A Heart Failure Clinical Pathway to Reduce Hospital Readmissions

Heart failure (HF) is the primary diagnosis in over 1 million hospitalizations annually,¹ and patients who are hospitalized for HF are at high risk for all-cause hospital readmission, with a 1-month readmission rate of 25%.² Total cost of HF care in the United States is over $30 billion annually, with over half being spent on hospitalizations, which includes health care services, medications, and lost productivity.¹ Research specifically shows that acute decompensated HF (ADHF) is the most common reason for hospital admissions and readmissions in the United States.³ Because the economic burden of HF-related health care costs is so severe, models of care to reduce costs while maintaining and improving care are needed.

As the US health care system shifts to a value-based care system, quality of care will have a direct impact on reimbursement. Indeed, the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP)⁴ has increased the urgency for initiatives, interventions, and care models that will truly curb readmissions and lower health care costs. While guidelines for care are available and consistently updated, unfortunately, many patients with HF are not receiving optimal care as recommended by clinical guidelines.⁵

Clinical pathways provide a means of implementing the most up-to-date guidance into clinical settings in order to improve the value and efficiency of the care provided. As you will learn later in this interview, the use of clinical pathways and clinical decision support tools in the management of HF is not a new trend. There is already a growing amount of research proving the effectiveness of clinical pathways for enhanced HF management, including in the reduction of readmission rates as well as costs. 

To better understand how clinical pathways are developed and executed in cardiovascular care, Journal of Clinical Pathways spoke with Travis B Wasserman, MPH; Thomas F Spiegel, MD; and Corey E Tabit, MD, MBA, MPH, from University of Chicago Medicine (Chicago, IL), who developed a multifaceted Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with HF.⁶ The pathway, along with several interventions, was implemented directly into the emergency department (ED) to increase its impact. They explain the development of the pathway, challenges to implementation, and the general use of clinical pathways in HF management and cardiovascular care.

Can you briefly describe your study?⁶ What motivated you to consider a clinical pathway for the management of HF? Is the overutilization of ED resources a significant concern for HF patients? 

Dr Spiegel: There were multiple reasons to develop this pathway—some global and some local. The global reasons involve the significant impact that ADHF has on patients: (1) it is the leading diagnosis for inpatients over age 65; (2) it is the most common reason for hospitalization and rehospitalization in the United States; (3) it continues to lead to poor patient experiences; and (4) there are potentially severe financial implications from failure of quality care within this population (eg, CMS penalize centers with excessive 30-day rehospitalizations).⁴ Local reasons include the fact that underserved patients are disproportionately affected by all of the above global impacts. Additionally, as target rehospitalization rates are not adjusted for social disparities, penalties are imposed disproportionately on centers that care for underserved patients.

These local and global reasons motivated the development of the HF pathway at our center, University of Chicago Medicine (UCM), which is a tertiary care center on Chicago’s South Side—one of the poorest and most violent regions of the city. Here, attempts to reduce rehospitalizations have had varying success, especially in low-socioeconomic urban patients. These patients consume disproportionately more health care resources than more affluent patients and often overutilize the ED for their care, leading to fragmented care and elevated health care costs.

Beginning in January 2015, we decided to treat patients at our center with ADHF according to a multidisciplinary ADHF clinical pathway developed in accordance with the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Management of Heart Failure.⁷ Patients received standardized education while admitted and received early outpatient follow-up after discharge. In addition, patients who returned to the ED after discharge received early consultation with a cardiologist.

The ED was concerned that this pathway would lengthen patients’ length of stay, as the consulted cardiologist would encourage diuresis in the ED. The ED envisioned their hallways running yellow with ADHF diuresis and were concerned that, after a prolonged attempt at diuresis, the patients would ultimately be admitted and would have increased the burden on the ED staff and other patients without reducing readmissions. The potential benefit of more inpatient beds by not admitting ADHF patients was the allure to the ED, as UCM’s inpatient bed occupancy is often 100%. We were pleased to report⁵ that this pathway reduced readmissions without increasing the ED’s length of stay, improved outpatient follow-up, and led to the ED’s ability to admit other non-ADHF patients to the hospital when patients would have otherwise been boarded in the ED.

Dr Tabit: Many of the patients we care for use the ED for their primary care. While this is arguably not an appropriate use of the ED, we felt it best to design an intervention that conformed to patients’ real use (or misuse) of the health system. By partnering with our colleagues in the ED, we were able to use ED resources more efficiently, which resulted in more patients safely discharged without increasing the work burden on the ED.

Please describe the development process of the ADHF clinical pathway (ADHFCP). What were some of the challenges to successful development and implementation?

Dr Spiegel: The development and success of this pathway is attributable to the passion, collaboration, and dedication to improving patient care that this multidisciplinary team rallied around and still maintains to this day. We included members from areas including cardiology, emergency medicine, inpatient and clinic (registered nurses), pharmacy, nutrition, physical and occupational therapy, social work, case management, the quality department, and senior administration. “It takes a village” has been the phrase repeated whenever the team convenes. Some of the key insights we gained during this process was that (1) planning for transitions of care was critical; (2) addressing the unique factors specific to our patient population was important (eg, many did not have scales so we bought them scales, if transportation was an issue we arranged for transportation, etc); and (3) early treatment and disposition planning in the ED between the ED physicians and cardiologists led to increased prompt outpatient follow-up visits as opposed to inpatient stays.

Dr Tabit: The multidisciplinary nature of this intervention was really crucial. In the past, many of our patients were readmitted for reasons that directly stemmed from social problems such as housing instability or lack of transportation. By working together across disciplines, we could ensure that potential causes for readmission were discovered and addressed early in the index admission. If the patient returned to the ED anyway, the multidisciplinary response team could correct further issues quickly and often facilitate a safe discharge with close outpatient follow-up.

Describe the benefits of the ADHFCP that you observed in your study. Were there any other relevant findings from the implementation of this pathway other than ED service utilization?

Dr Spiegel: Interestingly, the rates of presentation to the ED did not change. These are sick patients that need a higher level of care. Through this pathway, the effect of the care received (often aggressive and early diuresis) and improved follow-up outpatient planning led to the significant reduction in inpatient readmissions without prolonging the ED stays.  In addition to the reduced rates of rehospitalization, the total health care cost for our pathway patients compared with controls was significantly reduced. 

Mr Wassermann: As Dr Spiegel mentioned, the big change we saw was in the care that patients received after they reached the ED. Even though the clinical pathway did not change the likelihood that a patient would show up in the ED, it changed what happened once the patient got there. Patients being treated according to the clinical pathway got more diuretics in the ED, but they had a better chance of going home from there instead of going into the hospital. The extra diuretics did not make the patients spend a longer time in the ED, and the greater likelihood of being discharged home did not cause any increased risk of death or adverse outcomes. As our previous analysis³ showed, patients in the clinical pathway program had a 57% lower total 30-day health care cost after discharge from the hospital than patients outside of the program. Other benefits observed in the patients in the clinical pathway included significant improvement in their understanding of HF as measured by the Atlanta Heart Failure Knowledge Test as well as a greater improvement in HF symptoms 30 days after hospital discharge than typical HF patients experience.  

Dr Tabit: This multidisciplinary approach provides objectively better care for less money. In addition to a significant reduction in readmissions and total rehospitalized days, the pathway reduced total health care costs. Mortality was unchanged.³ 

Have you seen a trend toward the use of clinical pathways in HF management?

Dr Spiegel: Yes, the 2013 ACC/AHA Guideline for the Management of Heart Failure encourages such pathways,⁷ however, the term “clinical pathway” is not specifically used. The guidelines describe the elements of a clinical pathway without using a specific label, saying that guidelines can be useful in the development of decision support tools. Other phrases including “effective systems of care coordination” and “evidence-based plan of care” are also used in the guidelines⁷ and suggest a structured plan of care like those laid out in clinical pathways. 

Mr Wassermann: The use of clinical pathways in the management of HF is not a new phenomenon. A review⁸ in the AHA’s flagship journal in 2000 detailed the early stages of the use of clinical pathways in cardiovascular medicine, and a 2001 publication⁹ described the early results of a clinical pathway that had been implemented for patients with HF. In those early days, clinical pathways were an intriguing idea that might help more HF patients receive appropriate care, and scholars hoped that getting people that care would prevent rehospitalization. Now, we have a growing body of evidence demonstrating that clinical pathways really do increase the proportion of HF patients getting appropriate care, that they actually do decrease readmissions without increasing mortality, and that they can do all this at a financial savings to the health care system.^3,6 Perhaps that is why the AHA has moved from simply suggesting clinical pathways as a possibility in 2000 to actively encouraging hospitals to implement them in 2013.  

Dr Tabit: Yes, many forward-thinking centers are developing pathways for HF care. What sets our intervention apart is the immediate intervention in the ED, which is the primary portal of entry to the hospital for most of our patients.

What is the future of clinical pathways in the treatment and management of HF?

Dr Spiegel: Clinical pathways, with the proper support and sustained passion, have proven to be an effective tool in reducing readmissions, reducing costs, and improving the patient experience. Patients generally prefer to sleep in their own beds at night, and, with a successfully implemented pathway, they can do just that while having the comfort of a health care system ready to support them.

Mr Wassermann: Clinical pathways are increasingly accepted as a tool that can increase the proportion of patients receiving appropriate treatment for their HF and optimize the care they receive in the clinic, in the ED, and as inpatients. Previous work shows that clinical pathways reduce mortality and readmissions among HF patients and that they decrease length of hospital stay.¹⁰ Our work adds to the existing body of evidence by demonstrating that clinical pathway programs for heart failure patients can save the health care system money and improve the symptoms that patients experience.^3,6 While their implementation can be labor-intensive, the benefits of these programs are clear enough that we will likely see more hospitals using clinical pathways to optimize for HF programs in the future. While earlier clinical pathways aimed mainly at goal-directed care in the inpatient settings and in the clinic, modern clinical pathways are incorporating care in the ED and home-based care with better outcomes for patients as their care is becoming more comprehensive.  

Dr Tabit: In the next 10 years, clinical pathways will likely become the standard of care, not only for HF, but for virtually all types of cardiovascular disease.  

References

1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-e245.

2. Krumholz HM, Merrill AR, Schone EM, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2(5):407-413.

3. Tabit CE, Coplan MJ, Spencer KT, et al. Cardiology consultation in the emergency department reduces re-hospitalizations for low-socioeconomic patients with acute decompensated heart failure. Am J Med. 2017;130(9):1112.e17-1112.e31.

4. The Centers for Medicare & Medicaid Services (CMS). Readmissions reduction program (HRRP). CMS website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Updated November 30, 2017. Accessed February 20, 2018.

5. Ponikowski P, Anker S, AlHabib K, et al. Heart failure: preventing disease and death worldwide. ESC Heart Fail. 2014;1(1):4-25.

6. Spiegel TF, Wassermann TB, Neumann N, et al. A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED. Am J Emerg Med. In press. 

7. Yancey CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure, a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128(16):1810-1852.

8. Every NR, Hochman J, Becker R, Kopecky S, Cannon CP, the Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Critical pathways: a review. Circulation. 2000;101(4):461-465.

9.   Hoskins LM, Clark HM, Schroeder MA, Walton-Moss B, Thiel SL. A clinical pathway for congestive heart failure. Home Healthc Now. 2001;19(4):207-217.

10.  Kul S, Barbieri A, Milan E, Montag I, Vanhaecht K, Panella M. Effects of care pathways on the in-hospital treatment of heart failure: a systematic review. BMC Cardiovasc Disord. 2012;12(1):81.