Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient’s Perspective
Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient’s experience may reframe the readmission “problem” and, ultimately, inform alternative strategies.
To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission.
Observational qualitative study.
Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission.
Open-ended, semi-structured interviews. Conclusions vetted using focus groups.
Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients’ home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a “negative” outcome.
Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.
KEY WORDSheart failure qualitative research care management care transitions patient-centered outcomes research
The authors would like to acknowledge the contribution of Elizabeth Stelson, MSW; Breah Paciotti, MPH; and their colleagues in the Mixed Methods Research Lab (MMRL). Ms. Stelson and Ms. Paciotti conducted and coded the qualitative interviews with assistance from the MMRL staff.
The team would like to dedicate this article to Thomas Gallagher, our patient partner, who changed the way we understand the experience of people with heart failure. Tom passed away as this article was being prepared, but his voice will live on through these words.
All those who contributed to the manuscript meet criteria for authorship.
This work was presented as a poster on April 3rd, 2017, at the 2017 American Heart Association Quality of Care and Outcomes Research Scientific Sessions in Arlington, VA.
This work has received funding from the following sources:
•PCORI grant 1IP2PI000186-02 to SEK and FKB
•American Heart Association 2016 Student Scholarship in Cardiovascular Disease to JSC.
Compliance with Ethical Standards
Conflict of Interest
The authors would like to disclose the following potential conflicts of interests:
Jonathan Sevilla-Cazes, MD, MPH: None
Kathryn H Bowles, PhD, RN, FAAN, FACMI: None
Faraz S. Ahmad, MD: None
Tom Gallagher: None
Shreya Kangovi, MD, MSHP: None
Lee R Goldberg, MD, MPH: Medtronic
Lynn Alexander: None
Anne Jaskowiak, MS, BSW: None
Barbara Riegel, PhD, RN, FAAN, FAHA: None
Frances K Barg, PhD, MEd: None
Stephen E Kimmel, MD, MSCE: Bayer, Pfizer.
- 3.McIlvennan CK, Allen LA. Palliative care in patients with heart failure. BMJ (Online). 2016;353.Google Scholar
- 4.Centers for Medicare and Medicaid Services (CMS), HHS. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals’ FTE resident caps for graduate medical education payment. Final rules. Fed Regist. 2011 Aug 18;76(160):51476–846.Google Scholar
- 11.Currie K, Strachan PH, Spaling M, Harkness K, Barber D, Clark AM. The importance of interactions between patients and healthcare professionals for heart failure self-care: A systematic review of qualitative research into patient perspectives. Eur J Cardiovasc Nurs. 2015 Dec; 14(6):525–35.CrossRefPubMedGoogle Scholar
- 12.Jeon YH, Kraus SG, Jowsey T, Glasgow NJ. The experience of living with chronic heart failure: a narrative review of qualitative studies. BMC Health Serv Res. 2010 Mar 24;10:77,6963–10–77.Google Scholar
- 17.McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012 Jul;33(14):1787–847.Google Scholar
- 18.Yancy 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. J Am Coll Cardiol. 2013 Oct 15;62(16):e147–239.Google Scholar