Reducing Readmissions in Congestive Heart Failure
A friend called yesterday and he is also an internist. Somehow our conversation drifted to the topic of congestive heart failure (CHF). He told me about a small, impoverished town in near the coast in the Carolinas that had very few heart failure admissions. He asked how they had accomplished that. The hospital administrator introduced him to a nurse who was working under a grant, but she was very dedicated. She had a list of all the heart failure patients in the hospital service area. That was her job. Making certain that every patient was on the best treatment for CHF. She called the patients. She spent time with them. She had a trusting, caring, long term relationship with them. That’s it! That was the secret sauce. Every poor community in our country could do that, but they don’t.
The picture above is a screenshot from an article describing research from the Steno diabetes clinic in Denmark. They treated patients with high-risk diabetes very systematically using a protocol with aggressive control targets for blood pressure, blood sugar, and cholesterol using ACE inhibitors (lisinopril), statins, and metformin with an aspirin. Those are components of optimal medical therapy (OMT). They proved OMT over two decades of treatment reduced heart failure admissions by 70%! That is not a typo. 70%! That is critically important because heart failure cases are increasing—fast! And the impact on our healthcare system is great.
Consider this information from Milliman. To me, the statistics cited are astonishing. Twenty-two percent of heart failure patients who are admitted to the hospital are dead within a year. Patients with CHF generate a third of Medicare spending and 40% of Medicare fee-for-service deaths. Overall, heart failure patients have a mortality of 22%, compared with 4% for Medicare patients without heart failure. They are responsible for 55% of Medicare readmissions. That all seems crazy to me. But even if it is half of that. It is awful.
Of course, because it is such a big problem, there have been many quality improvement efforts. Here is a quote from the Milliman article.
”Prominent efforts to improve the care and reduce the cost of CHF have been implemented over the last several years. Despite these efforts the prevalence of heart failure is rising and only small improvements in survival have been realized. The high prevalence, cost, and mortality of the heart failure population combined with the lack of novel therapies and the limited improvement in medical management highlights the need for increased focus on CHF among the Medicare population.”
What??? I just reviewed an article that said investigators in Denmark proved optimal medical therapy reduceds heart failure admissions by 70% in diabetes compared with usual care. The patients who have the highest risk of heart failure are those who have had a heart attack. Optimal medical treatment after a heart attack is very effective compared with usual care. Over twenty years ago, Kaiser Permanente delveloped teams to deliver OMT to these patients and they reduced mortality by 76%. By 2008, they were treating 12,000 patients with these teams. They reduced healtcare costs by $21,900 per patient per years. A large part of these benefits came from slowing progression to CHF after an MI. As on the Carolina coast, nurses provided most of the management in both efforts. Updated protocols and systems can provide even better results today.
Most heart failure comes from hypertension. Spironolactone or eplerenone were not widely used in the efforts in the last paragraph. These medications in resistant hypertension dramatically improve blood pressure control and interfere directly with the molecular biology that causes heart failure. Now we know metformin and empagliflozin for diabetes do the same. Telemedicine can make it much easier and more efficient for nurses to get in touch with these patients, even in remote rural areas. Twenty years ago, the National Academy of Medicine developed a blueprint to improve care. The American College of Cardiology calls for optimal medical therapy first after a heart attack. Medical leaders have ignored both, and the American people are paying a dear price! It is time to move systematically to provide OMT for cardiometabolic patients. Only then will we be providing patient-centered care.