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Dimissione e periodo vulnerabile: come evitare le reospedalizzazioni precoci.

G. Di Tano

Cardiologia, Cremona

Scompenso Cardiaco Acuto

Convention Centri Scompenso

De novo HF

OHF - Chronic HF Worsening HF ED

Hospital

Admission for AHF

OHF - Chronic

HF

In-hospital

Mortality

Early Mortality

Early Re-hospitalizations

The steps of Heart Failure patient’s “journey”…

30 days

DT14

Early and Later Post-discharge

period ……

Rehospitalization is high in the early and later phase after hospitalization

30 days from discharge

1 patient out of 4 is readmitted

1855 AHF enrolled

118 (6.4%) died in-hospital

159 transferred to other hospital 57 discharged to skilled nursing facilities 1 lost

1520 Discharged home

94 readmitted (6.1%) - 91% for CV causes -

42 dead (2.8%)

126 overall dead or readmitted (8.3%)

0 At 30 days from discharge

Progetto re-ospedalizzazioni precoci Area Scompenso 2012-2014

0 At 30 days from

admission 7.6% dead

The 30-day metric in Acute Heart Failure revisited. Data from IN-HF Outcome, an Italian Nationwide Cardiology Registry

G. Di Tano, R. De Maria et al. EJHF submitted

30-d read-free survivors 30-d readmitted or dead

IN-HF 30 day outcome in 1520 discharged home

Il pz che muore/rericovera nelle Cardiologie a breve, ha SC cronico avanzato, disf renale, degenza lunga, con inotropi, meno RAS-inib.

Combined death+read p 0R 95%

Days Length of stay 0.0016 1.023 1.008 1.037

Worsening HF vs de novo 0.0045 1.828 1.206 2.772

Inotropes 0.0006 2.189 1.398 3.426

ACE/ARBs at discharge 0.0012 0.522 0.352 0.774

C statistic 0.695

Days Length of stay 0.0076 1.020 1.005 1.034

Worsening HF vs de novo 0.0079 1.909 1.185 3.076

ACE/ARBs at discharge 0.0013 0.486 0.313 0.754

C statistic 0.662

Logistic regression independent predictors of death+ readmission or readmission at 30 days

Predictors of 30-Day Readmission in 412 Pts Hospitalized With Decompensated Heart Failure ( Hernadez MB et al, Clin. Cardiol. 2013 )

• TROPONIN, injury, cardiovascular events • AST/ALT, organ damage

Early HF readmission and 30-day

mortality are associated with the process

of inpatient care …

Meta-analysis of 13 studies: The risk of

early readmission is increased by 55%

when inpatient care is of relatively low

quality ...

I was discharged early ! They told me to just take these tablets !!!

Ashton CM et al. Ann Intern Med. 2005;122:415. Ashton CM et al. Med Care. 2007;35:1044

IN HOSPITAL …

Valle R et al

For many if not most patients, hospitalization is

just one step in chronic Heart Failure …

Once acute decompensation is stabilized we move

quikly to optimize chronic therapy IN HOSPITAL to

prevent rehospitalization.

PRE-DISCHARGE therapy determines early outcome …

Discharge and Follow-up:

The beginning of the “journey” of a vulnerable patient …

2001

Hospital Discharge Recommendation or Indication COR LOE

Performance improvement systems in the hospital and early postdischarge outpatient

setting to identify HF for GDMT I B

Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up

visits, the following should be addressed:

a) initiation of GDMT if not done or contraindicated;

b) causes of HF, barriers to care, and limitations in support;

c) assessment of volume status and blood pressure with adjustment of HF therapy;

d) optimization of chronic oral HF therapy;

e) renal function and electrolytes;

f) management of comorbid conditions;

g) HF education, self-care, emergency plans, and adherence; and

h) palliative or hospice care.

I B

Multidisciplinary HF disease-management programs for patients at high risk for hospital

readmission are recommended I B

A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of

hospital discharge is reasonable IIa B

Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is

reasonable IIa B

Patient Care Plan

Date of discharge

Name and contact information for physician and DA

Medications

Pending tests and results

Follow-up appointments

Calendar

Other orders (diet, activity, etc.)

Information about disease or condition

When to call physician or seek emergency care

Form for writing down questions

Map for locating appointments (optional)

Other information about your center (optional)

(52% of HF patients are not seen in the first 30 days after a hospitalization... Jencks et al. N Engl J Med 2009 )

First post-discharge assessment …

When ?

For a patient hospitalized due to AHF, pre-discharge phase is

crucial for the optimal preparation to the vulnerable period of

transition from in-patient to out-patient care.

During this phase the following aspects should be addressed:

Disease-modifying therapies should be initiated before discharge

and carefully optimized during early post-discharge period.

Comorbid conditions detected and managed.

Patients at the highest risk identified and carefully followed.

Potential precipitant causes of recurrent HF characterised.

Patients enrolled in the multi-faced disease management projects.

1) Partnering with community physicians or physician groups to reduce readmission (0.33 percentage point lower RSRRs; P=0.017)

1) Partnering with local hospitals to reduce readmissions (0.34 percentage point;

P=0.020)

2) Having nurses responsible for medication reconciliation (0.18 percentage point; P=0.002)

3) Arranging a follow-up appointment before discharge (0.19 percentage point; P=0.037)

4) Having a process in place to send all discharge paper or electronic summaries directly to the patient’s primary physician (0.21 percentage point; P=0.004),

5) Assigning staff to follow up on test results that return after the patient is discharged (0.26 percentage point; P=0.049)

Circ Cardiovasc Qual Outcomes.

2013

Un MINIMAL DATA SET alla dimissione per il Medico di Famiglia

FOLLOW-UP DOPO LA DIMISSIONE OSPEDALIERA

PZ A BASSO PROFILO DI RISCHIO

Follow-up di 1-(3)-6 mesi presso l’ambulatorio Scompenso Cardiaco per

up-tritation della terapia, FU strumentale, valutazione devices, …

Pz stabile Pz instabile

PZ AD ALTO PROFILO DI RISCHIO

Visita precoce (< 7 gg) presso l’Ambulatorio Scompenso Cardiaco

Protocolli Terapeutici ambulatoriali

Stretto monitoraggio telefonico

domiciliare

Reinvio e coinvolgimento del MMG - Follow-up

telefonico

Prosecuzione del Follow-up (tempi succ visita variabili…) ambulatoriale e telefonico

Decorso osp …. BNP no - Re-ammissione … - compliance Disf. Renale Comorbidità +++ Score +++

N Engl J Med 370;8, 2014