Postdischarge assessment and management of patients with heart failure






Martin R. COWIE,MD, MSc, FRCP, FRCP (Ed), FESC
Professor of Cardiology
Imperial College London – Royal Brompton Hospital
London, UNITED KINGDOM

Postdischarge assessment and management of patients with heart failure


by M. R. Cowie, United Kingdom



After discharge from hospital, patients with heart failure are at high risk of mortality and rehospitalization: around 20% of patients are readmitted within 30 days, and 5% may die during that period. In most countries, only a minority of patients gain access to multiprofessional disease management programs, which can provide early and repeated contact between the patient (and family) and the health care professional team. The evidence for improved outcome and experience of care of such an approach is robust. International guidelines clearly recommend this type of approach, with the most recent US guideline stating that a follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital discharge is “reasonable.” The key components of a disease management program include optimized medical and device management, patient education, involvement in symptom monitoring and flexible diuretic dosing, follow-up after discharge, facilitated access to care during periods of decompensation, access to advanced treatment options, and the provision of psychosocial support to patients and the family/carers. A person-centered approach is essential to ensure optimal adherence to treatment and lifestyle changes. Technology can help support patient education, monitoring, and self-care. Increasingly, health care systems are aligning payment systems to improve heart failure care, particularly in the transition from hospital care to longer-term care in the community, but the room for improvement remains huge.

Medicographia. 2015;37:155-162 (see French abstract on page 162)



After discharge from hospital, patients with heart failure are at high risk of mortality and rehospitalization. In the most recently available data from England, 9.4% of patients died during the hospitalization, a further 6.1% died within 30 days of discharge, and readmission occurred in 19.1% by 30 days.1 In other European countries, reported rehospitalization rates are typically around 25% at 12 weeks.2 In the United States, 30-day readmission rates are similar: between 20% to 25%.3,4 Recurrence of heart failure is the single most common reason, accounting for 30% to 60% of all readmissions.4,5 More broadly, unscheduled contact with the health service after hospital discharge is greatest in the first few weeks and months, rising to 50% by 12 months.6

International guidelines recommend that patients undergo a clinical review by a clinician with experience in heart failure soon after discharge from hospital.7,8 The 2014 guideline from the National Institute for Health and Care Excellence (NICE) in England also recommends early clinical review.9 The goal is to provide a high-quality transition to outpatient and community care, supporting self-care where possible. Ideally, patients should be enrolled in a disease management program, but in the absence of such a structured multidisciplinary program, review by a clinician with experience in heart failure is considered better than “routine” follow-up in a general clinic or only in primary care.





The most recent US guideline suggests that it is reasonable for patients to have a telephone follow-up within 3 days of discharge and/or a face-to-face clinical review within 1 to 2 weeks (Table I).7,10-27 Data from several countries suggest that such early follow-up is the exception rather than the rule. In the United Kingdom only 56% of hospitalized patients have any follow-up organized with a multiprofessional heart failure team, and only 34% have such a follow-up within 2 weeks of discharge,1 and in France only 28% of patients visited their cardiologist within 3 months of discharge.28

Content of disease management programs

Heart failure–specific disease management programs are now standard in many high-income countries, at least for patients who are seen by cardiologists. They have evolved from nurse-led programs for drug titration and education, and have incorporated evidence from programs used to manage other chronic conditions, such as diabetes or asthma. The structure of the programs varies, but they usually start during the hospital admission and involve multiple follow-up visits either at the clinic or at home. The European Society of Cardiology (ESC) has published guidelines on such programs,8,29 with emphasis on several key components (Table II).8

The evidence for the benefit of such disease management programs is good, with reductions in rates of readmission and mortality, and improvements in quality of life compared with usual care.30-31 The nature of the interventions studied in randomized trials has varied, but most include inpatient contact and then early follow-up, often with telephone support in addition to face-to-face visits either in a clinic or at home.

However, the evidence base for such recommendations is largely confined to randomized trials from high-income countries. In a recent meta-analysis of disease management programs for heart failure, including 46 studies,32 30 (65%) were based in the United States or Canada, 9 in Europe, 6 in Australia or New Zealand, and only 1 came from a middle-income country, Argentina. More recently, a small randomized study of a nurse-based management program following discharge from hospital in Brazil reported an improved outcome for patients with heart failure, even for those with a low background level of education.33 The program consisted of up to 4 home visits of an hour’s duration after discharge from hospital. The first occurred within 10 days of discharge (in keeping with the most recent North American guidelines), and then at 1 month, 2 months, and 4 months after discharge. In addition, there were telephone calls during the program (4 calls of around 10 minutes) to reinforce the recommendations made during the home visits, to check the use of prescribed medication, and to answer questions about the condition and its treatment.


Table I
Table I. Summary of recommendations for hospital discharge in the most recent US guidelines on heart failure management.

Abbreviations: COR, class of recommendation; HF, heart failure; GDMT, guideline-directed medical therapy; LOE, level of evidence After reference 7: Yancy et al. J Am Coll Cardiol. 2013;62:e147-e239. © 2013 American College of Cardiology Foundation and American Heart Association, Inc.



Table II
Table II. Key components of a disease management program for patients with heart failure.

After reference 8: McMurray et al. Eur Heart J. 2012;33(14):1787-1847. © 2012, The European Society of Cardiology. All rights reserved.



There may be an optimal amount of patient contact, particularly where the quality of “usual” care is high. In the COACH study (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure),34 there was no improvement in patient outcome with an intensive support program provided by a nurse compared with either a moderate-intensity program or usual follow-up by a cardiologist.

Patient (and family) education is a key component of all disease management programs. The guideline of the Heart Failure Association of the ESC gives an extensive list of items that should be covered (Table III, page 158).8

A person-centered approach

It can be easy to lose sight of the individual when running a disease management program: there can be a temptation to let “one size fit all,” and to “tick the boxes” rather than tailor the speed and approach to the patient and their family.

Health policy has increasingly signaled a move away from an emphasis on specific organs and disease, toward placing the “whole” person at the center of medicine.35 The health professional must try to understand what the illness means for the individual, within a social and psychological context. This necessitates listening to that particular person’s point of view, with the ultimate goal of sharing responsibility with them.36

Clinicians should learn to ask not only “what is the matter?” but “what matters?” In other words, what are the patient’s interests, concerns, and fears about the specific conditions, symptoms, or treatment options?37 This moves us from the strictly biomedical view to a broader biopsychosocial and spiritual view, with power shared between the health care professional and the patient.38

Clinical guidelines in cardiology are largely silent about the person-centered approach, other than to state or imply that the clinician must consider how best to apply the evidence base to their patient. In the guidelines for chronic conditions (such as heart failure), the multidisciplinary approach is strongly supported, with professionals working together (with the patient and family) in a coordinated manner.8 An explicit discussion of the person-centered approach is not given, but rather indicators of which “type” of patients might or might not benefit from specific interventions. This approach is still directive—the application of what the professionals consider the best treatment—without a fuller discussion of the issues on a more equal basis. Two key components of person-centered care are collaborative goal setting and action planning: agreeing on what, when, where, and how often specific actions are required and the barriers to such actions for that individual patient.39 Such an approach helps foster self-efficacy and may assist the person in moving from a position of dependence to that of being an “expert,” if that is what they wish.40

The evidence that this can make a difference is emerging,41 and is likely to be something that politicians and society will increasingly expect of health care systems.

Self-care

Obviously, the individual with heart failure is key to the success of long-term management after hospitalization for this condition. Even with frequent contact with health care professionals, active involvement of the patient and their family or carers is important to optimize outcomes and the experience of care. Disease management programs aim to support self-care, where this is wished by the patient. There are 3 key components to self-care: maintenance, monitoring, and management. Maintenance involves adherence to medication and life-style changes; monitoring includes keeping an eye on signs and symptoms of heart failure and activities such as daily weighing; and management implies making changes to therapy (such as diuretic dose) in response to a fluctuation in symptoms.


Table III
Table III. Essential topics that should be covered during patient education and the skills and self-care behaviors that should be taught
in relation to these topics, according to the most recent European Society of Cardiology (ESC) guidelines.

After reference 8: McMurray et al. Eur Heart J. 2012;33(14):1787-1847. © 2012, The European Society of Cardiology. All rights reserved.



A large variation in adherence to self-management has been reported.42,43 In a global study, most patients reported taking their medication as prescribed, but adherence to exercise prescriptions was below 50%.43 Other studies report lower adherence to medication, even after hospital discharge, with adherence of only 80% at 1 month after discharge, and 60% to 65% between 3 months and 1 year after discharge.44 One survey suggested that a lack of understanding of discharge instructions and confusion engendered by conflicting instructions from the discharging physician and primary care physician were the main reasons for nonadherence to medication.45 Many patients continue to take previously prescribed medications, despite them being discontinued in hospital.46 In a recent US study, large variations in self-management were reported, even though individuals received self-care education at regular clinic visits. 42 Only 9% of patients showed good adherence to 8 key behaviors—such patients had the lowest risk of hospital admission, days in hospital, and emergency room visits, and better health status (Figure 1).42


Figure 1
Figure 1. Adherence levels to self-care behaviors
among patients with heart failure.

Good adherence is defined as patients reporting adherence
to a given behavior “all of the time” or “most of the
time” over the past 4 weeks.
After reference 42: Marti et al. Congest Heart Fail.
2013;19:16-24. © 2012, Wiley Periodicals, Inc.


Role of the family/carers

Higher levels of social support from friends and family are associated with increased medication and dietary adherence.47,48 High levels of support from a partner are also important and improve self-care.49 Negative influence from family or friends is also possible,50 suggesting that health care professionals should work with the social network of patients where possible. Caring for a family member with heart failure can be a physical, emotional, and financial strain on carers,51,52 and many report a lack of social and emotional support and a lack of information and advice.53

Who should be involved in postdischarge follow-up?

Disease management programs are almost universally multiprofessional, and are typically coordinated by a heart failure nurse specialist. Evidence from observational datasets suggests that any clinical follow-up improves outcomes in heart failure, but there is incremental benefit from involvement of a multiprofessional team over that of either a primary care physician or a cardiologist alone.54 The core team may be small, but the skills of a wider range of health care professionals can be drawn upon when appropriate, such as a nutritionist, physiotherapist, occupational therapist, palliative care service, psychologist, or pharmacist.

Remote monitoring

In theory, remote monitoring of patients after discharge should allow remote decision making, facilitate patient self-care, and improve outcome after discharge from hospital. Although meta-analyses of small studies have suggested benefits on mortality and heart failure hospitalizations,55,56 large randomized trials have not confirmed such benefits.57,58 Many patients with heart failure have an implanted cardiac device, such as cardiac resynchronization therapy, and/or an implantable cardio-verter defibrillator. Remote monitoring of such devices may, in some circumstances, improve the outcome for patients,59 although once again the evidence base is not consistent.60 Further studies are ongoing.61

Technology offers other opportunities to improve heart failure management by both professionals and patients. Interactive Internet-based education programs (such as heart failure matters. org operated by the Heart Failure Association of the ESC), and patient support groups can provide useful material for patients and their families. Smartphone applications (“apps”) are also increasingly used to support lifestyle management, and may be useful in supporting rehabilitation. Online consultations (by Skype or other systems), e-mail communication, and transfer of data from home monitoring systems are changing the way patients and their families interact with their health care team. Concerns regarding legal liability, data confidentiality, and reimbursement are slowing implementation of these technological changes in many countries.62

Palliative and end-of-life care

Traditionally, cardiac services have not embraced a palliative care approach to end-of-life issues, although this has changed dramatically in recent years, particularly where multiprofessional disease management programs and teams are involved in care. In England, only 4% of heart failure patients were referred to palliative care services in 2012 after their admission, despite 6% of patients dying within 30 days of discharge, and 25% by 6 months.1 Palliative care takes a broad approach to disease management, addressing the physical, as well as psychological, social, and spiritual needs of patients and their families. Pain and symptom management are key elements of this approach and are most useful when introduced early on in the disease process so that patients and their families are familiar with the concepts and services available as the needs arise. Organization and funding of palliative care services varies from country to country.

Patient surveys suggest that the majority of patients with heart failure do not feel that they have had an opportunity to adequately discuss end-of-life issues with their health care professionals, with unwillingness to tackle the subject found in both the patients and the health care team.53

Driving change

In a survey published in 2006, only 7 of 26 European countries reported that heart failure–management programs were being used in more than 30% of hospitals.63 Even when programs are in place, they are often underutilized. A survey in Canada showed that only 15% of patients hospitalized for heart failure were referred to a specialist clinic for follow-up.64

In France, a recent publication suggested that only 26% of patients were seen by a cardiologist within 12 weeks of discharge,28 and in the United Kingdom only 56% of patients were referred for heart failure follow-up at the time of discharge.1 In the United States, a Web-based survey reported wide variation in the implementation of key practices in a quality improvement initiative to reduce preventable readmissions after heart failure hospitalization: only 15% of hospitals employed all 4 recommended discharge and follow-up practices, and only 5% ensured all 3 classes of disease-modifying medication were in place.65

Health care systems have attempted to drive care toward multiprofessional and community care by a variety of means, including the introduction of “performance metrics.” Often, these relate to process measures, such as the use of various drugs or echocardiography, or evidence ofdelivery of education about smoking cessation or exercise advice. Readmission within 30 days is penalized in several countries, including the United States, Germany, and the United Kingdom. In the latter country, consideration is being given to the introduction of a “payment by results” tariff, so that reduced payment is made if certain procedures are not followed. There is good evidence that the adherence of clinical teams to guideline-recommended therapy is associated with better outcomes for patients. In the MAHLER survey (Medical mAnagement of chronic Heart faiLure in Europe and its Related costs), which was conducted in 6 European countries, after adjustment for potential confounding factors, patients that were seen by a clinical team that was highly compliant with guideline-based therapy had a 36% lower rate of cardiovascular rehospitalization over a 6-month period after discharge.66 Similar results have been reported more recently from Germany.67 Recent data from the national audit of heart failure admissions in the United Kingdom confirm that patients who see specialists, and those who are given more guideline-recommended therapy, have a better outcome after discharge from hospital.1 This has supported NICE to mandate universal access to such specialist input for patients admitted with heart failure to English hospitals from 2014 onward.9

Conclusions

The evidence base strongly supports the international guideline recommendations that heart failure patients should be followed-up by specialist services after discharge from hospital, ideally within the context of a multi-professional disease management program. The highest risk period is in the first weeks to months after discharge, and input from the multi-professional team during this period will help optimize the outcome and experience of care for the patient and their family/ carers. A patient-centered approach is essential to ensure that support is tailored to the individual’s needs. Increasingly, health care systems are aligning payment mechanisms to incentivize best practice and better outcomes. Globally, the data suggest that there is considerable room for improvement— the majority of patients with heart failure who are admitted to hospital do not have access to good post-discharge follow up and care, even in the wealthiest countries.

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Keywords: heart failure; hospitalization; postdischarge follow-up; postdischarge management