A new study asserts that disease-management clinics, home visits by nurses and nurse case management should become the standard of care for elderly patients with heart failure after they are discharged from the hospital.
January 29, 2020 - By Beth Duff-Brown
Elderly patients hospitalized with congestive heart failure have a poor prognosis and high risk of death and hospital readmission, so their post-discharge care can strongly influence their outcomes.
Yet despite data showing that transitional care interventions, such as home visits by nurses, can reduce death rates and hospital readmissions by more than 30%, many health systems have not implemented such programs. Health policy experts say this is due in part to cost concerns and doubts about the effectiveness of these delivery services.
Now, a team of Stanford Medicine and Veterans Affairs researchers has sought to assess whether transitional care interventions provide good value and better outcomes, as there are 5 million people living with congestive heart failure in the United States and 500,000 new cases diagnosed each year. Congestive heart failure is the stage of chronic heart disease in which fluids build up around the heart, causing it to pump inefficiently.
The researchers updated a 2017 study on the impact of transitional care intervention with four years of additional data. They then used it to compare standard post-discharge management regimes for patients 75 and older with three transitional post-discharge regimes for elderly patients that were determined to be most effective: disease management clinics, nurse home visits and nurse case management.
All three transitional care interventions delivered appreciable health benefits to the patient population, said Jeremy Goldhaber-Fiebert, PhD, associate professor of medicine at the Stanford School of Medicine and core faculty member of Stanford Health Policy.
The findings were published Jan. 28 in the Annals of International Medicine. Goldhaber-Fiebert is the senior author. The lead authors are Manuel Blum, MD, MS, a graduate student in epidemiology and clinical research at Stanford in 2019 and now on the faculty of the University Hospital of Bern in Switzerland; Henning Øien, PhD, a researcher at the Norwegian Institute of Public Health; and Harris Carmichael, MD, a Stanford/Intermountain fellow in population health, delivery science and primary care.
“Transitional care interventions for older individuals with congestive heart failure — particularly nurse home visits — offer a high-value care alternative that could improve the health and longevity of millions of Americans,” he said.
The researchers said these transitional care services should become the standard of care for post-discharge management of patients who are 75 and older with heart failure.
Heart failure causes 1 in 8 deaths nationwide
The prevalence of heart failure is estimated to be 26 million people worldwide and growing. In the United states, 5.7 million adults have been diagnosed with heart failure, with an estimated annual medical cost of $39.2 billion to $60 billion. Total heart failure costs in the United States are expected to exceed $70 billion by 2030, the authors wrote. According to the Centers for Disease Control and Prevention, heart disease costs the United States about $219 billion each year as a result of health care services, medicines and lost productivity.
Of the 15 million Americans in their mid-70s and 80s today, about 1 million suffer heart failure.
“So population gains from more effective post-discharge care would be hundreds of thousands of life years,” Goldhaber-Fiebert said. “Likewise, tens of thousands of costly rehospitalizations could be prevented each year if these interventions were delivered successfully.”
Heart failure primarily affects older people and is the second-most common inpatient diagnosis billed to Medicare. Yet the authors cite a recent study of 18 million Medicaid charges which found that only 7% of eligible patients at risk of rehospitalization received transitional services.
The standard post-hospital care for those patients includes sending them home with some advice and scheduling follow-up cardiology appointments for them within 14 days of discharge. The researchers found that patients averaging 75 years old who received this standard post-hospitalization care had an average life expectancy of 3 years and an average of 3 hospitalizations during their remaining lifetime. While the other interventions — disease management clinics and nurse case management — were also helpful, nurse home visits were the most beneficial. Those visits decreased the number of hospitalizations by 10 readmissions per 100 patients and increased life expectancy by approximately four months, the study found.
“If these interventions were successfully implemented at scale, they could provide important substantial benefits with very good value,” said co-author Douglas Owens, MD, the Henry J. Kaiser Jr. Professor and professor of medicine at Stanford.
Reduced hospitalizations for congestive heart failure, according to the research, produce substantial cost savings that partially offset the costs of delivering the interventions. Though nurse home visits increase lifetime health care costs by $4,622, the substantial health benefits that they deliver justify their costs: $19,570 quality adjusted life years gained, which is considered highly cost-effective. Quality of life years is a measurement used by health policy experts to determine how much should be spent to get one additional year in full health. If the price is relatively low — as it is here — it’s the type of investment that a health system should consider, the authors said.
Hospital and insurance administrators take note
“Our results have important implications for decision-makers in hospital administration as well as in insurance and policy settings,” the authors wrote. They concluded:
· Transitional care services should become the standard of care for post-discharge management of patients with heart failure.
· This research is particularly informative to government decision-makers in programs like the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program, as restrictions and regulations affecting heart-failure hospital readmissions grow.
· Hospital administrators could use the research to determine which transitional services are most cost-effective for its rural population, overall patient base and hospital system.
The other Stanford co-author of the study was Paul Heidenreich, MD, professor of medicine and health research and policy.
The study was supported by the Swiss National Science Foundation, the Research Council of Norway and an Intermountain-Stanford collaboration.
About Stanford Medicine
Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.