Patients discharged from heart failure (HF) hospitalizations are more than 40% more likely to be rehospitalized within 30 days if they are admitted to hospitals’ general medicine services than to their cardiology services, concludes researchers of a small study.
Also in the analysis, based on 900 patients hospitalized with HF, hospitalists caring for the 40% admitted to the general medicine service were more likely to omit important information from discharge summaries. And they were less likely to ensure patients were scheduled for a follow-up outpatient appointment with a cardiologist.
On the other hand, only 54% of patients in both the general medicine and cardiology services were scheduled for any kind of physician follow-up, a shortfall that is consistent with national figures, senior author, Parag Goyal, MD, Weill Cornell Medicine, New York City, told theheart.org | Medscape Cardiology.
The best way to have a follow-up visit is to schedule it before discharge, he said, “but the reality is, across the country, it’s just not happening, so patients are frequently falling through the cracks.”
The analysis, published online February 7 in the American Journal of Cardiology with lead author Brian M Salata, MD, Weill Cornell Medicine, is retrospective and based on patients at only a single center, but its findings are consistent with those of other studies. They include a retrospective study from a major US tertiary care center reported last year and a prior registry study with more than 30,000 patients from centers across England and Wales.
“The volume of heart failure patients who are being hospitalized across the country exceeds the capacity of heart failure doctors and cardiologists. So to realistically take care of these patients, there needs to be shared responsibility between the cardiologists and the hospitalists,” Goyal said.
To that end, the field should “figure out a way to empower hospitalists and provide them with the tools for taking care of this highly complicated patient population.” One approach within hospital systems might be to “expand the opportunities for hospitalists to learn about optimal strategies for treating heart failure patients.”
Processes that promote more thorough discharge summaries and better chances of scheduling appropriate follow-up appointments would help, Goyal said. “I think that involving hospitalists to help develop strategies to implement these processes on their services would be beneficial.”
The study looked at 926 patients with a median age of 73 years, discharged from an HF hospitalization at a major academic center in 2013 and 2014. All providers shared a common electronic medical record system and discharge summary templates, the report states.
The cohort’s unadjusted 30-day rate of readmission for any cause was 28% overall; it was 32% among those triaged to general medicine and 25% for those managed on the cardiology service.
The odds ratio (OR) for 30-day readmission for the general-medicine vs cardiology cohorts was 1.43 (95% CI, 1.05 – 1.96; P = .02), after adjustment for age, sex, third-party payer status, left ventricular ejection fraction (LVEF) less than 50% or 50% or greater, presence of right ventricular dysfunction, ventricular tachycardia (VT), admission systolic blood pressure, hospital length of stay, and whether a cardiology outpatient follow-up was scheduled.
Table. Characteristics of Hospitalized Patients With HF and Outcomes by Service Providing Care
| Parameter | General Medicine (n = 371) | Cardiology (n = 555) | P Value |
|---|---|---|---|
| LVEF (median %) | 52 | 38 | <.001 |
| HF with preserved ejection fraction (%) | 53 | 37 | <.001 |
| VT (%) | 3 | 7 | .008 |
| Any scheduled follow-up appointment (%) | 54 | 54 | .78 |
| Scheduled cardiology follow-up appointment (%) | 37 | 47 | .003 |
| Readmission within 30 days (%) | 32 | 25 | .02 |
Notably, patients triaged to the general medicine service were more likely than those who went to the cardiology service to have HF with preserved ejection fraction (HFpEF); it followed, as well, that their mean LVEF was higher and they included more women.
That’s consistent with observations that a low LVEF is more likely to prompt triage to cardiology service, Goyal said.
However, “a lot of providers don’t fully appreciate how sick a patient can be when their EF is greater than 50%.” Prognosis is just as poor with HFpEF as with reduced-EF HF, he said, and it can be harder to treat because of a shortage of proven therapies and an often greater comorbidity burden.
“Yet they’re the ones who are more likely going to the general medicine services.” The rationale for that might actually be their abundance of comorbidities, Goyal acknowledged. But a secondary message from the study is that patients hospitalized with HFpEF “generally need more attention from cardiologists and heart failure doctors.”
Goyal, Salata, and the other authors had no relevant disclosures.
Am J Cardiol. Published online February 7, 2018. Abstract
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