Dimissione e periodo vulnerabile: come evitare le reospedalizzazioni precoci.
G. Di Tano
Cardiologia, Cremona
Scompenso Cardiaco Acuto
Convention Centri Scompenso
De novo HF
OHF - Chronic HF Worsening HF ED
Hospital
Admission for AHF
OHF - Chronic
HF
In-hospital
Mortality
Early Mortality
Early Re-hospitalizations
The steps of Heart Failure patient’s “journey”…
30 days
DT14
Early and Later Post-discharge
period ……
Rehospitalization is high in the early and later phase after hospitalization
30 days from discharge
1 patient out of 4 is readmitted
1855 AHF enrolled
118 (6.4%) died in-hospital
159 transferred to other hospital 57 discharged to skilled nursing facilities 1 lost
1520 Discharged home
94 readmitted (6.1%) - 91% for CV causes -
42 dead (2.8%)
126 overall dead or readmitted (8.3%)
0 At 30 days from discharge
Progetto re-ospedalizzazioni precoci Area Scompenso 2012-2014
0 At 30 days from
admission 7.6% dead
The 30-day metric in Acute Heart Failure revisited. Data from IN-HF Outcome, an Italian Nationwide Cardiology Registry
G. Di Tano, R. De Maria et al. EJHF submitted
30-d read-free survivors 30-d readmitted or dead
IN-HF 30 day outcome in 1520 discharged home
Il pz che muore/rericovera nelle Cardiologie a breve, ha SC cronico avanzato, disf renale, degenza lunga, con inotropi, meno RAS-inib.
Combined death+read p 0R 95%
Days Length of stay 0.0016 1.023 1.008 1.037
Worsening HF vs de novo 0.0045 1.828 1.206 2.772
Inotropes 0.0006 2.189 1.398 3.426
ACE/ARBs at discharge 0.0012 0.522 0.352 0.774
C statistic 0.695
Days Length of stay 0.0076 1.020 1.005 1.034
Worsening HF vs de novo 0.0079 1.909 1.185 3.076
ACE/ARBs at discharge 0.0013 0.486 0.313 0.754
C statistic 0.662
Logistic regression independent predictors of death+ readmission or readmission at 30 days
Predictors of 30-Day Readmission in 412 Pts Hospitalized With Decompensated Heart Failure ( Hernadez MB et al, Clin. Cardiol. 2013 )
• TROPONIN, injury, cardiovascular events • AST/ALT, organ damage
Early HF readmission and 30-day
mortality are associated with the process
of inpatient care …
Meta-analysis of 13 studies: The risk of
early readmission is increased by 55%
when inpatient care is of relatively low
quality ...
I was discharged early ! They told me to just take these tablets !!!
Ashton CM et al. Ann Intern Med. 2005;122:415. Ashton CM et al. Med Care. 2007;35:1044
IN HOSPITAL …
Valle R et al
For many if not most patients, hospitalization is
just one step in chronic Heart Failure …
Once acute decompensation is stabilized we move
quikly to optimize chronic therapy IN HOSPITAL to
prevent rehospitalization.
PRE-DISCHARGE therapy determines early outcome …
Discharge and Follow-up:
The beginning of the “journey” of a vulnerable patient …
2001
Hospital Discharge Recommendation or Indication COR LOE
Performance improvement systems in the hospital and early postdischarge outpatient
setting to identify HF for GDMT I B
Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up
visits, the following should be addressed:
a) initiation of GDMT if not done or contraindicated;
b) causes of HF, barriers to care, and limitations in support;
c) assessment of volume status and blood pressure with adjustment of HF therapy;
d) optimization of chronic oral HF therapy;
e) renal function and electrolytes;
f) management of comorbid conditions;
g) HF education, self-care, emergency plans, and adherence; and
h) palliative or hospice care.
I B
Multidisciplinary HF disease-management programs for patients at high risk for hospital
readmission are recommended I B
A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of
hospital discharge is reasonable IIa B
Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is
reasonable IIa B
Patient Care Plan
Date of discharge
Name and contact information for physician and DA
Medications
Pending tests and results
Follow-up appointments
Calendar
Other orders (diet, activity, etc.)
Information about disease or condition
When to call physician or seek emergency care
Form for writing down questions
Map for locating appointments (optional)
Other information about your center (optional)
(52% of HF patients are not seen in the first 30 days after a hospitalization... Jencks et al. N Engl J Med 2009 )
First post-discharge assessment …
When ?
For a patient hospitalized due to AHF, pre-discharge phase is
crucial for the optimal preparation to the vulnerable period of
transition from in-patient to out-patient care.
During this phase the following aspects should be addressed:
Disease-modifying therapies should be initiated before discharge
and carefully optimized during early post-discharge period.
Comorbid conditions detected and managed.
Patients at the highest risk identified and carefully followed.
Potential precipitant causes of recurrent HF characterised.
Patients enrolled in the multi-faced disease management projects.
1) Partnering with community physicians or physician groups to reduce readmission (0.33 percentage point lower RSRRs; P=0.017)
1) Partnering with local hospitals to reduce readmissions (0.34 percentage point;
P=0.020)
2) Having nurses responsible for medication reconciliation (0.18 percentage point; P=0.002)
3) Arranging a follow-up appointment before discharge (0.19 percentage point; P=0.037)
4) Having a process in place to send all discharge paper or electronic summaries directly to the patient’s primary physician (0.21 percentage point; P=0.004),
5) Assigning staff to follow up on test results that return after the patient is discharged (0.26 percentage point; P=0.049)
Circ Cardiovasc Qual Outcomes.
2013
Un MINIMAL DATA SET alla dimissione per il Medico di Famiglia
FOLLOW-UP DOPO LA DIMISSIONE OSPEDALIERA
PZ A BASSO PROFILO DI RISCHIO
Follow-up di 1-(3)-6 mesi presso l’ambulatorio Scompenso Cardiaco per
up-tritation della terapia, FU strumentale, valutazione devices, …
Pz stabile Pz instabile
PZ AD ALTO PROFILO DI RISCHIO
Visita precoce (< 7 gg) presso l’Ambulatorio Scompenso Cardiaco
Protocolli Terapeutici ambulatoriali
Stretto monitoraggio telefonico
domiciliare
Reinvio e coinvolgimento del MMG - Follow-up
telefonico
Prosecuzione del Follow-up (tempi succ visita variabili…) ambulatoriale e telefonico
Decorso osp …. BNP no - Re-ammissione … - compliance Disf. Renale Comorbidità +++ Score +++
N Engl J Med 370;8, 2014