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A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

      Abstract

      Objective

      Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.

      Design

      Cluster-randomized controlled trial.

      Participants

      The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).

      Methods

      The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.

      Results

      Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.

      Conclusions and Implications

      The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

      Keywords

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      References

        • Hines A.L.
        • Barrett M.L.
        • Jiang H.J.
        • Steiner C.A.
        Conditions with the largest number of adult hospital readmissions by payer, 2011.
        Agency for Healthcare Research and Quality, 2014
        • Centers for Medicare & Medicaid Services
        The skilled nursing facility value-based purchasing program (SNF VBP).
        (Available at:)
        • Medicare Payment Advisory Commission
        Skilled nursing facility services.
        (Available at:)
        • Rich M.W.
        • Beckham V.
        • Wittenberg C.
        • et al.
        A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.
        N Engl J Med. 1995; 333: 1190-1195
        • Stewart S.
        • Horowitz J.D.
        Home-based intervention in congestive heart failure: Long-term implications on readmission and survival.
        Circulation. 2002; 105: 2861-2866
        • Roccaforte R.
        • Demers C.
        • Baldassarre F.
        • et al.
        Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis.
        Eur J Heart Fail. 2005; 7: 1133-1144
        • Stewart S.
        • Wiley J.F.
        • Ball J.
        • et al.
        Impact of nurse-led, multidisciplinary home-based intervention on event-free survival across the spectrum of chronic heart disease: Composite analysis of health outcomes in 1226 patients from 3 randomized trials.
        Circulation. 2016; 133: 1867-1877
        • Huynh Q.L.
        • Whitmore K.
        • Negishi K.
        • Marwick T.H.
        • ETHELRED Investigators
        Influence of risk on reduction of readmission and death by disease management programs in heart failure.
        J Card Fail. 2019; 25: 330-339
        • Albert N.M.
        • Barnason S.
        • Deswal A.
        • et al.
        Transitions of care in heart failure: A scientific statement from the American heart association.
        Circ Heart Fail. 2015; 8: 384-409
        • Jurgens C.Y.
        • Goodlin S.
        • Dolansky M.
        • et al.
        Heart failure management in skilled nursing facilities: A scientific statement from the American heart association and the heart failure society of America.
        J Card Fail. 2015; 21: 263-299
        • Gilman B.H.
        • Cromwell J.
        • Adamache W.A.
        • Donoghue S.
        Study of the Effect of Implementing the Postacute Care Transfer Policy Under the Inpatient Prospective Payment System.
        Health Economics Research, Inc, Baltimore, MD2000
        • Krumholz H.M.
        • Currie P.M.
        • Riegel B.
        • et al.
        A taxonomy for disease management: A scientific statement from the American heart association disease management taxonomy writing group.
        Circulation. 2006; 114: 1432-1445
        • Bonow R.O.
        • Bennett S.
        • Casey Jr., D.E.
        • et al.
        ACC/AHA clinical performance measures for adults with chronic heart failure: A report of the American college of cardiology/American heart association task force on performance measures (writing committee to develop heart failure clinical performance measures): Endorsed by the heart failure society of America.
        Circulation. 2005; 112: 1853-1887
        • Hunt S.A.
        • Abraham W.T.
        • Chin M.H.
        • et al.
        ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American college of cardiology/American heart association task force on practice guidelines (writing committee to update the 2001 guidelines for the evaluation and management of heart failure): Developed in collaboration with the American college of chest physicians and the international society for heart and Lung transplantation: Endorsed by the heart rhythm society.
        Circulation. 2005; 112: e154-e235
        • Kemp E.C.
        • Floyd M.R.
        • McCord-Duncan E.
        • Lang F.
        Patients prefer the method of "tell back-collaborative inquiry" to assess understanding of medical information.
        J Am Board Fam Med. 2008; 21: 24-30
        • Pignone M.
        • DeWalt D.A.
        • Sheridan S.
        • et al.
        Interventions to improve health outcomes for patients with low literacy. A systematic review.
        J Gen Intern Med. 2005; 20: 185-192
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • de Groot V.
        • Beckerman H.
        • Lankhorst G.J.
        • Bouter L.M.
        How to measure comorbidity: A critical review of available methods.
        J Clin Epidemiol. 2003; 56: 221-229
      1. Protecting Access to Medicare Act of 2014, Pub L No. 113-93, 128 Stat 1040. 2020 (Available at:)
        • Centers for Medicare & Medicaid Services
        Skilled nursing facility quality reporting program (SNF QRP): Requirements for the fiscal year 2018 reporting year.
        (Available at:)
        • Daddato A.E.
        • Dollar B.
        • Lum H.D.
        • et al.
        Identifying patient readmissions: Are our data sources misleading?.
        J Am Med Dir Assoc. 2019; 20: 1042-1044
        • Green C.P.
        • Porter C.B.
        • Bresnahan D.R.
        • Spertus J.A.
        Development and evaluation of the Kansas city Cardiomyopathy Questionnaire: A new health status measure for heart failure.
        J Am Coll Cardiol. 2000; 35: 1245-1255
        • Riegel B.
        • Carlson B.
        • Moser D.K.
        • et al.
        Psychometric testing of the self-care of heart failure index.
        J Card Fail. 2004; 10: 350-360
        • Riegel B.
        • Lee C.S.
        • Dickson V.V.
        • Carlson B.
        An update on the self-care of heart failure index.
        J Cardiovasc Nurs. 2009; 24: 485-497
        • Heidenreich P.A.
        • Spertus J.A.
        • Jones P.G.
        • et al.
        Health status identifies heart failure outpatients at risk for hospitalization or death.
        J Am Coll Cardiol. 2006; 47: 752-756
        • Spertus J.A.
        • Jones P.G.
        • Kim J.
        • Globe D.
        Validity, reliability, and responsiveness of the Kansas City Cardiomyopathy Questionnaire in anemic heart failure patients.
        Qual Life Res. 2008; 17: 291-298
        • Little R.J.A.
        A class of pattern-mixture models for normal incomplete data.
        Biometrika. 1994; 81: 471-483
        • Mor V.
        • Intrator O.
        • Feng Z.
        • Grabowski D.C.
        The revolving door of rehospitalization from skilled nursing facilities.
        Health Aff (Millwood). 2010; 29: 57-64
        • Dunlay S.M.
        • Redfield M.M.
        • Jiang R.
        • et al.
        Care in the last year of life for community patients with heart failure.
        Circ Heart Fail. 2015; 8: 489-496
        • Lum H.D.
        • Studenski S.A.
        • Degenholtz H.B.
        • Hardy S.E.
        Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries.
        J Gen Intern Med. 2012; 27: 1467-1474
        • Davis J.D.
        • Olsen M.A.
        • Bommarito K.
        • et al.
        All-payer analysis of heart failure hospitalization 30-day readmission: Comorbidities matter.
        Am J Med. 2017; 130: 93e99
        • Dharmarajan K.
        • Hsieh A.F.
        • Lin Z.
        • et al.
        Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        JAMA. 2013; 309: 355-363
        • Ambrosy A.P.
        • Cerbin L.P.
        • Armstrong P.W.
        • et al.
        Body weight change during and after hospitalization for acute heart failure: Patient characteristics, markers of congestion, and outcomes: Findings from the ASCEND-HF Trial.
        JACC Heart Fail. 2017; 5: 1-13

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