Telehealth And 30-Day Readmission In Heart Failure Patients

Abstract

Cardiovascular disease (CVD) remains the leading cause of death in the United States. Among adult patients with CVD, congestive heart failure (CHF) is one of the most prevalent complications resulting in high rates of morbidity and mortality. Moreover, adult patients with diagnosis of CHF experience one of the highest 30-day readmission rates as compared to patients with other complications of CVD.

The healthcare costs associated with readmission of heart failure patients are substantial and are expected to continue rising. The primary objective of this evidence-based paper is to assess effectiveness of telehealth monitoring in reducing 30-day readmission rates in adult population with congestive heart failure compared to clinical follow up alone. Additionally, this study aims to identify research supported interventions the advance practice nurses (APRNs) can implement utilizing the concept of telemedicine in improving various health attributes of the identified population.

Cardiovascular disease (CVD) remains the leading cause of death in the United States. According to Centers for Disease Control and Prevention (CDC), heart disease is responsible for more than 600,000 deaths each year (2016). One in every four deaths in this country is secondary to complications of CVD. Congestive heart failure (CHF) is one of the most prevalent complications of CVD, which will be the focal point of this paper. Although CHF affects people across the lifespan, this paper will focus mainly on adult population, which includes any person over the age of 18. Current CHF statistics are quite staggering. Nearly five million Americans are living with CHF (Emory Healthcare, 2019).

The number of new cases diagnosed each year is approximately 550,000. The prevalence of CHF increases with age. For instance, CHF is present in two percent of people between ages 40 and 59; it is five percent in persons ages 60 to 69 (Emory Healthcare, 2019). Presently, the annual incidence of heart failure approaches 10 in 1000 in population 65 years of age and older. Demographically, males and females are equally affected, and African-Americans are one in a half times more likely to develop heart failure than Caucasians. More than 50% of people with CHF die within the five years of diagnosis, which currently equals to 287,000 deaths per year. One in nine deaths in 2016 included CHF as a contributing cause (Emory Healthcare, 2019)

Financial burden related to treatment and management of patients with congestive heart failure is equally astonishing. CHF accounts for approximately 11 million physician visits each year, and more hospitalizations than all forms of cancer combined. In patients 65 years of age and older, CHF is the primary diagnosis in one-fifth of all hospitalizations. Total number of hospitalizations in the same age group related to CHF is approximately 875,000 per year. An estimated annual cost of treatment and management of heart failure is $30.7 billion. Considering that a number of individuals affected by CHF will increase to 8.5 million by 2030, the associated costs will continue to rise. Moreover, the economic burden of CHF will be further compounded by high readmission rates.

Hospital readmissions present a major challenge in the care of a heart failure patient. High readmission rates in CHF patients are directly related to worse outcomes as well as mounting costs to healthcare system. The acuity of this problem is so high that a requirement for the development of a readmission reduction program was included in the Affordable Care Act of 2010. Furthermore, in 2012, the Hospital Readmission Reduction Program (HRRP) was introduced, which imposed penalties onto hospitals for excessive rates of readmission for the following conditions: CHF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG) surgery, pneumonia, and certain orthopedic procedures, i.e. joint arthroplasties. Interestingly, among aforementioned conditions, CHF posses the highest risk for 30-day readmission, which is estimated at 25%.

Reduction of heart failure related admissions is one of the major Healthy People 2020 objectives and has been defined as “reduce hospitalizations of older adults with heart failure as the principal diagnosis” (2019). A recent retrospective, observational study that analyzed data from 63,678 Medicare beneficiaries with a mean age of 81.8 years admitted for heart failure yielded worrisome statistics. The mean per patient cost of CHF related admission was $14,631; however, given that an average heart failure patient will have at least one admission, and more than half will be hospitalized three or more times within 4–5 years of diagnosis, the total lifetime cost of inpatient admissions has been estimated at $83,980 (Kilgore, Patel, Kielhorn, Maya, & Sharma, 2017).

Essentially 80% of the total lifetime treatment cost associated with CHF was directly related to inpatient admissions (Kilgore et al., 2017). In summary, CHF represents the most common admission and readmission diagnosis for Centers for Medicaid and Medicare Services (CMS), which in turn is mitigating associated healthcare costs by penalizing hospitals and healthcare systems with readmission rates exceeding a model-derived risk standardized readmission rate (Vader et al., 2016). The punitive approach adopted by the federal government by penalizing healthcare systems for what is deemed as unnecessary heart failure admissions, has been vehemently opposed by heart failure practitioners.

The causes for CHF readmissions vary significantly and are dependent on age, comorbidities, heath status, geographic location, educational level, as well as other socioeconomic attributes of the patient. Tertiary healthcare systems located in the urban communities often argue that low income population has a higher rate of readmissions due to multiple socioeconomic barriers that are beyond control of the hospital, and its providers. Thus, healthcare systems are eagerly exploring various models in addressing this problem. In summary, a mutual, proactive, and novel approach must be utilized in search for a viable solution to decrease readmission rates.

Health systems developed and implemented various strategies in preventing heart failure readmissions. Optimization of inpatient care, reviewing treatment protocols, evaluating admission/discharge guidelines, prolongation of hospital stays, utilization of transition nurses, close collaboration with skilled nursing facilities, providing thorough patient education, prompt medication reconciliation along with provision of a month supply of new medications prior to discharge, and arranging follow up care are few examples of such interventions. Despite allocation of significant resources, very little progress has been made in the last five years in decreasing rehospitalization rates.

Several studies evaluated interventions provided by registered as well as advance practice nurses in improving outcomes in adult population with CHF. Nurses being natural communicators and educators play a unique role in management of patients with complex health needs. According to a new systematic review of nursing interventions aimed at reducing heart failure admissions, such strategies as patient/caregiver education, phone call follow up, aggressive discharge planning, multidisciplinary collaboration, optimization of community resources resulted in 40% reduction in readmission rates (Cavalier & Sickels, 2015).

Specifically, a benchmark a 30-day readmission rate of 28.8% was decreased to 17.4% through successful implementation of aforementioned nursing interventions in a cited study. However, the sustainability and continued application of the above measures were found to be an extremely resource-intensive, and time-consuming process. It requires patients’ compliance, effective intradisciplinary communication, high degree of professional expertise, readily available access to care among other equally important factors. Hence, there is a need to explore alternative methods of achieving similar outcomes that could effectively consolidate and streamline delivery of such care. The concept of telehealth is a promising trend that has a strong potential to be an effective tool in management of CHF and reduction of preventable admissions.

What is the definition of telehealth? In 2007, the World Health Organization has defined telehealth as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” (Kruse, Soma, Pulluri, Nemali, & Brooks, 2017).

Telehealth is emerging as a valuable tool in various clinical settings. Neurology, remote intensive care unit monitoring, emergency department triage, dermatology, primary care, urgent care, post-operative follow up are only few examples of application of telehealth. Many tertiary healthcare systems routinely use telemedicine in chronic condition management through the specialty clinics. Application of this technology in the management of patients with CHF follows similar principles and demonstrates promising outcomes. The systematic review of 20 articles related to the use of telehealth in CVD management identified strong association between use of telemedicine in reduction in hospitalizations and readmissions in CHF population (9 out 20 articles, 45%) (Kruse et al., 2017). Additionally, improved mortality and cost-effectiveness both had 40% association rate (Kruse et al., 2017).

A prospective, single-arm, quality improvement program conducted by researchers from American Heart Association (AHA) achieved a 30-day readmission rate of 10.2% compared to Illinois state average of 17.8% during same time period utilizing telehealth monitoring (2017). Improved quality of life has also been documented through post study interview conduction. The Hospital of the University of Pennsylvania (HUP) home health services employed telehealth monitoring as a standard of care in management of heart failure patients following a study conducted in 2015-2016. According to the published paper, the baseline 30-day all-cause readmission rate was 19.3% which decreased by 14 percentage points to 5.2% in three years with integration of telehealth (O’Connor et al., 2016).

The proposed technology employs the use of a tablet device equipped with a cellular service to assure data connection independent of availability of wireless internet in a residential setting. This device collects and transmits such vital parameters as blood pressure, heart rate, oxygen saturation, and patient weight through Bluetooth connected peripherals. Additionally, the tablet can be preloaded with patient specific questionnaires, instructional videos, and other pertinent information related to condition management. Most importantly, patient has an ability to directly connect to his or her provider by means of the video conferencing. Patients should be carefully selected, instructed, and encouraged to participate in the program as part of the discharge planning. Patients can be provided with the telehealth kits at the time of discharge or as part of the transitional care model by visiting nurses.

The length of participation can vary between 30, 60, and 90 days depending on individual risk factors, and local risk prevalence. Following competition, the equipment can be either picked up or mailed back by prepaid postage. The average cost of telehealth care per patient per year is approximately $1600. The associated healthcare savings primarily result from decreased emergency room visits and hospitalizations. It is estimated that the use of telehealth reduces average annual costs from $11,549 to $3,263 in heart failure care per patient (O’Connor et al., 2016).

Participation in such programs has shown to increase patients’ confidence, realize the degree of personal accountability related to disease management, bridging the gap between patient, and provider, and facilitating access to care. The role of APRNs in such model of care is invaluable. For instance, APRNs can perform post discharge video calls, reconcile/adjust medications, review answers to questionnaires, review vital signs trends, perform patient assessment, risk stratification, care management among other interventions. The use of this technology is particularly useful in homebound patients, patients residing in rural, and medically underserved areas as well as patients who are known to be noncompliant with plan of care. Review of literature indicates that patients who participate in telehealth monitoring report higher satisfaction rates, better understanding of disease process, daily prevention measures, ability to recognize early signs, and symptoms of disease exacerbation. Moreover, patients feel connected to their providers, which is very encouraging and empowering, and contributes to better outcomes.

In summary, telehealth is an emerging and promising intervention to reduce 30-day readmission rates in adult population with congestive heart failure compared to clinical follow up alone. Analysis of available data demonstrates viability of telehealth monitoring at improving outcomes, reducing admissions, improving quality of life, decreasing healthcare costs, and promoting healthier lifestyle in defined population.

However, additional research is needed to provide stronger evidence base to support consistent utilization of telehealth in CHF management. Further improvements in provision of healthcare services by telehealth can be achieved through appropriate provider and patient training. Telehealth is a viable method of managing chronically ill patients while facilitating patients’ ability for self-care.