A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure
Michael W. Rich, M.D., Valerie Beckham, R.N., Carol Wittenberg, R.N., Charles L. Leven, Ph.D., Kenneth E. Freedland, Ph.D., and Robert M. Carney, Ph.D.
Background Congestive heart failure is the most common indicationfor admission to the hospital among older adults. Behavioralfactors, such as poor compliance with treatment, frequentlycontribute to exacerbations of heart failure, a fact suggestingthat many admissions could be prevented.
Methods We conducted a prospective, randomized trial of theeffect of a nurse-directed, multidisciplinary intervention onrates of readmission within 90 days of hospital discharge, qualityof life, and costs of care for high-risk patients 70 years ofage or older who were hospitalized with congestive heart failure.The intervention consisted of comprehensive education of thepatient and family, a prescribed diet, social-service consultationand planning for an early discharge, a review of medications,and intensive follow-up.
Results Survival for 90 days without readmission, the primaryoutcome measure, was achieved in 91 of the 142 patients in thetreatment group, as compared with 75 of the 140 patients inthe control group, who received conventional care (P = 0.09).There were 94 readmissions in the control group and 53 in thetreatment group (risk ratio, 0.56; P = 0.02). The number ofreadmissions for heart failure was reduced by 56.2 percent inthe treatment group (54, vs. 24 in the control group; P = 0.04),whereas the number of readmissions for other causes was reducedby 28.5 percent (40 vs. 29, P not significant). In the controlgroup, 23 patients (16.4 percent) had more than one readmission,as compared with 9 patients (6.3 percent) in the treatment group(risk ratio, 0.39; P = 0.01). In a subgroup of 126 patients,quality-of-life scores at 90 days improved more from base linefor patients in the treatment group (P = 0.001). Because ofthe reduction in hospital admissions, the overall cost of carewas $460 less per patient in the treatment group.
Conclusions A nurse-directed, multidisciplinary interventioncan improve quality of life and reduce hospital use and medicalcosts for elderly patients with congestive heart failure.
Congestive heart failure is the most common indication for hospitalizationamong adults over 65 years of age,1 and the rate of admissionto treat this condition has increased progressively over thepast two decades.2 Elderly patients with heart failure are alsoat increased risk for early rehospitalization, with rates ofreadmission ranging from 29 to 47 percent within three to sixmonths of the initial discharge.3,4,5 Moreover, behavioral factors,such as noncompliance with medications and diet, and socialfactors, such as social isolation, frequently contribute toearly readmissions, suggesting that many such readmissions couldbe prevented.5,6
We hypothesized that a multidisciplinary approach to treatmentcould significantly reduce the rate of readmission for elderlypatients at high risk, and we conducted a feasibility studyto evaluate this hypothesis.7 In that study 98 patients 70 yearsof age or older who were hospitalized with congestive heartfailure were randomly assigned to receive either the study treatmentor conventional care. During a 90-day period of follow-up, thetreatment group had a 27 percent reduction in the readmissionrate, but the reduction was not statistically significant.7We then conducted a prospective, randomized trial of 282 patients,described in this report, to assess the effect of the interventionon the rate of readmission, quality of life, and the overallcost of medical care.
Methods
Patients
All patients 70 years of age or older who were admitted to themedical wards of Jewish Hospital at Washington University MedicalCenter were screened for congestive heart failure. For a diagnosisof heart failure, either definite radiographic evidence of pulmonarycongestion or typical symptoms and signs of heart failure inconjunction with definite clinical improvement in response todiuresis were required. Patients with confirmed heart failurewere eligible to participate in the study if they had at leastone of the following risk factors for early readmission, asdetermined in a previous study5: prior history of heart failure,four or more hospitalizations for any reason in the precedingfive years, or congestive heart failure precipitated by eitheran acute myocardial infarction or uncontrolled hypertension(systolic blood pressure >200 mm Hg or diastolic blood pressure>105 mm Hg). The criteria for exclusion from the study includedresidence outside the catchment area of Jewish Hospital HomeCare, planned discharge to a long-term-care facility, severedementia or other serious psychiatric illness, anticipated survivalof less than three months, refusal to participate by eitherthe patient or the physician, and logistic or discretionaryreasons (including participation in the pilot study7). The studywas approved by the institutional review board of Jewish Hospital,and all patients provided informed consent.
A total of 1306 patients 70 or more years of age met the criteriafor congestive heart failure from July 1990 through June 1994.Among them, 391 (29.9 percent) were excluded because they hadno risk factors for early readmission. An additional 633 patientswere excluded because they lived outside the catchment area(141 patients), because discharge to a long-term-care facilitywas planned (114), because they had dementia or psychiatricillness (19) or terminal illness (68), because the patient orthe physician decided not to participate (116), or for logisticor discretionary reasons (175), most commonly the inabilityto complete enrollment before discharge.
Randomization and Study Treatment
The patients underwent blinded randomization with the use ofa computer-generated list of random numbers immediately afterconsenting to participate in the study. Neither the patientnor the members of the study team were aware of the treatmentassignment until after randomization.
The study treatment consisted of intensive education about congestiveheart failure and its treatment by an experienced cardiovascularresearch nurse, using a teaching booklet developed by the studyinvestigators for geriatric patients with heart failure; individualizeddietary assessment and instruction given by a registered dietitianwith reinforcement by the study nurse; consultation with social-servicepersonnel to facilitate discharge planning and care after discharge;an analysis of medications by a geriatric cardiologist who madespecific recommendations to eliminate unnecessary medicationsand simplify the overall regimen; and intensive follow-up afterdischarge through the hospital's home care services, supplementedby individualized home visits and telephone contact with themembers of the study team. The principal goals of follow-upwere to reinforce the patient's education, ensure compliancewith medications and diet, and identify recurrent symptoms amenableto treatment on an outpatient basis. Additional details aboutthe intervention have been published previously.7
Patients assigned to conventional care (the control group) wereeligible to receive all standard treatments and services orderedby their primary physicians. In no case was standard or generallyaccepted therapy withheld.
Data Collection and Follow-Up
Detailed data were collected at the time of enrollment, includingdemographic and psychosocial information; items pertaining tothe patient's medical history, physical examination, and laboratoryevaluation; results of cardiac tests; and pertinent informationpertaining to the hospital course. All patients were followedfor 90 days after discharge. For patients rehospitalized duringfollow-up, data on the cause of readmission, the contributingfactors, and information on the hospital course during readmissionwere obtained. To minimize the burden placed on participatingpatients, data on quality of life and costs were collected onlyfor subgroups, as described below.
Quality of Life
Quality of life as the patient perceived it was assessed atbase line and at three months in 126 patients with the ChronicHeart Failure Questionnaire.8 This instrument consists of 20items that the patient was asked to rate on a scale from 1 (lowest)to 7 (highest); there are four subscales: dyspnea (containing4 items), fatigue (5 items), emotional function (7 items), andenvironmental mastery (4 items). Previous studies have shownthis questionnaire to be responsive to quality-of-life changesin patients with heart failure.8,9
Cost Analysis
Detailed data on all medical costs and costs for care giverswere collected prospectively, with cost logs, for 57 patientsduring the final year of the study. The logs were checked regularlyfor accuracy by study nurses. Logs were also maintained by thestudy personnel to determine the cost of the treatment, exclusiveof costs for research and monitoring (i.e., screening, randomization,data collection, and follow-up). An hourly rate of $20 was chosenas the cost of nursing time (including direct contact with thepatient, travel, and telephone calls), as well as for time spentby the dietitian, social worker, and home care team. An hourlyrate of $6 was chosen as the cost of time spent by unpaid caregivers (i.e., spouses, family, and friends). Costs for hospitaladmissions were based on the allowed reimbursements providedaccording to standard codes for each diagnosis-related group(DRG). To calculate the overall cost of medical care duringthe 90-day follow-up period, the mean cost of readmission forall patients in each group was added to the average cost fornonhospital medical services and care givers, and, in the treatmentgroup, for the intervention. All costs were adjusted to 1994dollars.
Study End Points and Statistical Analysis
All the analyses were conducted according to the intention-to-treatprinciple, with survival for 90 days without readmission asthe primary, prespecified outcome measure. Secondary end pointsincluded the number of readmissions for any cause, the numberof readmissions for congestive heart failure, the cumulativenumber of days of hospitalization during follow-up, quality-of-lifescores, and the overall cost of medical care.
The two study groups were compared by Student's t-test (two-tailed)for normally distributed continuous variables, by the chi-squaretest for discrete variables, and by the Wilcoxon rank-sum testfor categorical variables and continuous variables not normallydistributed. Stepwise proportional-hazards regression was usedto identify predictors of readmission within 90 days of dischargefrom the hospital. A backward, sequential survival analysiswas performed with the Cox proportional-hazards model to determinewhether the treatment assignment was an independent predictorof readmission after adjustment for other relevant covariates.10Kaplan–Meier survival curves were constructed to assessthe probability of survival without readmission during the follow-upperiod. In both the Cox and the Kaplan–Meier analyses,data on patients who died without readmission to the hospitalwere censored at the time of death. Risk ratios and 95 percentconfidence intervals were calculated, when appropriate, to compareoutcomes between groups.11 A P value of less than 0.05 was consideredto indicate statistical significance in the major comparisonsbetween groups. The results are expressed as means ±SDunless otherwise specified.
Results
Base-Line Characteristics
The base-line characteristics of the study patients are shownin Table 1. The median age of the patients was 79 years; 63percent were women, and 45 percent were white (except for twoAsians, the remainder were black). The two groups were wellbalanced with respect to most base-line characteristics, includingNew York Heart Association functional class and left ventricularejection fraction. The patients in the treatment group weresomewhat older and better educated, however. They also had higherheart rates on the base-line electrocardiogram and were morelikely to have undergone previous coronary-artery revascularization.It is important to note, however, that none of those variableshad a significant effect on the rate of readmission.
Table 1. Base-Line Characteristics of the Study Patients.
Event-Free Survival
As Table 2 shows, 17 patients in the control group (12.1 percent)died during the study period, as compared with 13 patients inthe treatment group (9.2 percent). Survival for 90 days withoutreadmission, the primary end point, occurred in 75 patientsin the control group (53.6 percent), as compared with 91 patientsin the treatment group (64.1 percent), but this difference wasnot significant (absolute difference, 10.5 percent; 95 percentconfidence interval, -0.9 to +21.9 percent; percent difference,19.6 percent; P = 0.09). When the analysis was restricted tosurvivors of the initial hospitalization, however, a significantdifference in survival for 90 days without readmission was noted(54.3 percent in the control group vs. 66.9 percent in the treatmentgroup; 95 percent confidence interval for the difference, 1.1to 24.1 percent; P = 0.04).
Table 2. Readmission and Death within 90 Days of Initial Discharge from the Hospital.
Readmissions
As Table 2 and Figure 1 show, 59 patients in the control group(42.1 percent) had at least one readmission during follow-up,as compared with 41 patients in the treatment group (28.9 percent;absolute reduction, 13.2 percent; 95 percent confidence interval,2.1 to 24.3 percent; P = 0.03). Multiple readmissions were morefrequent in the control group (16.4 percent, vs. 6.3 percentin the treatment group; 95 percent confidence interval for thedifference, 2.8 to 17.4 percent; P = 0.01), so that the totalnumber of readmissions during follow-up was reduced by 44.4percent (P = 0.02). Similarly, the total number of days of hospitalizationwas reduced from 865 in the control group to 556 in the treatmentgroup, for a net reduction in hospital use of 35.7 percent (P= 0.04).
Figure 1. Kaplan–Meier Curves for the Probability of Not Being Readmitted to the Hospital during the 90-Day Period of Follow-up.
Data on patients who died without being readmitted were censored at the time of death.
Overall, 78 of the 147 readmissions were for recurrent heartfailure (53.1 percent). In the control group, there were 54readmissions due to heart failure, as compared with only 24in the treatment group (risk ratio, 0.44; P = 0.04). Readmissionsfor reasons other than heart failure were also more frequentin the control group (40 vs. 29; risk ratio, 0.71), but thisdifference was not significant.
To determine whether assignment to the treatment group was associatedwith a reduced rate of readmission after adjustment for base-linedifferences between groups and other prognostic factors, weconstructed a Cox proportional-hazards model. As Table 3 shows,the strongest independent predictors of readmission were higherblood urea nitrogen level, higher systolic blood pressure, higherserum sodium level, and presence of diabetes mellitus. Afteradjustment for these variables as well as for other univariatepredictors of readmission, assignment to the control group remaineda significant independent predictor of rehospitalization.
Table 3. Independent Predictors of Readmission, According to the Cox Proportional-Hazards Model.
Quality of Life
Table 4 shows base-line and three-month scores on the ChronicHeart Failure Questionnaire administered to 126 patients. Althoughthe quality of life improved in both groups, there was significantlymore improvement in the treatment group (22.1±20.8 vs.11.3±16.4, P = 0.001). In addition, quality of life improvedconsistently on each of the four subscales among the patientsreceiving the treatment (range, 52 percent to 195 percent).During the 90-day follow-up period, 11 patients were admittedto long-term care facilities (5 in the treatment group and 6in the control group).
Table 4. Changes in Quality-of-Life Scores as Determined from the Chronic Heart Failure Questionnaire.
Cost of Care
The average cost of the study intervention was $216 per patient(Table 5). Two thirds of this amount was spent on nursing time,representing an average of 7.2 hours per patient. Other costsfor medical care, excluding those for readmissions, were similarbetween the two study groups. However, care givers spent 33more minutes per patient per day attending to the patients inthe treatment group than to those in the control group, foran estimated incremental cost of $336 per patient. This extratime was anticipated and reflected increased involvement bycare givers in the home. The costs of hospital readmissionswere higher in the control group by an average of $1,058 perpatient ($3,236 vs. $2,178, P = 0.03). As a result, the overallcost of care was higher in the control group by $460, or anaverage of $153 per patient per month.
The Agency for Health Care Policy and Research (AHCPR) recentlypublished guidelines for the evaluation and care of patientswith congestive heart failure.12 These guidelines contain recommendationsfor patient and family counseling, dietary assessment, nursingand social-service interventions, support groups, and specificmeasures to improve compliance. These recommendations, thoughlogical, are based principally on expert opinion, with few publisheddata to verify their efficacy.12 The present study providesstrong support for the AHCPR guidelines by demonstrating thata multidisciplinary intervention can significantly reduce therate of readmission, improve the quality of life, and decreasethe overall cost of medical care. The benefit in terms of reducinghospital admissions and improving quality of life was at leastas great as that reported with vasodilator therapy, includingtreatment with angiotensin-converting–enzyme inhibitors.13,14,15,16Moreover, in contrast to treatment with vasodilators, the benefitsof which are associated with incremental increases in cost,17the current intervention reduced costs.
Several previous investigators have attempted to reduce readmissionsin various patient populations,18,19,20,21,22,23,24,25,26,27,28,29but except for our pilot study,7 only one trial has specificallybeen addressed to patients with heart failure.28 Although theresults of these studies were generally favorable, the benefitwas slight, perhaps reflecting the nature of the study populationsand the interventions used. We focused specifically on elderlypatients with heart failure, who are known to be at high riskfor early readmission,3,4,5 and we developed a multidisciplinaryintervention to address previously identified causes of rehospitalization.5Although our findings are generally concordant with earlierreports,18,19,20,21,22,23,24,25,26,27,28,29 we believe thatour approach of targeting a high-risk population and using amore comprehensive intervention resulted in more favorable outcomes.
As expected, the principal effect of the intervention was inreducing the rate of readmission due to recurrent heart failure;this rate declined by 56.2 percent. However, in the treatmentgroup there were also fewer readmissions for other causes. Althoughthis difference was not statistically significant, it suggeststhat close follow-up may provide additional benefits beyondsimply reducing the likelihood of exacerbations of heart failure.
This study has several limitations, the first of which concernsthe generalizability of the results. A total of 1306 patientsfulfilled the criteria for a diagnosis of congestive heart failure,but only 282 (21.6 percent) were randomized. The distinguishingcharacteristics of the randomized cohort included advanced age(median, 79 years), a high prevalence of hypertension (75.9percent), moderate functional impairment, and relatively wellpreserved left ventricular systolic function. The applicabilityof our findings to other patients with heart failure requiresfurther study.
A second limitation is that because of the multidisciplinarynature of the intervention, we are unable to say which elementswere most important in reducing readmission rates and improvingthe quality of life. To do so is important from the perspectiveof cost, since the elimination of any unnecessary features couldresult in further cost savings. To clarify this issue, additionalanalyses were performed to assess compliance with medication,evaluate the review of medications, and determine the effectsof the intervention on the patients' understanding of heartfailure. Good compliance with medication, as assessed by pillcounts 30 days after discharge and defined as having been accomplishedwhen 80 percent of pills or more were taken correctly, was achievedin 82.5 percent of patients in the treatment group as comparedwith 64.9 percent in the control group (P = 0.02). With regardto the number of medications and dosing frequency, the onlydifference between groups was that the maximal number of dailydoses at discharge from the hospital was significantly lowerin the treatment group (2.7±1.0, vs. 3.0±0.9 inthe control group; P = 0.01), suggesting that the interventionhad a slight effect in simplifying the medication regimen. Finally,on the basis of the results of an eight-item multiple-choicequestionnaire, the patients in the treatment group had a betterunderstanding of heart failure than those in the control group,both at the time of discharge and at the three-month follow-up(P<0.001 for both). These findings suggest that all componentsof the intervention were beneficial. Given the relatively lowcost of the intervention ($72 per patient per month), eliminatingany of its components would be unlikely to lower the cost substantially.
A third limitation is the relatively short duration of the follow-upperiod. We selected a 90-day follow-up interval on the basisof previous studies showing that the period with the highestrisk for readmission is the first 30 days after initial dischargeand that readmission rates decline substantially after 3 months.Thus, to maximize cost effectiveness, the study was designedfor high-risk patients during the high-risk period. Nonetheless,we followed all patients for one year. Readmission rates duringthe nine months after the discontinuation of the study interventionhave been similar in the two groups (155 in the control groupvs. 138 in the treatment group), but readmissions for heartfailure have been less frequent in the treatment group (80 vs.57, P = 0.08). These data strongly suggest that the interventiondid not simply postpone readmissions, but its beneficial effectsalso appeared to persist for up to one year. Thus, the long-termcost savings with the intervention may be even greater thanour data indicate.
Although we believe that the reduced rate of readmission andthe improved quality of life in our patients were direct consequencesof the study intervention, two alternate hypotheses could explainour findings. First, the patients assigned to the control groupmay have received substandard care. As we noted in the Methodssection, the patients in the control group were treated by theirprivate physicians, and no standard therapy was withheld. Whenwe analyzed the medications taken at discharge, there were nodifferences between the groups in the use of digoxin, diuretics,angiotensin-converting–enzyme inhibitors, or other cardiovascularagents. Thus, differences in outcome cannot be attributed todifferences in the medication regimen. With regard to the useof other services, dietary consultation was obtained by 49 percentof patients in the control group; 46 percent were seen in consultationby social-service personnel; and 39 percent had home care afterdischarge. These figures likely reflect current practice patternsfor the use of these services in the United States.
Another alternative explanation for our findings is that thepatients in the treatment group may have had better outcomessimply because of the increased attention and care they received.However, we consider it unlikely that the greater attentiongiven to these patients accounted for the wide differences inoutcomes; instead, the focused nature of the intervention andthe fact that it had multiple components provide the most plausibleexplanations for our findings.
In summary, this study demonstrates that a nurse-directed, multidisciplinarytreatment strategy can significantly reduce hospital readmissionsand improve the quality of life for elderly patients with heartfailure. Widespread use of this intervention in caring for thegrowing number of elderly patients hospitalized with heart failurecould substantially reduce costs for health care.
Supported by a grant (HL44739) from the National Heart, Lung,and Blood Institute.
We are indebted to the following persons and agencies, withoutwhose support this study could not have been successfully completed:Kathe Berger, R.N., Terri Daiber, R.N., Karen Jefferson, R.N.,Karen Schnarr, R.N., Pam Story, R.N., Diane Baldus, R.Ph., JanetStaicoff, R.D., Maria Ylagan, R.D., Jane Huber, D.T.R., NancyCarrol, L.C.S.W., Savannah Davis, L.C.S.W., Mary Moore, L.C.S.W.,Gary Borgard, M.S.W., Maria Nguyen, M.S.W., Marge Leaders, andthe Division of Home Care, the Department of Social Work, andthe Department of Pharmacy at Jewish Hospital.
Source Information
From the Geriatric Cardiology Section, Division of Cardiology (M.W.R., V.B., C.W.), and the Behavioral Medicine Section, Department of Psychiatry (K.E.F., R.M.C.), Jewish Hospital at Washington University; and the Department of Economics, Washington University (C.L.L.) — both in St. Louis.
Address reprint requests to Dr. Rich at Jewish Hospital of St. Louis, 216 S. Kingshighway, St. Louis, MO 63110.
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A Trial of Increased Access to Primary Care
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