BY, MSN, RN
Approximately 6 million Americans have heart failure (HF). More than 25% of patients readmitted to the hospital within 30 days after discharge are HF patients (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952725/). By 2030, the cost of medical care for HF patients is estimated to be about $53 billion. Almost a decade ago, the Centers for Medicare & Medicaid Services (CMS) implemented a program of financial penalties for hospitals with higher-than-expected readmission rates for HF patients. The program has had limited success (Henning, 2020).
There are many causes of HF. Some lifestyle choices can damage the heart. Diabetes, hypertension, heredity, various cardiac conditions and chemotherapies can result in HF. Sometimes there is no identifiable cause. Patients can develop shortness of breath and extreme fatigue and be diagnosed with HF of an unknown etiology.
Currently, HF patients are divided into two groups: those with preserved ejection fraction and those with reduced ejection fraction. Approximately 50% of HF patients have normal left ventricular (LV) function but the LV is stiff. This is called heart failure with preserved ejection fraction (HFpEF). These patients tend to be older women with several comorbidities including hypertension, obesity, diabetes, ischemic heart disease and atrial fibrillation. They often do not see a cardiologist during hospitalization and tend to die from the comorbidities. The goal of treatment for HFpEF patients is weight reduction, exercise and effective management of blood pressure (BP) and heart rate (HR). There currently is no standard of care for HFpEF (Henning, 2020).
Heart failure patients with reduced ejection fraction are diagnosed with HFrEF. For these patients, there is a comprehensive medical treatment plan that has been shown to improve outcomes for these patients. This is called Guideline Directed Medical Therapy (GDMT). The guidelines have evolved and are updated over time as different or new medications prove to be effective in treating HFrEF. The GDMT is based on research that has improved outcomes, reduced mortality and extended the lives of patients with HFrEF.
There are now 4 pillars in the medical treatment of HFrEF (https://www.uscjournal.com/articles/optimizing-guideline-directed-medical-therapies-heart-failure-reduced-ejection-fraction):
- Renin-Angiotensin-Aldosterone-System Inhibitor/Angiotensin Receptor
- Neprilysin Inhibitor o In this therapy, a neprilysin inhibitor may or may not be added to renin-angiotensin-aldosterone system inhibitors. Research shows that adding the neprilysin inhibitor produces better outcomes.
- RAAS-I includes the use of an angiotensin converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB), which altogether becomes more expensive than ARNI.
- These medications prevent vasoconstriction and hypertension, which can cause heart remodeling and result in progression of HF.
- A neprilysin inhibitor facilitates vasodilation, natriuresis, diuresis and lowers BP.
- The literature shows a 35-45% reduction in all-cause mortality in HF.
- 30-day post-discharge reduction in mortality.
- Mineralocorticoid Receptor Antagonist
- These medications block aldosterone, which is responsible for water retention.
- The diuresis reduces BP and fluid around the heart.
- Sodium-Glucose Cotransporter-2 Inhibitor (recently added)
- These medications reduce all-cause mortality risk by 13%.
- Readmissions are reduced by 25%.
- Benefits are evident within 12 days of initiation (even in patients without Type 2 diabetes).
- The low rate of use is attributed to the novelty of the medication and concerns for blood glucose levels in those with and without Type 2 diabetes.
- Recommended for approximately 80% of patients with HFrEF.
It is clear that following GDMT can dramatically improve outcomes for HFrEF patients (Dixit, Shah, Ziaeian et al., 2021).
Discharge instructions usually include:
- Medications to treat HF (GDMT).
- Nutrition recommendations.
- Salt restrictions.
- Daily monitoring of fluids, weight and BP.
- Follow-up appointments.
- Exercise recommendations.
- Tobacco cessation and substance abuse counseling as needed.
BARRIERS TO FOLLOWING DISCHARGE INSTRUCTIONS
Guideline Directed Medical Therapy for HFrEF patients:
- Patients are not started on all of the recommended medications while in the hospital.
- There is evidence that some patients are not started on the recommended medications at outpatient visits.
- Recent literature demonstrates that GDMT is not initiated for many patients who qualify.Does this reflect a lack of provider understanding of GDMT?
- Patients do not understand why they are taking the medication.
- Patients do not or cannot afford to fill their prescriptions.
- Patients do not know how to take the medication correctly.
- Patients might believe they are having a reaction to the medication and stop taking it.
- Both HFrEF and HFpEF patients have similar issues with medication adherence.
Diet changes and nutritional counseling:
- There might be delays in getting nutritional counseling.
- The patients might not want to make other changes in their daily lives.
- If the rest of the family is unwilling to make changes to their diet, it might prevent the patients from making the recommended changes.
- If patients are unable to prepare their own meals, they are at the mercy of someone who may not understand their needs.
- Patients are often unaware of the sources of hidden salt.
- The patients may not understand fluid restrictions and how to pay attention to the amount of fluids they consume during a 24-hour period.
- There is also confusion on “daily” fluid restriction, where the belief is that the restriction just applies during the daytime, between breakfast and supper.
- Does the patient own a scale?
- Can they afford one?
- Do they understand how and when to weigh themselves to get an accurate reading?
- Does the patient have a BP cuff at home?
- Can they afford one?
- Do they understand the process of accurately taking their BP to get an accurate reading?
- Do they know who to call for the appointment?
- Are they able to get to the appointment? If not, telehealth can be an effective option. Telehealth appointments have been reported to be more effective in reducing 90-day mortality than telephone appointments (https://pubmed.ncbi.nlm.nih.gov/34587763/. Yuan, Botting, Elad et al., 2021).
- Does the patient have access to a computer?
- Is the patient able to use a computer for a telehealth visit?
- Does the patient have access to a cardiac rehabilitation clinic?
- Are they able to get to the exercise class?
Smoking Cessation/Substance Abuse Counseling:
- Are they ready to quit smoking or reduce alcohol consumption?
IMPROVING ADHERENCE WITH DISCHARGE INSTRUCTIONS
Living well with HF can require several adjustments to daily life. The patients might be overwhelmed by the diagnosis and the lifestyle changes needed in order to manage their HF. They might be depressed and need the familiar habits as they come to terms with their new reality.
It is clear that many patients need help managing their self-care, and they often do not have anyone to help them. Patients who live alone often face isolation. Even those who have family or friends nearby may struggle to manage and need extra support.
It is becoming increasingly difficult to get that initial appointment within two weeks of discharge from the hospital, and referrals to nutrition and rehab clinics can be hard to come by when demand outpaces availability.
McKinsey (2021) reports that one-third of patients surveyed required avoidable, unplanned follow-up care as a result of inadequate outpatient care or their inability to understand their discharge instructions. In 2019, Frenius Medical Care reported that the estimated hospitalizations due to medication non-adherence cost $100 billion and caused 125,000 deaths each year (https://fmcna.com/insights/articles/medication-adherence-and-compliance-/).
HF patients are still returning to the hospital within 30 days of discharge due, in large part, to their inability to follow their discharge instructions. Overwhelmingly, they struggle to take their medications as intended. There is much discussion in the literature about why patients are not taking their medications as prescribed, but there is a dearth of successful strategies to address this issue (AMA, 2020; Frenius Medical Care, 2019).
The medication label is difficult to interpret. When the bottle says “take twice a day,” some patients take two at the same time because they are not sure when they should take the second dose (Hello Pharmacist, 2021). In recent surveys, nearly 90% of patients have reported that medication labels are confusing, and nearly 73% stated the confusion was the reason for non-adherence to their medication regimen, and 23% had actually taken a medication incorrectly as a result of not understanding the label (Pallangyo, Millinga, Bhalia et al., 2020; School of Pharmacy, University of Wisconsin-Madison, 2019).
There had been some interest in making medication labels easier for patients to understand. Yet since label changes were discussed almost a decade ago, there appears to have been little progress. In 2013, the United States Pharmacopeia (USP) offered a set of standards to make medication labels easier for patients to understand. Yet by 2019, the only state to have embraced these standards is Utah (School of Pharmacy, University of Wisconsin-Madison, 2019).
The importance of the GDMT medications on the health of HFrEF patients is clear. It is easy to see how these patients can run into trouble when they don’t take their medications as prescribed, for whatever reasons. This can quickly become a serious situation if patients cannot get to their follow-up appointments in the prescribed timeframe. Compound this with the inability or disinclination to explore a heart-healthy diet and it is no wonder that the readmission rate for these patients can rise even for those who qualify for the CMS chronic care management program.
The importance of helping patients to follow their discharge instructions includes the impact that not managing HF has on other aspects of health. If they don’t have their fluid balance optimized and they get sepsis, how are they going to deal with the fluid challenge? Will the physician adjust the fluid boluses when the patient is overloaded and they present with sepsis? The overloaded sepsis patients have an increased risk of ending up on a ventilator due to the sepsis protocol. This is just one example of how not following HF discharge instructions affects other health concerns.
HF patients with and without reduced ejection fraction need help to manage their HF post discharge. The HFpEF patients are often not seen by a cardiologist, and as there is no standard of care for them, it might be more difficult for them to manage their HF and to make their follow-up appointment (Henning, 2020).
Although the number of HF patients who return to the hospital has decreased in recent years, many opportunities remain to help patients to understand and follow their discharge instructions to avoid readmission. Some studies have described patient education programs administered the day prior to or on the day of discharge (Oh, Lee, Yang et al., 2021). However, the literature suggests that a single education event around the time of discharge results in minimal retention, with 40% to 80% forgotten right away (Gardenier, Valles-Gutierrez, Ballard-Hernandez, 2018). This suggests that more than one encounter prior to discharge and even more than the 15 minutes per month in the CMS chronic care management program is required to help patients to live well with HF.
A meta-analysis of strategies to address readmission of HF patients found that post discharge education and support was effective in reducing readmission (Wan, Terry, Cobb et al., 2017). A study from 2020 found that scheduling the follow-up appointments and providing education related to the specific HF discharge instructions prior to discharge reduced the readmission rate by 50% (Nair, Lak, Hasan et al., 2020).
The literature suggests that comprehensive education specifically targeting the importance of each component of HF discharge instructions and scheduling the follow-up appointments prior to discharge has the best chance of success. The difficulty in implementing this strategy is probably related to staffing issues. Is it economically feasible to hire staff to provide the education and arrange the follow-up appointments prior to discharge? If it reduces CMS penalties, then it just might be.
Helping patients to live well with HF requires a multi-faceted approach that begins well before the day of discharge and continues long after discharge. Although this remains a challenge, it appears that healthcare organizations are finding some strategies that might prove effective.
AMA. (2020, December 2). 8 reasons patients don’t take their medications. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications.
Dixit, N. M., Shah, S., Ziaeian, B., Fonarow, G. C., & Hsu, J. J. (2021) Optimizing guideline-directed medical therapies for heart failure with reduced ejection fraction during hospitalization. US Cardiology Review 2021;15:e07. DOI:https://doi.org/10.15420/usc.2020.29.
Frenius Medical Care. (2019, July 31). Medication adherence and compliance. https://fmcna.com/insights/articles/medication-adherence-and-compliance-/.
Gardenier, D., Valles-Gutierrez, L., & Ballard-Hernandez, J. (2018) Do discharge instructions make a difference in patients with heart failure? The Journal for Nurse Practitioners, 14(10), 708-709. https://doi.org/10.1016/j.nurpra.2018.07.001.
Hello Pharmacist. (2021, September 2) Two tablets at the same time or one twice daily? https://hellopharmacist.com/questions/two-tablets-at-the-same-time-or-one-twice-daily.
Henning, R. J. (2020). Diagnosis and treatment of heart failure with preserved left ventricular ejection fraction. World Journal of Cardiology, 12(1). doi: 10.4330/wjc.v12.i1.7.
McKinsey & Company. (2021, August 5). The role of personalization in the care journey: An example of patient engagement to reduce readmissions. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/the-role-of-personalization-in-the-care-journey-an-example-of-patient-engagement-to-reduce-readmissions?cid=other-eml-alt-mip-mck&hdpid=55da8e23-d492-4dcf-a5fc-e23ba6bd7abc&hctky=9646326&hlkid=ec9637cbdba9414ea33e571cc421d6f5.
Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020) Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: A quality improvement initiative. Cureus, 12(3). doi: 10.7759/cureus.7420.
Oh, E. G., Lee, H. J., Yang, Y. L., Lee, S., & Kim, Y. M. (2021) Development of a discharge education program using the teach-back method for heart failure patients. BMC Nursing, 20(109). https://doi.org/10.1186/s12912-021-00622-2.
Pallangyo, P., Millinga, J., Bhalia, S., Mkojera, Z., Misidai, N., Swai, H. J., Hemed, N. R., Kaijage, A., & Janabi, M. (2020) Medication adherence and survival among hospitalized heart failure patients in a tertiary hospital in Tanzania: a prospective cohort study. BMC Res Notes 13(89).
School of Pharmacy, University of Wisconsin-Madison. (2019, June 10). A sticking point for medication adherence. https://pharmacy.wisc.edu/redesigning-prescription-labels/.
Wan, T. T. H., Terry, A., Cobb, E., McKee, B., Tregerman, R., & Barbro, S. D. S. (2017). Strategies to modify the risk of heart failure readmission: A systematic review and meta-analysis. Health Serv Res Manag Epidemiol, Jan-Dec; 4. doi: 10.1177/2333392817701050.
Yuan, N., Botting, P. G., Elad, N., Miller, S. J., Cheng, S., Ebinger, J. E., & Kittleson, M. M. (2021). Practice patterns and patient outcomes after widespread adoption of remote heart failure care. Circ Heart Fail, 14(10). doi:10.1161/CIRCHEARTFAILURE.121.008573.