Introduction

Approximately 1 million Americans with a primary diagnosis of heart failure (HF) are seen in emergency departments (ED) annually, with 70–80 % ultimately being admitted to the hospital [1, 2]. For many patients, hospitalization for acute decompensated HF created a vicious cycle of HF “revisits” back to the ED and hospital [3]. The cost for HF care in the US is exorbitant, with projections that direct and indirect costs will double from $31 billion in 2012 to $70 billion in 2030 [4]. Even though HF inpatient mortality rates declined by 40 % and mean length of stay declined by 30 % in the past decade, HF rehospitalization rates remained stable, with approximately 25 % of patients being readmitted within 30 days and 50 % within 6 months [5]. Moreover, following hospitalization, 30-day mortality rates were unacceptably high at 11 % [5], and rehospitalization was associated with very high short- and long-term mortality rates [6, 7]. Thus, decompensated HF places a tremendous burden on patients, families, caregivers, hospitals, society and the entire health care system. The focus of this article is to provide outcomes of studies of HF-based programs and strategies aimed at reducing HF revisits. Based on results from a review of the literature, implications for clinical practice and future research will be discussed.

Economic Consequences of Heart Failure Revisits

Improving outcomes of care is important to patients, clinicians, hospitals, and insurers. Leadership of the Centers for Medicare & Medicaid Services (CMS) believed that facilities providing high-quality HF care during hospitalization, in conjunction with quality transitions to outpatient environments, would have improved patient outcomes, including reduced readmissions and mortality, as well as improved functional ability and quality of life. Thus, CMS began publicly reporting select outcome measures to increase transparency of care, aid in consumer selection of care and assist hospitals in quality initiatives [8]. Public reporting of risk-adjusted mortality rates in patients with HF began in 2007 and expanded to include 30-day, all-cause risk-adjusted HF readmission rates in 2008, using claims and administrative data [9]. Both outcome measures were endorsed by the National Quality Forum and have been incorporated into Hospital Value Based Purchasing (HVBP) scores used to determine value-based incentive payment adjustments.

The HVBP payment methodology links reimbursement more directly to quality of care delivered by acute care hospitals. Stemming from the Deficit Reduction Act of 2005, HVBP was developed by CMS to provide an on-going process for assessing quality and efficiency in hospital inpatient settings [10]. In May 2011, CMS issued the HVBP final rule, linking Medicare reimbursement to quality performance in acute care hospitals. In fiscal year 2013 (patient discharges as of October 1, 2012), HF was one of three initial conditions selected for HVBP. Acute care hospitals participating in HVBP had their base diagnosis-related group (DRG) HF payments reduced by 1 % in fiscal year 2013; the reduction increased to 1.25 % in fiscal year 2014 (began October 1, 2013). Annual reductions of 0.25 % are scheduled, with a maximum of 2 % slated for fiscal year 2017 and beyond [10]. Although an inability to meet or improve baseline HVBP scores will result in DRG payment reductions, it is possible for hospitals to offset or “earn back” fees charged for HVBP with demonstrated improvement in quality scores.

The pervasiveness of HF revisits may be related to sub-quality care during the index hospitalization and self-care deficits at home [11]. The Hospital Readmission Reduction Program, as part of the Affordable Care Act to improve quality of care delivered, was implemented in fiscal year 2013. The program reduced payment to acute care hospitals with excessive readmissions [12]. Reductions are calculated based on a hospital’s actual 30-day readmission rate compared to the national average; a ratio greater than 1 has financial consequences for the facility. In fiscal year 2013, facilities that had higher ratios received a 1 % reduction penalty, and the penalty increased to 2 % on October 1, 2013 (fiscal year 2014). Over 2,200 hospitals will receive the full 2 % reduction this year, equating to approximately $227 million in penalties [12].

Programs and Strategies to Decrease Heart Failure Revisits

Revisits in HF are compounded by the progressive nature of HF and multifactorial issues, such as social, psychological, financial or medical needs. Revisits for decompensated HF create challenges for patients, families, health care providers and hospitals. Challenges include care related to care transitions, knowledge deficits about HF and management, medication reconciliation, higher intensity outpatient care and support, and ED clinical processes and services aimed at preventing hospital admission. Further, research targeted at reducing HF revisits did not have comparable findings, primarily due to a lack of homogeneity in the interventions assessed, creating difficulties in translating findings clinically. See the supplement, which provides a broad-based review of research findings of programs or strategies aimed at reducing ED or hospital revisits. No matter the program or strategy employed, one universal theme of care is to ensure adherence to guideline-directed medical and cardiac device therapies known to improve outcomes in patients with stage C and D HF [13••, 14].

Inpatient-Based Strategies

Delivery of comprehensive patient education prior to discharge is recommended in all major HF guidelines [13, 14] and is a quality performance measure for hospitals [15, 16]. Required topics are activity, diet, understanding medications and follow-up care, daily weight monitoring, and what to do with worsening signs or symptoms of HF. Although only a few randomized controlled trials (RCT) were available, HF education is one of only a few management strategies that, even when unbundled and applied as a single intervention, was effective in reducing 6- and 12-month HF revisits [17, 18]. However, education on HF self-care may not be a strong enough strategy to decrease HF revisits at 30 days [19], and no evidence was available about outcomes associated with ED-delivered education strategies. A non-intervention per se, longer hospital length of stay, may provide greater opportunities to stabilize and educate patients, but that did not always translate into decreased HF hospital revisits (see supplement) [20–23].

Care transitions, especially from hospital to home, have become important strategies for hospitals in reducing HF revisit rates. Interventions can be singular or bundled, involve actions by one health care provider or multidisciplinary providers, be short or long term in duration, and be focused on the hospital, the community or start in the hospital and continue into the community (see supplement) [24–27]. Although frequently used, there was marked heterogeneity in published programs and strategies, making it difficult to identify what really worked (see supplement legend, which contains hospital-to-home transitional care program websites that provide interventional components and other details of transitional care used clinically or in clinical research). Since utilization of multiple, resource-intensive bundled interventions is costly, it will be important to determine the effect size of different combinations of care coordination, medication reconciliation, patient education, early post-discharge follow-up communication and other interventions that make up care transition strategies. To incentivize physicians and hospital administrators to improve coordination among care settings and reduce revisits, CMS implemented a transitional care code in January 2013 that supports compensation for work associated with transitioning a patient into the community after hospital discharge [28].

Outpatient-Based Strategies

Early follow-up post-discharge is recommended, since it theoretically improves communication between patients and care providers, promotes patient re-assessment and facilitates early identification of post-discharge medical and socioeconomic problems, yet little evidence is available to support this recommendation. Other outpatient-based strategies, such as frequent outpatient HF clinic visits, reduced revisits by nearly 50 % at 1 year in a systematic review and meta-analysis of RCT evidence [29]. Outpatient surveillance of daily weights or other signs and symptoms of worsening HF, whether human to human or human to machine in nature, failed to consistently reduce hospitalization, and little is known about the impact on ED revisits. Well-designed RCTs that examine the effects of home care on HF hospital and ED revisits are missing (see supplement). Self-care management interventions did not always meet the desired endpoints [19, 30, 31]; however, exercise capacity, when evaluated by 6-min walk test or home exercise frequency [32–34], was associated with reduced HF hospital revisits.

When delivering outpatient care, the best model is uncertain. A review of the literature on HF disease management (HFDM) supported a chronic care model, but there were no single, specific HF delivery models or interventions with superior efficacy [35]. Studies that reported improved morbidity, mortality or both typically utilized a “multimodal” approach, including some or all of the following: frequent assessments, inclusion of family or caregivers in the treatment plan, proactive education, discharge planning with established follow-up plan of care, ongoing medication review and monitoring for potential side effects, and adherence to evidence-based guidelines [36••]. In a Cochrane meta-analysis of the types of professionals delivering interventions, RNs with specialty training in HF were successful in reducing revisits; community-based nurses and multidisciplinary teams with pharmacists or social workers were not [37••].

HF Observation Care

Observation medicine is emerging as a strategy aimed at reducing HF revisits. It is geared toward patients who do not require the length or level of services provided by inpatient care but require management beyond traditional ED care [38]. Descriptive studies demonstrated the efficacy of the observation medicine approach (see supplement) [39–41]; however, there are no RCTs that examined 30-day revisit rates. Identification of the right patients, right services, right therapies, right length of treatment and right level of care providers that lead to optimal patient safety and best outcomes are needed.

Other Strategies and Issues Potentially Related to Heart Failure Revisits

Many other programs or services were assessed with the goal of reducing hospital revisits. Home care programs that involved telemonitoring or other forms of remote monitoring had inconsistent findings [42•, 43–45], and home-based programs that did not involve telemonitoring had a high [46] or no difference [47] in 30-day or longer term rehospitalization rates, even though patients who were rehospitalized had a shorter length of stay in one report [47]. When home care nurses’ knowledge of HF self-care principles was assessed, researchers found gaps in knowledge [48–50]. It is unknown if improvement in nurses’ knowledge of HF self-care (and possibly other aspects of HF) would promote higher intensity or accuracy of home health care delivery that might result in a decrease in HF revisits. For some patients, assessing and revising the programming of cardiac resynchronization therapy may improve cardiac function and reduce HF revisits [51]. Patient factors that might be difficult to modify, such as chronic kidney disease, muscle weakness, slow gait, depression, diabetes and advanced HF, were associated with HF rehospitalization in long-term follow-up [52]. Medicaid enrollment status was also associated with higher 30-day rehospitalization rates [21]. Of note, research on ED revisits for decompensated HF is more limited. An ED may be selected over being treated in an office setting for multiple reasons. More research is needed to learn whether assessment of risk factors and initiation of preventive interventions would decrease HF revisits. Finally, variation in the delivery of transitional care programs and other HF services [53, 54] could affect outcomes and must be addressed. Continuous quality monitoring of all services, no matter the environment of care or health care provider delivering care, might improve adherence to programs aimed at decreasing HF revisits.

Conclusion

Many research studies and some systematic reviews and meta-analyses are available on HF-based programs and strategies aimed at reducing early or longer term HF rehospitalization or ED revisits after hospital discharge. Unfortunately, many programs that utilized similar themes (for example, disease management or transitional care) had bundled interventions or research methods or interventions that were heterogeneous, making it difficult to determine best practices and their overall effectiveness in reducing HF revisits. Some HF strategies thought to be important in decreasing HF revisits did not meet expected endpoint outcomes (for example, telemonitoring and self-care behavior adherence). It was difficult to determine whether lack of program or strategy efficacy was due to a lack of differences in the intensity of the usual- and intervention-care strategies or other factors surrounding usual care or the intervention (such as inclusion and exclusion criteria, qualifications of the people completing the intervention, quality assessment of the intervention to determine study fidelity, changing patient preferences over time, and general patient adherence to trial interventions or established core HF therapies). Research regarding programs and strategies that may reduce HF ED and hospital revisits are in their infancy, especially related to early revisits. Further, we must be careful not to determine that a program or strategy is ineffective just because 30-day outcomes are not improved. Many core HF drug and device trials had similar between-group results early after randomization; it was 6- and 12-month outcomes—not early outcomes—that provided the benefits of interventions. Finally, as bundled interventions can be time consuming and costly to implement, it may be important to unbundle interventions whenever possible to lower cost of care without interrupting or compromising quality of care. As value-based care moves forward, it is inevitable that new programs and strategies will emerge that allow us to deliver better care with optimal clinical revisit outcomes. Innovative research approaches are needed to assess the effectiveness of previously understudied and unstudied factors that could decrease HF revisits.