Kelley M. Anderson, PhD, FNP 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

Heart Failure Society of America HFSA Comprehensive Guidelines, 2010 Discharge Guidelines Exacerbating factors addressed (dyspnea) Near optimal volume status achieved Ambulation before discharge to assess functional capacity Level C = Expert opinion

Criteria Inclusion 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

Methodology Descriptive, 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 assistance Toileting with assistance Crackles Congestion on chest radiograph Assistive devices for ambulation Intake and outputs Dyspnea Ambulation with assistance Effusions on chest radiograph History of previous heart failure Left ventricular ejection fraction (LVEF) Ethnicity 2

Correlation Matrix for Key Factors 1 2 3 4 5 6 7 8 9 10 1. Readmission 2 Age .030 3. Gender -.123 -.263* 4. ADLs .433+ .264+ -.147 5. Crackles .327+ .127 -.062 .254* 6. Dyspnea 7. Congestion 8. Devices 9.Intake/Output 10. 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 -.264* -.038 -.046 .221* .108 .090 -.057 -.046 .012 *P<.05 +P<.001

Selection of Factors for Model Theoretical, Prior research, Nursing Sensitive Key Factors Activities of Daily Living, Crackles, Dyspnea Age, Gender Factors Not in Model Congestion – missing data, chest x-ray Ambulation devices – correlated ADLs Intake/output records – missing data Did not improve model/amenable to Heart failure history Ethnicity

Evaluation of the Model Omnibus Test of Model Coefficients Chi square 47.642, 5 df, significance .000 Hosmer and Lemeshow Test Chi square 6.432, 8 df, significance .599 Model Summary Cox & Snell R Square .339 Nagelkerke R Square .453 OTMC – overall indication of model performance over and above the results with no predictors entered into the model; “goodness of fit” test; test of the null HandL- most reliable test of model fit; interpreted differently; poor fit indicated by significance value less than .05, so to support model want greater than .05 Model Summary – amount of variation in the dependent variable explained by the model; pseudo R square 33.9%-45.3% variability explained by set of variables

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 Hierarchical logistical regression a model was derived which demonstrated the ability to correctly classify

Logistic Regression Evaluation of Readmission 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 5.41 1.79 1.87-15.61 .572-5.57

Generalizability Evaluation of National Hospital Discharge Survey (NHDS) 2005; Heart Failure, n=10,000+ Acute Decompensated Heart Failure Registry (ADHERE); n=52,047

Age, years 74.38 (SD 13.37) 75.2 Median 75.25 (SD 11.34) Gender 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 2002-2003 n=134 n=52,047 2006-2007 2002-2003 n=134 n=52,047 % % ______________________________________________________________________ Hypertension 79.1 72 Diabetes mellitus 51.5 44 Coronary artery disease 55.2 58 Valvular heart disease 50.7 23 Cardiac rhythm abnormalities 57.5 Atrial Fibrillation 45.5 31 Renal Insufficiency 45.5 29 Pulmonary 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 health Long-term care facilities Outpatient follow up Hospice Goal – to improve outcomes by reducing readmissions, avoid exacerbations of illness and maintain health based on empirical data

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