Final Project Presented as a Palliative Care Fellow at the University of Kansas during Palliative Care Grand Rounds, June 24 2014.

1. Does Palliative Care consultation
reduce 30-day readmission Rates in
patients with Heart Failure?
Andi Chatburn, DO, MA
Palliative Care Fellow Grand Rounds
June 24, 2014

3. Acknowledgements
• Dr. Lori Olson
• Dr. Deon Hayley
• Heart Failure Nurse Specialists:
–Christy Russell
–Audra McDonald
–Tammy Brown

4. Abbreviations
• KUMC = The University of Kansas Medical
Center
• PC = Palliative Care
• HF = Heart Failure
• CV = Cardiovascular
• GOC = Goals of Care

5. Objectives
• Review:
– Guidelines used in advanced heart failure
• Discover and describe:
– 30-day readmission rates of patients admitted
with Heart Failure at KUMC after Palliative Consult
– Characteristics of these patients

6. WHY? relevance
• CMS: “Readmission after hospitalization is a
costly and often preventable event”
–Reports 30 day readmit for:
• HF, Pneumonia, Acute MI
• Seen as a marker of quality
• 2003-2004: 20% of Medicare beneficiaries
(2.3 million patients) readmitted within 30
days of hospital discharge
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-
WideAll-ConditionReadmissionRate.pdf Page 7. Accessed 6/11/14

7. Cost of care
• Jenks: Estimate these cost Medicare $17
billion annually
• Commonwealth: Estimate reducing readmit
rates to levels comparable to top performing
institutions would save CMS $1.9 billion
annually
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-
WideAll-ConditionReadmissionRate.pdf Page 7. Accessed 6/11/14

8. World bank: 1.351 billion people in China as of 2012
$1,900,000,000 = 1.9 x109
Photo by Greg Barber, Shanghai New Year

9. Why? effect Local practice
Baseline measurement of HF consult behaviors
and demographics, prior to embedding into HF
Clinic
Future: Create a trigger for when to consult
Palliative Care in patients with Heart Failure

10. Why?
• Current Hospice Guide: NHPCO 1996
guidelines:
–Symptoms of HF at Rest (Class IV)
–Optimal Medical Management
• BB/ACE/ARB/Diuretic
–EF <20%
• Other factors predict morbidity in HF:
– READMISSION
– Stage D

11. Stage D
• “Patients with truly refractory HF who might be
eligible for specialized, advanced treatment
strategies”
– Mechanical circulatory support
– Procedures to facilitate fluid removal
– Continuous inotropic infusions
– Cardiac transplantation
– Or for End-of-life care, such as hospice
– *ICDs are NOT warranted in patients with Stage D HF
ACCF/AHA Practice Guideline. “2009 Focused Update Incorporated iInto the ACC/AHA 2005 guidelines for the Diagnosis and Management
of HF in Adults” Circulation March 26, 2009. epub. http://circ.ahajournals.org/content/early/2009/03/26/CIRCULATIONAHA.109.192065

12. Prognostication in Heart Failure
• Two schools of thought:
• HF disease trajectory is unpredictable
• Patients don’t perceive HF as terminal
• Patients referred to hospice too late
• HF disease trajectory is predictable
• Goals of Care can be discussed in light of
typical HF trajectory

13. Heart Failure Disease Trajectory
• 20.5% unexpected death
• 13.3% steady decline, starting 12 months prior
to actual death.
• 29.9% decline starting 6 months prior
• 36.3% decline starting 3 months prior
Khierbek, et al. “Trajectory of Illness for Patients with CHF” JPM, 2013 May;16(5):478-84 .

14. Benefits of PC consultation
• Objective Prognosticator
• Verbalize values + Discuss goals of care
• Consultant matches goals to prognosis
• Recommend level of support and setting of
care that fits patient

15. “Communication to define goals of care
for the individual patient and then to
design therapy concordant with these
goals is fundamental to patient-centered
care.”
Whellan, Goodlin et al. “EOL Care in patients with Heart Failure.” Journal of Cardiac Failure, Feb 2014, Vol. 20, p 121-134.

16. Hypothesis
• Palliative Care Consultation should
30-day Readmission Rates for
patients admitted with Heart
Failure

17. Benefits of reduced 30-day
readmission Rates
–Decrease Side Effects of frequent
Re-hospitalization:
• Increased risk of infection
• Increased risk of medical bankruptcy
• Opportunity cost: time/events

18. Inclusion Criteria
• Patients admitted to KUMC
• Who had a Palliative Care Consult
• With Diagnosis of Heart Failure
• AND: Had HF exacerbation during same
admission as consult
• OR: Had HF exacerbation within 30 days prior
to consult admission

19. methods
• Database: 1110 Inpatient PC Consults in 2013
• 85 patients with Potential Cardiac Diagnosis
Retrospective Chart Review
• Excluded 15 patients with CV/Pulmonary disease but did not
have Heart Failure
• N = 64 HF patients with PC Consults

20. Database
• Age
• Gender
• Diagnosis System
• Admit Date
• Consult Date
• Disposition on Discharge

21. Chart Review
• Date of Discharge
• Date of Death VS. HF Clinic Follow Up
• Discharge Location and Support Plan
• Enrolled in HF RN tracking system?
• Goals of Care
• Prior 30 day Re-Admission and Dates
• Future 30 day Re-Admission and Dates
• Admission Diagnosis

22. 2013 Palliative Care consults
Non- Heart Failure
Consults
Consults with
Heart Failure
5.4%

23. Exclusion Criteria
•64 Palliative Care consults- patients
with HF diagnosis
• Total of 11 patients excluded
• Total Study patients: 53

24. Excluded patients
–5: re-consult on same patient
–2: unknown prior 30 day admit hx
• transfer from OSH
–1: unknown post-hospital readmits
• Lost to Follow Up
–3: Both Transfer from Outside Hospital and
Lost to Follow-up

25. Demographics
• Age Range 35 to > 85
• Average Age: 75.9 years old
• Median Age: 76 years old
• 10 Patients >85 “Oldest old”
• 28 Male
• 25 Female

26. 1 1
2
9
20
10 10
<40 40-49 50-59 60-69 70-79 80-84 >85
Number of Patients Per Decade

27. Non-Cardiac Multimorbidity
• 4: Renal
• 4: Cancer
• 3: COPD
• 3: Neuro
• 3: Infectious Disease (Sepsis)
• 2: GI

28. 32%
68%
53 study patients with Heart Failure and
Palliative Care Consult
Prior 30 day
readmission
No prior 30-day
readmission

29. Prior 30 day readmits
• 17 patients had <30 day readmits prior to
consult admission
–5 of the 17 went on to have future <30 day
readmissions
•2 are still alive at time of chart review
•3 died

30. Where are they now?
–5 of the 17 went on to have future <30 day
readmissions:
– 2 Alive
• 1: At home, refused services
• 1: Nursing Home (LTC)
– 3 Died
• 1 : home on home hospice
• 1 : inpatient hospice
• 1 : discharged to SNF, died in Nursing Home

31. No 30-D Readmit after PC Consult
9 Died
• 2 died in hospital on comfort measures
• 5 Died on Hospice
–2: Inpatient + 2 Home + 1 Travel
• 1 Died at home with Palliative Home Health
• 1 Unsure of location of death, likely Nursing
Home

32. No 30-D Readmit after PC Consult
3 Alive at time of chart review
• 1 : Home Health
• 2 : SNF vs. LTC

33. The One that got away
One Patient who didn’t have a 30
day readmission
PRIOR to Palliative Care consult,
but did AFTER Palliative Care
Consult.

34. 35 Patients without 30-day readmits
26 Died
• 8: hospital (7 at KU)
• 6: Inpatient Hospice
• 10: Home with Hospice
• 1: Home without Hospice
• 1: Skilled Nursing, rehab
7 Alive
• 4: Home/Nursing Home
with Hospice
• 1: Palliative Home Health
• 1: Home Health
• 1: Home without Hospice
2 Patients: Unknown
Status

35. Died, 38
Alive, 13
Unknown, 2
All HF Patients who had PC Consult in 2013

36. Conclusions
• HF trajectory is predictable.
• Patients with Stage D HF ought have GOC
conversation with provider
• Patients >85 admitted with HF ought to have
PC Consult
• Patients with HF and prior <30 day
readmission ought to have a GOC
conversation with provider