Factors Affecting Heart Failure Readmission Rates in VA Patients

METHODS

The purpose of this study was to identify factors contributing to the high HF readmission rates in veterans enrolled at JBVAMC. This study was an Institutional Review Board and VA Research and Development Committee-approved retrospective, electronic chart review of patients with an ICD-9 principal discharge diagnosis code for HF and hospitalization for HF exacerbation anytime between October 1, 2010, and March 1, 2011. A patient chart was reviewed for 6 months after inclusion. A report was generated to identify patients discharged from JBVAMC with a principal discharge diagnosis of HF between October 1, 2010, and March 1, 2011, using the following ICD-9 HF codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, and 428.9.

Patients were included if aged ≥ 18 years with one of the ICD-9 HF codes as the principal discharge diagnosis within the study period. Patients were excluded from the study if transferred to or from an outside hospital, discharged without an ICD-9 principal diagnosis code for HF, electively admitted for HF, not treated for HF during hospitalization, left the hospital against medical advice, had chart documentation with comfort measures only, were discharged/transferred to hospice, had active HF medications listed under non-VA medications in the electronic medication profile, or did not receive follow-up at JBVAMC. Study participants were included in the study once, which was classified as their index HF hospitalization, and were followed for 6 months thereafter.

The primary endpoint was the difference in patient characteristics between 2 groups of patients: those readmitted for HF within 30 days of the index hospitalization and those readmitted after 30 days or not at all.

The study had multiple secondary endpoints. One was the difference in patient characteristics between 2 groups of patients: those readmitted for HF within 90 days of the index hospitalization and those readmitted after 90 days or not at all. Another secondary endpoint was the difference in patient characteristics between 2 groups of patients: those with ≥ 2 readmissions for HF within 6 months and those with < 2 HF readmissions within 6 months. Additional secondary endpoints included percentage of patients readmitted for HF within 30 days of the index HF hospitalization, time to readmission if applicable, time to death if applicable, and average number of readmissions per patient within 6 months.

Index data collected included age, gender, ethnicity, prior diagnosis of HF, date of diagnosis, hospitalization for HF within 30 days of the index HF admission, in-hospital cardiac arrest, comorbid conditions, systolic blood pressure (BP), heart rate, respiratory rate, weight, serum sodium, blood urea nitrogen, serum creatinine, hematocrit, and glucose. For this study, comorbid conditions gathered were diabetes mellitus, coronary artery disease, prior percutaneous coronary intervention, aortic stenosis, stroke, chronic obstructive pulmonary disease, and dementia.

Medication profiles were reviewed at the time of admission to determine whether the patient was prescribed an ACE-I/ARB, ß-blocker, diuretic, hydralazine and isosorbide dinitrate, aldosterone antagonist, digoxin, NSAIDs, nonvasoselective calcium channel blocker, and an antiarrhytmic other than amiodarone and dofetilide. Hospitalization data included the most recent LVEF, the number of days on oral diuretic therapy after stopping IV diuretics, the number of days admitted, and documentation of an in-person inpatient dietitian consultation.

Data collected at discharge included diet/weight/medication instructions, weight, BP, American College of Cardiology/American Heart Association HF stage and New York Heart Association (NYHA) HF functional class, if documented. Discharge medication profiles were assessed for the number of medications (< 9 or ≥ 9), documentation of active prescriptions for an ACE-I/ARB and a ß-blocker (or contraindication documented), diuretic, hydralazine and isosorbide dinitrate, aldosterone antagonist, and digoxin. Other data collected were documentation of a scheduled follow-up appointment with primary care physician, urgent care, chronic HF (CHF) clinic, or cardiologist, and whether the patient was discharged to home, skilled nursing facility, shelter, or homeless. Additionally, if the patient was discharged on a diuretic, the dose was compared with the baseline diuretic. If the diuretic at discharge was different from the home diuretic, equivalent doses were used for comparison with that of the baseline diuretic.

Postdischarge data collection included telephone follow-up within 48 hours of discharge, medication compliance since the initial hospitalization, date of first outpatient follow-up after initial hospital discharge, enrollment in CHF clinic/CHF-PharmD/Care Coordination Home Telehealth (CCHT) program, outpatient dietitian consultations, and date of death if applicable. Medication adherence was defined as ≥ 80% of lowest percentage filled medication of all HF medications, determined by the refill history in the computerized patient record system (CPRS). First outpatient follow-up was defined as a visit in which HF was addressed in the assessment and plan.