergency 69.9% 76.1% Urgent 17.7% 9%Discharge Home 64.7% 79.1%

Co-Morbidities

Study Data ADHERE 2006-2007 2002-2003n=134 n=52,047% %

______________________________________________________________________Hypertension 79.1 72Diabetes mellitus 51.5 44Coronary artery disease 55.2 58Valvular heart disease 50.7 23Cardiac rhythm abnormalities 57.5Atrial Fibrillation 45.5 31Renal Insufficiency 45.5 29Pulmonary Disease 36.6 31

Limitations

Controlling all factors Adequacy of data is determined by

documentation Evaluation of home care after index

hospitalization Generalizability

Clinical Practice Implications Return to Framingham (clinical) criteria Potentially modifiable patient clinical factors at

discharge Evaluation of discharge readiness Clinical guidelines of care Post-discharge management

Home healthLong-term care facilitiesOutpatient follow upHospice

Significance & Originality Improve understanding of patient factors

related to readmissions Exploration of the discharge phase Heart failure admissions and re-

admissions only Nursing sensitive indicators Implications for discharge management

and follow-up

Conclusion

Hospital admission is a marker of clinical instability in patients with heart failure

Heart failure patients have frequent adverse outcomes after hospitalizations, including re-hospitalizations

Novel understanding of clinical characteristics at the time of discharge associated with 60-day heart failure readmissions