Reducing heart failure readmission

Key points

Treating HF patient readmissions following hospitalizations is incredibly costly for hospitals, with HF accounting for up to 26.9% of total readmission rates4 at a treatment cost of $15,000 to $25,000 per patient5; post-discharge remote patient monitoring may relieve some of the financial burden now that these services are eligible for Medicare reimbursement.
HF patients are benefiting from longer-term, more collaborative relationships with their specialists in which HF can be identified at an earlier stage, potentially informing care plan changes, allowing additional provider outreach and preventing costly readmissions.
Hospitals that include this technology in their HF protocol for patients with implanted devices can gain valuable patient insight while also boosting patient satisfaction.

Heart failure (HF) is a costly condition that is increasingly diagnosed in the U.S., impacting the physical and financial health of patients and the organizations that care for them. More than six million Americans currently have HF, with predicted estimates reaching more than eight million cases at a cost of $69.7 billion by 2030.¹ The costs associated with inpatient HF care are substantial, typically compounded by comorbidities, invasive procedures and readmissions.² Advancing awareness and treatment options (e.g., drug therapies, mechanical support devices) present provider and patient with new collaboration opportunities to slow disease progression and improve the patient’s quality of life.

The acute repercussions of readmissions

HF patient readmissions following hospitalization are extremely prevalent, second only to septicemia (Figure 1).³ HF has the highest 30-day readmission rate among surgical and medical conditions, accounting for up to 26.9% of total readmission rates⁴ at a treatment cost of $15,000 to $25,000 per patient.⁵ A 2017 study revealed that more than 40% of HF patients were readmitted within 90 days of hospitalization (Table 1).⁵

Figure 1. Heart failure readmission diagnosis ranked by volume

Principal diagnosis at Index admission

Source: Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018. HCUP Statistical Brief #278. Agency for Healthcare Research and Quality. July 2021. Accessed May 30, 2022. www.hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.pdf

Table 1. Readmissions following hospitalization for heart failure

Timeframe

Readmission rate

Readmitted within 30 days

22.3%

Readmitted within 60 days

33.3%

Readmitted within 90 days

40.2%

Source: Kilgore M, Patel HK, Kielhorn A, Maya JF, Sharma, P. Economic burden of hospitalizations of Medicare beneficiaries with heart failure. Risk Manag Healthc Policy. 2017;May10(10):63-70. doi: 10.2147/RMHP.S130341

A 2017 study revealed that more than 40% of HF patients were readmitted within 90 days of hospitalization⁵

Financial impact of heart failure inpatient encounters⁶

An analysis of Vizient member hospital data set

Based on an analysis of data mined from the Vizient Clinical Data Base, our analysts extrapolated additional insight. While many Vizient member hospitals and health networks outperform national averages, opportunities exist for improving care and financial performance.

The evaluated admission encounter data set was across 743 acute hospitals from April 2021 through March 2022.
Data set represents 311,480 patients with HF as a principal diagnosis on their initial visit to the hospital; approximately 2.1% had an implanted device.
Approximately 16.2% of patients admitted with the principal diagnosis of HF and an implanted device were readmitted to the hospital within a 30-day period; of this population.
Table 2 outlines the Medicare Severity-Diagnosis Related Groups (MSDRGs) associated with the analyzed data set’s readmissions.⁶

Table 2: Vizient Clinical Data Base data set analysis of MS-DRG, length of stay and average cost

MS-DRG

Description

Percentage of cases (%)

Average length of stay (days)

Average cost of care

291

HF and shock with MCC

32.7

6.12

$7,153.10

871

Septicemia or severe sepsis without MV > 96 hours with MCC

5.4

7.84

$11,200.03

292

HF and shock with CC

3.8

4.67

$5,139.16

280

AMI, discharged alive with MCC

3.6

6.54

$8,155.70

286

Circulatory disorders except AMI, with cardiac catheterization with MCC

3.1

10.74

$15,278.04

Abbreviations: AMI = acute myocardial infarction ; CC = complication or comorbidity; HF = heart failure; MCC = major complication or comorbidity ; MS-DRG = Medicare Severity-Diagnosis Related Groups; MV= mechanical ventilation

Source: Vizient Clinical Data Base: Date range Q2 2021 – Q1 2022. Estimated 743 hospitals surveyed across the United States.

What else can data tell us about post-discharge?

Vizient data also presents questions and opportunities around patient and device selection criteria. For example, can devices that monitor and detect trends help physicians identify patients with the highest risk for HF? Also, could providers reduce readmission rates through early detection of HF using HF diagnostics via remote monitoring? These questions about how different implanted devices influence patient outcomes warrant closer evaluation.

Improving post-discharge practices with remote monitoring

Leading up to and immediately following HF patient discharge, specialists typically follow similar best practices that establish a short-term connection with the patient, such as coaching patients on self-management, reconciling medication and providing additional education within seven days of discharge. Conducting in-person or virtual clinic appointments are other short-term points of contact for discharged HF patients.⁷ The four primary cardiac rhythm management suppliers — Abbott, Boston Scientific, Biotronik and Medtronic — all offer remote monitoring technology devices to monitor and manage patients.

Continued cardiac technology advancement and enhanced Medicare reimbursement are allowing new populations to benefit from ongoing remote monitoring, which may reveal trends that inform care plan changes or allow additional provider outreach. With remote patient monitoring services now Medicare eligible, new revenue opportunities exist for healthcare providers that incentivize them to provide virtual care.⁸ Remote patient monitoring is a monthly billable program that requires at least 20 minutes of patient service each month for Medicare reimbursement.

Providers, who receive an average of $52 for 20 minutes of service monthly per patient, may also receive an additional $56 monthly when patients use their remote patient monitoring devices daily. Changes to Medicare policy are particularly powerful considering that overall readmission rates are highest among Medicare patients.³

Technologies for heart failure patients

The pandemic accelerated technological advancements for HF remote monitoring, making at-home care easier and more pervasive. It also created an increase in patient comfort level — and in many instances, a preference — for remote monitoring and consultation. The main goal of this collaborative strategy, which involves monitoring patients with implanted devices post-discharge, is to identify worsening HF at the earliest possible stage.

Hospitals that include this technology in their protocol for HF patients with implanted devices can gain valuable patient insight while also boosting patient satisfaction. Medtronic’s Triage HF and Boston Scientific’s HeartLogic systems present opportunities to support existing care pathways and enable early detection of patient heart issues requiring clinician intervention.

Medtronic: TriageHF

TriageHF by Medtronic prioritizes HF patients by assigning patient risk scores, enabling clinicians to easily identify those at the highest risk of hospitalization within 30 days. Triage HF information and data is transmitted to clinicians via the Carelink Network, which is the Medtronic remote monitoring platform. While TriageHF does not replace standard clinical practice assessments, clinicians can use it in conjunction with standard guidelines for patient management.⁹

Boston Scientific: HeartLogic

HeartLogic by Boston Scientific includes multiple physiologic sensors with high sensitivity and low-alert burden to provide weeks of HF patient monitoring. Heart Logic information and data is transmitted to clinicians via the Latitude Network, which is the Boston Scientific remote monitoring platform. Their PREDICt-RM study, a retrospective analysis of nearly 40,000 patients, found that patients using the LATITUDE Remote Patient Management System had a 33% reduction in the risk of death and a 19% decrease in all-cause hospitalizations compared to those not remotely monitored.¹⁰

Member perspective: collaboration and follow-up care for device patients

The after-care plan for patients who receive a pacemaker or defibrillator is also an important factor to consider in a heart failure program. These patients are at risk for exercise intolerance, repeat hospitalizations and early death.

Cardiac resynchronization therapy (CRT) is a proven treatment for individuals with advanced heart failure, but as many as one-third of patients may not improve as much as would have been expected. Patients receiving CRT devices are among the sickest within the field of cardiology; however, the follow up for such patients is often fragmented. CRT recipients are the target population of a dedicated combined heart failure-electrophysiology clinic launched under the leadership of electrophysiologist John Rickard, MD, MPH, director of the CRT-CHF Clinic at Cleveland Clinic,¹¹ Vizient partner for Excelerate.

The CRT-HF clinic evaluates all patients witha low ejection fraction who receive a CRT device six months post-implant with the goal of standardizing the early follow up of these patients. The follow-up appointment includes a repeat echocardiogram and a 45-minute comprehensive physical assessment by both an electrophysiologist and a heart failure specialist, as well as functional testing with a nurse. A multidisciplinary team then reviews results together to make joint recommendations for an individualized patient plan.¹¹ The plan ranges anywhere from small medication changes to referral for a left ventricular assist device and everything in between. The clinic has spurred national attention with multiple sister sites adopting the algorithm. With such success, the adoption of CRT clinics is a consideration for future cardiac guidelines.

Conclusion

Even small numbers of readmitted HF patients within a 30-day period can significantly affect overall costs and potential readmission penalties. With a clear opportunity to positively influence patient care and reduce the economic impact of readmissions, evaluating patient and device selection criteria may benefit healthcare organizations. Transitioning appropriate patient care and follow up to remote monitoring and assessment can free up valuable clinician time and resources for higher acuity departments in hospitals, while also helping hospital staff stay prepared for patient influxes.

HF patients will ultimately benefit from ongoing monitoring and evaluation post-discharge, as the practice gains momentum as an effective strategy toward better clinical outcomes. Healthcare teams can garner the best results through a collaborative process that includes communication between the electrophysiology and HF teams. Incorporating patient participation, education, self-monitoring and remote monitoring into a chronic care management program can lead HF patients to an improved quality of life.

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