Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study.
ABSTRACT To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure.
Prospective, randomized clinical trial, with 2:1 assignment to the study intervention or usual care.
550-bed secondary and tertiary care university teaching hospital.
98 patients > or = 70 years of age (mean 79 +/- 6 years) admitted with documented congestive heart failure.
Comprehensive multidisciplinary treatment strategy consisting of intensive teaching by a geriatric cardiac nurse, a detailed review of medications by a geriatric cardiologist with specific recommendations designed to improve medication compliance and reduce side effects, early consultation with social services to facilitate discharge planning, dietary teaching by a hospital dietician, and close follow-up after discharge by home care and the study team.
All patients were followed for 90 days after initial hospital discharge. The primary study endpoints were rehospitalization within the 90-day interval and the cumulative number of days hospitalized during follow-up. The 90-day readmission rate was 33.3% (21.7%-44.9%) for the patients receiving the study intervention (n = 63) compared with 45.7% (29.2%-62.2%) for the control patients (n = 35). The mean number of days hospitalized was 4.3 +/- 1.1 (2.1-6.5) for the treated patients vs 5.7 +/- 2.0 (1.8-9.6) for the usual-care patients. In a prospectively defined subgroup of patients at intermediate risk for readmission (n = 61), readmissions were reduced by 42.2% (from 47.6% to 27.5%; p = 0.10), and the average number of hospital days during follow-up decreased from 6.7 +/- 3.2 days to 3.2 +/- 1.2 days (p = NS).
These pilot data suggest that a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization. Further evaluation of this treatment strategy, including an assessment of the cost-effectiveness, is warranted.
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ABSTRACT: We reviewed the three-month hospital readmission rates of 410 patients ages 70 years or older discharged alive with a first time diagnosis of congestive heart failure during the period January 1983-June 1986. The mean age was 79.8 years, 59.5 per cent were women. Mean length of initial hospital stay decreased from 10.8 days in 1983 to 7.8 days in 1986. One hundred-nineteen patients (29 per cent) were rehospitalized at least once within three months of initial discharge. The readmission rates by year were: 1983, 40.0 per cent; 1984, 27.5 per cent; 1985, 21.4 per cent; 1986, 23.2 per cent. During this same interval, the percentage of patients referred for home health care services increased from 3.3 per cent in 1983 to 13.0 per cent in 1984, 5.8 per cent in 1985, and 12.5 per cent in 1986. Thus, decreased length of hospital stay was associated with a parallel decline in early readmission rate and increased utilization of home health care services. Although this study has important methodologic limitations, the data suggest that shorter hospital stays under the DRG system are not necessarily associated with an increased rate of early rehospitalization.American Journal of Public Health 07/1988; 78(6):680-2. · 3.93 Impact Factor
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ABSTRACT: Repetitive hospitalizations are a major health problem in elderly patients with chronic disease, accounting for up to one fourth of all inpatient Medicare expenditures. Congestive heart failure, one of the most common indications for hospitalization in the elderly, is also associated with a high incidence of early rehospitalization, but variables identifying patients at increased risk and an analysis of potentially remediable factors contributing to readmission have not previously been reported. We prospectively evaluated 161 patients 70 years or older that had been hospitalized with documented congestive heart failure. Hospital mortality was 13% (n = 21). Among patients discharged alive, 66 (47%) were readmitted within 90 days. Recurrent heart failure was the most common cause for readmission, occurring in 38 patients (57%). Other cardiac disorders accounted for five readmissions (8%), and noncardiac illness led to readmission in 21 cases (32%). Factors predictive of an increased probability of readmission included a prior history of heart failure, four or more admissions within the preceding 8 years, and heart failure precipitated by an acute myocardial infarction or uncontrolled hypertension (all P less than .05). Using subjective criteria, 25 first readmissions (38%) were judged possibly preventable, and 10 (15%) were judged probably preventable. Factors contributing to preventable readmissions included noncompliance with medications (15%) or diet (18%), inadequate discharge planning (15%) or follow-up (20%), failed social support system (21%), and failure to seek medical attention promptly when symptoms recurred (20%). Thus, early rehospitalization in elderly patients with congestive heart failure may be preventable in up to 50% of cases, identification of high risk patients is possible shortly after admission, and further study of nonpharmacologic interventions designed to reduce readmission frequency is justified.Journal of the American Geriatrics Society 01/1991; 38(12):1290-5. · 3.98 Impact Factor
Article: High-cost users of medical care.[show abstract] [hide abstract]
ABSTRACT: Cost characteristics of hospital patients were analyzed in 2238 medical records randomly selected from 42,880 dicharges in six contrasting hospital populations in the year 1976. Total hospital billings were concentrated on a few patients. On average, the high-cost 13% of patients consumed as many resources as the low-cost 87%. Repeated hospitalizations for the same disease were more characteristic of the expensive patients than were single cost-intensive stays, "intensive care," or prolonged single hospitalizations. Potentially harmful personal habits (e.g., drinking and smoking) were indicated in the records of high-cost patients substantially more often than in those of low-cost patients. Unexpected complications during treatment were five times more frequent in the high-cost group. Public policy programs for health insurance or cost control should include provisions based on the special characteristics of high-cost patients.New England Journal of Medicine 06/1980; 302(18):996-1002. · 51.66 Impact Factor