How to Keep Heart-Failure Patients Alive: Better After-Hospital Care, Not Longer Stays
As the average hospital length of stay for patients with congestive heart failure (CHF) has decreased over the past two decades, their readmission rate has increased. The authors of the JAMA study that showed this correlation believe it might indicate that some CHF patients are being discharged too early. Perhaps so. But a bigger issue is how they're being cared for after they leave the hospital.
As CMS Administrator-designate Donald M. Berwick, Thomas W. Nolan and John Whittington pointed out in a 2008 Health Affairs article, 40 percent of Medicare patients discharged with CHF are readmitted within 90 days. But, they added, "well-designed demonstration projects have shown for years that that rate can be reduced by more than 80 percent with proper management of patients."
That care management includes making sure that the patients are taking the proper medications, are watching their weight and their diet, and are staying in close touch with their physicians in case they experience warning signs that could lead to readmission. A recent study showed that the use of home-based interactive telehealth systems could cut CHF-related hospitalization rates by 68 percent.
So why isn't this happening, or at least not to the extent that it could? The problem is twofold: The handoffs between hospitals and ambulatory-care providers are poor, and physicians lack the financial incentives to participate in disease management or telehealth programs that could help keep their CHF patients functioning reasonably well at home. The heart failure readmission crisis, Berwick and his coauthors wrote, is "a prime example of what goes wrong when a health system lacks the capacity to integrate its care over time and across sites of care."
The JAMA study found that the average length of stay for a patient with heart failure decreased 26 percent to 6.4 days in 2005-2006 from 8.6 days in 1993-1994. During the same period, readmissions within 30 days after discharge jumped to 20.1 percent from 17.3 percent.
The mortality rate for 30 days after admission dropped to 10.8 percent from 12.6 percent, but the death rate within 30 days of discharge increased to 6.4 percent from 4.3 percent. So overall, it appears that the quality of care did not improve over the study period, despite the advent of new technologies that keep people alive in the hospital.
In 2005-2006, 74 percent of the patients were sent home, either to the care of their families or to professional home health care. Twelve years earlier, the figure was 67 percent. The number of patients discharged to skilled nursing facilities increased to 20 percent from 13 percent.
The latter figure reflects the tendency of hospitals to discharge patients "quicker and sicker." That's the result of Medicare's prospective payment system, which pays fixed amounts for "diagnosis-related groups" (DRGs), as well as the pressures of managed care. The growth of home care companies has also paralleled the trend of earlier discharges. But one leading CHF expert, cardiologist Harlan Krumholz of Yale, questions whether people should stay in the hospital longer, even though he thinks that discharging them earlier may have raised downstream costs. The real answer, Krumholz told the WSJ, is for hospitals to invest in ensuring that "the transition to outpatient status goes smoothly."
That's certainly part of the solution, but the ambulatory-care sector is simply not organized to provide adequate care to patients with CHF and other chronic diseases. This is what Berwick and his colleagues, as well as the Institute of Medicine, have been saying for years. Let's hope that Berwick is confirmed by the Senate as Medicare chief and that he can start the wheels rolling toward a better system of healthcare delivery.
Image supplied courtesy of Wikimedia Commons
