Running head: REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 1

Reducing Hospital Readmissions Among Heart Failure Patients Using a Post-Hospitalization

Education Program

Marline Faustin

University of South Florida

REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 2

Abstract

Clinical problem: Heart failure (HF) is the leading cause of hospitalization in the United States

(Deeka, Skouri, & Noureddine, 2016). Patients with chronic HF have a higher rate of

readmissions due to the complexity of the condition.

Objective: To determine if a post-hospitalization program would decrease the rate of readmission

in heart failure patients > 60 years old. PubMed, CINAHL, American Heart Association and the

Centers for Medicare and Medicaid were accessed to obtain randomized clinical trials (RCT) and

clinical guidelines. Education, heart failure, readmission, adults, post-hospitalization were key

search terms used to obtain RCTs and clinical guidelines.

Results: The American Heart Association provided a program that could reduce 30-day

readmissions to meet the reimbursement measures of the Center for Medicare and Medicaid

services (American Heart Association, 2016). Balaban et al. (2015) showed that the use of

patient navigators (PN), who provided a 30-day post-discharge education to HF patients >60

years old, had a statistically significant 4.1% decrease in hospital readmissions (CI=95%, 0.2-8,

p<.05) as compared to a statistically significant 11.8 % increase in hospital readmission (CI=

95%,4.4-19, p<.05) for patients who werent provided PNs post-discharge. Basoor et al. (2013)

showed that a checklist that provided effective discharge education decreased the number of

readmissions in patients who were exposed to the checklist than patients who werent (p <.001).

Yu et al. demonstrated that providing transitional care (TC) to HF patients post-discharge

showed fewer readmission rates at six weeks (p=.048).

Conclusion: The literature showed that for the completion of the controlled trials there was a

mild reduction in readmission rates. More research is needed to determine if there is truly a

correlation between a post-hospitalization education program and HF readmission rates.

REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 3

Reducing Hospital Readmissions Among Heart Failure Patients Using a Post-Hospitalization

Education Program

The leading cause of hospitalization in the United States (U.S.) and other developing

countries, among adults greater than 60 years old is heart failure (HF) (Deeka, Skouri, &

Noureddine, 2016). In reviewing the quality of care of patients with HF, the key performance

measure is the readmission rates of these patients with this chronic condition (Deeka et al.,

2016). The Affordable Care Act (ACA) added a section to the Social Security Act, which

developed a Hospital Readmission Reduction Program (HRRP). The ACA required the Center

for Medicare and Medicaid Services (CMS) to hold their reimbursements for hospitals with

excessive hospital readmissions, which included HF patients (Centers for Medicare and

Medicaid Services, 2016). The American Heart Association created Get With The Guidelines-

Heart Failure, as an in-hospital program to decrease 30-day readmissions, helping hospitals meet

the HRRP criteria (American Heart Association, 2016). The purpose of this paper is to discuss

the effectiveness of a post-hospitalization education program, in decreasing readmission rates for

this population. In adult patients with HF, how does a post-hospitalization education program,

compared to no education program, affect hospital readmission rates over three months?

Literature Search

The databases that were accessed to obtain clinical trials and guidelines about reducing

HF readmissions were PubMed, the American Heart Association and the Center for Medicare

and Medicaid Services. Education, heart failure, readmission, adults, post-hospitalization, were

key search terms used to find the supporting literature. The years the literature was searched for

were 2013,2015, and 2016.

REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 4

Literature Review

In evaluating the effectiveness of a post-hospitalization program in reducing the rate of

HF readmission rates, three randomized control trials (RCT) were used. Balaban et al. (2015)

conducted an RCT, in which patients were randomly assigned using a computer algorithm to

determine if interventions led by patient navigators (PN) (hospital-based community health

workers) would reduce hospital readmissions among high risk, low socioeconomic patients.

There was 585 intervention group patients and 925 control group patients. The intervention

group was exposed to PNs that provided coaching and assistance through a transition from

hospital to home by making hospital visits and weekly telephone outreach, supporting patients

for 30-day post-discharge with discharge preparation, providing medication management,

scheduling of follow-up appointments, communicating with primary care, and maintaining

symptom management. The control group was exposed to the standard outpatient and inpatient

care. The outcomes of this study were evaluated as an entire cohort, then stratified by patients

age >60 years old or <60 years old. Patients in the intervention group >60 years old showed a

statistically significant 4.1% decrease in hospital readmissions (CI=95%, 0.2-8, p<.05) and an

increase in 30-day outpatient follow-up. Intervention patients < 60 showed a statistically

significant 11.8 % increase in hospital readmission (CI= 95%,4.4-19, p<.05) with no change in

30-day outpatient follow-up. Some strengths of this study were that the participants were

randomized, random assignment was concealed from the individuals who enrolled as patients for

the study, the rationale for participant attrition was explained, the patients were analyzed in the

groups they were randomly assigned, the patients in each group were similar in demographics

and clinical variables, and there was a large sample size. Some weaknesses of the study were the

30-day post-discharge time frame, which was a short amount of time to observe a change in
REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 5

patients with complex health issues, the patient navigators were not blinded to the study, and the

validity and reliability of the instruments used to measure the study were not given.

Basoor et al. (2013) evaluated the use of a checklist that provided effective discharge

instructions, appropriate dose uptitration, education regarding HF monitoring, and strict follow-

up to decrease readmissions for HF patients. The design of the study was an RCT. There was a

total of 96 diagnosed HF participants. Forty-eight participants that were randomized to the

control and 48 participants randomized to the intervention group. The intervention group was

exposed to a post-discharge checklist, which included effective discharge instructions,

appropriate dose uptitration, education regarding HF monitoring, and strict follow-up guidelines.

The control group was exposed to the standard post-discharge guidelines. The outcomes of the

study resulted in decreased readmissions. The result showed a statistical significance (p <.001).

At 30 days, the intervention group had fewer readmissions (6%) than the control group (19%).

At six months, the intervention group had fewer readmissions (23%) than the control group

(42%) (p<.001). The use of a post-discharge checklist was associated with decreased readmission

rates for patients admitted with HF. Weaknesses of the study included the small sample size

which made it less representative of the patient population and the subjects were not blinded to

the study. Some strengths of this study were the measure of readmission outcomes was valid, the

randomization of both control and intervention groups, the random assignment was concealed

from the patients, patients in the study had similar demographics and baseline clinical variables,

the control was appropriate for the study, a rationale was provided as to why participants were

not able to complete the study, and the six months follow-up was enough time to evaluate the

effectiveness of the intervention.

REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 6

Yu et al. (2015), designed a single-centered, RCT of transition care (TC) versus usual

care (UC) to examine the effects of nurse-implemented transitional care (TC) upon readmission

rates. There was a total of 178 chronic HF participants over the age of 60; 88 participants

randomized to the control group, and 90 participants randomized to the intervention group. The

control group was exposed to the usual inpatient care (UC), while the intervention group

received pre-discharged visits, two home visits and phone calls to provide education, self-care,

and support over a nine-month period. Thirty individuals did not complete the study with a

higher number of attrition in the UC group. The study results showed fewer readmission rates at

six weeks (p=.048). Strengths of the study included, patients randomly assigned to an

intervention and a control group, a rationale was given for those who did not complete the study,

follow-up assessments were conducted over nine months, which was long enough to examine the

effects of the intervention, the control group was appropriate for the study, the subjects were

analyzed in the groups they were randomly assigned, and all subjects of both groups were similar

in demographics and baseline clinical variables. Some weaknesses that the study had were nurses

who implemented the care were not blind to the study, the study was a single centered RCT, and

the validity and reliability of the instruments used to measure the study were unclear.

Synthesis

Balaban et al. (2015) showed that a post-discharge education program involving PNs for

HF patients resulted in fewer readmissions for patients that were > 60 years old (p<.05). Basoor

et al. (2013) demonstrated that a post-discharge checklist was associated with decrease

readmission rates in HF patients in the intervention groups (p<.001). Finally, Yu et al. (2015)

discovered that patients who were exposed to nurse-implemented transitional care only had

fewer readmission rates at six weeks (p=.048).

REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 7

The research shows that the use of a post-hospitalization program does have an effect

upon reducing readmission rates in patients with HF > 60 years old. Each study demonstrates a

different method of a post-hospitalization program in reducing HF readmissions. All three of the

studies showed a mild reduction of readmission in HF patients. In the study Balaban et al.

conducted, there was the largest difference in the control group and intervention group and

largest sample size compared to the other two studies conducted by Yu et al. (2015) and Basoor

et al. (2013). More research is needed to determine if there is truly a positive correlation between

a post-hospitalization program and HF readmission rates. Lastly, the way the program is

delivered may also be a factor in how effective it is in reducing the rate of readmissions in HF

patients > 60 years old that warrants further research.

Clinical Recommendation

Clinical guidelines for treatment of HF that include strategic education do not yet exist.

The AHA created the Get With the Guidelines-Heart Failure program to ensure full

reimbursement for hospitals. This AHA program aimed to improve care by promoting consistent

adherence to the latest scientific treatment guidelines which included access to the most up-to-

date research, patient education resources, and clinical tools (American Heart Association,

2016). Numerous studies have shown that the AHA Get With The Guidelines-Heart Failure

program has shown a significant improvement in patient outcome. One of these outcomes was a

reduction in 30-day readmissions in HF patients. In determining reimbursement rates, the CMS

measures the number of readmissions within 30-days of discharge for patients being admitted

with the same diagnosis like HF, pneumonia and myocardial infarction (Centers for Medicare

and Medicaid Services, 2016). A clinical guideline and this program would drive practice in very
REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 8

similar ways as a post-hospitalization education program in reducing hospital readmissions for

HF patients.
REDUCING READMISSIONS FOR HEART FAILURE PATIENTS 9

Reference

American Heart Association (2016). Get with the guidelines-heart failure overview. Retrieved

from

http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines/GetWithTheGui

delines-HF/Get-With-The-Guidelines-Heart-Failure-

Overview_UCM_307806_Article.jsp#.WCgHRy0rLIU

Balaban, R. B., Galbraith, A. A., Burns, M. E., Vialle-Valentin, C. E., Larochelle, M. R., &

Ross-Degnan, D. (2015). A patient navigator intervention to reduce hospital readmissions

among high-risk safety-net patients: A randomized controlled trial. Journal of Internal

Medicine, 30(3), 907-915. doi: 10.1007/s11606-015-3185-x.

Basoor, A., Doshi, N. C., Cotant, J. F., Saleh, T., Todorov, M., Choksi...Halabi, A. R. (2013).

Decreased readmissions and improved quality of care with the use of an inexpensive

checklist in heart failure. Congested Heart Failure, 19(4), 200-206. doi:

10.1111/chf.12031

Centers for Medicare and Medicaid Services (2016). Readmissions reduction program (HRRP).

https://www.cms.gov/medicare/medicare-fee-for-service-

payment/acuteinpatientpps/readmissions-reduction-program.html

Deeka, H., Skouri, H., & Noureddine, S. (2016). Readmission rates and related factors in

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Yu, D. S., Lee, D. T., Stewart S., Thompson, D. R., Choi, K. C., & Yu, C. M. (2015).

Effect of nurse-implemented transitional care for Chinese individuals with chronic heart

failure in Hong Kong: A randomized controlled trial. Journal of the American Geriatric

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