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?