2) It’s not readmissions that are the problem—it’s avoidable readmissions.
“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”
Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.2 He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”
“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”
3) New interventional technologies will mean more complex patients, so be ready.
Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.
“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”
Many of these patients have other problems, including renal insufficiency, diabetes, and the like.
“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.
4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.
“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”
5) Switching from IV diuretics to an oral regimen calls for careful monitoring.
Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.
Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.
“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”
6) Patients with heart failure with preserved ejection
fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.