Factors Affecting Heart Failure Readmission Rates in VA Patients

DISCUSSION

Based on the trends observed in this study, multiple recommendations can be made to further improve the quality of care and reduce HF readmissions at JBVAMC. The medical center physicians currently use a discharge note template, which already includes sections such as HF discharge instructions and follow-up appointments. The template also prompts providers to prescribe an ACE-I in appropriate patients.

When JBVAMC providers are ready to enter discharge notes into the CPRS, they first select the discharge note template from available note template options. The electronic template contains spaces for the provider to enter a patient’s primary reason for hospitalization, date of admission, discharge medication list, specific or suggested dates for follow-up with outpatient provider(s), general diet/weight/medication instructions, a space to answer whether the patient has HF, a space to record NYHA HF class if applicable, and a space to record whether the patient is prescribed or will be prescribed an ACE-I if appropriate, or whether ACE-I is contraindicated. The providers are able to modify and add information to the discharge note template as they see appropriate.

The findings of this study suggest that modifying the existing discharge template to include additional provider prompts in a form of designated spaces asking for specific information may help improve HF care outcomes. If providers are prompted to answer whether an oral diuretic was continued for at least 24 hours after stopping IV diuretics for HF, adherence to the HF guideline-recommended duration of oral diuretic therapy may improve. Additionally, ß-blocker prescribing in appropriate systolic HF patients may increase if providers are prompted. To enhance continuity of care, the discharge note template may be modified to include a section in which the providers can document patients followed by outside providers. This can be done by incorporating a space in the discharge template to enter the patient’s non-VA provider information if applicable and may help further coordinate the care of such patients to ensure that they are not lost.

Furthermore, the discharge template may be modified to include a prompt to place a CHF clinic consult to increase provider awareness about the availability of CHF and CHF-PharmD clinics at JBVAMC. CHF and CHF-PharmD clinics collaborate to provide comprehensive care to HF patients. After an initial evaluation at the CHF clinic, patients are referred to the clinical pharmacist for further medication therapy management when necessary. Currently, the physicians are encouraged to refer HF patients to the CHF clinic after discharge, but not all providers know that such a service is available. The prompt within the discharge note template would provide CHF/CHF-PharmD clinic provider contact information, clinic times, and a link that would take the provider to an appropriate screen for placing the consult.

Limitations

There are several limitations to this study, including its retrospective design and small sample size. Another source of potential study limitation was the initial process for creating a study patient list. The study list was designed to use ICD-9 codes to capture readmissions only for HF and only at JBVAMC. This was achieved by specifying any of the HF ICD-9 codes as the principal discharge diagnosis. However, the providers may not have always used a HF specific ICD-9 code for the principal discharge diagnosis, even if a patient was admitted primarily for HF. The provider may have chosen another principal discharge diagnosis for which the patient received treatment during the hospitalization.

There are multiple ways to obtain HF patient lists, one includes using the diagnosis-related group codes instead of ICD-9 codes. Due to the way the patient list was obtained and an inherent possibility that some patients admitted for HF had a non-HF ICD-9 code recorded as their principal discharge diagnosis, some eligible patients may not have appeared on the generated list. Additionally, this study captured readmission rates for only HF whereas the national HF 30-day readmission rate represents all-cause readmissions for HF patients. This difference may be reflected in the low 30-day readmission rate observed.

Another possible limitation was the timing of the launch of the CHF-PharmD clinic and the initiative for telephone follow-up 48 hours postdischarge. The CHF-PharmD clinic was launched in April 2011, and the initiative for telephone follow-up 48 hours postdischarge began in January 2011. As the start dates fell within the study period, these services may not have been available to all patients. Therefore, the data describing patient enrollment in CHF-PharmD clinic and those who received postdischarge telephone follow-up may not accurately reflect current practice. Last, statistical tests were not used in the study data analysis leaving any differences found open to interpretation. To minimize these limitations, larger prospective studies with statistical analysis capturing all-cause readmissions are necessary to further evaluate patient characteristics that may be contributing to HF readmissions at JBVAMC.