the relationship between discharge clinical characteristics and readmission in patients hospitalized...
TRANSCRIPT
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