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Heart failure admissions can be shortened and readmissions reduced with care management, two trials found with a standardized approach to care and with lung impedance-guided care, respectively.

Both trials were presented at the Heart Failure Society of America meeting in Nashville, Tennessee.

Care Technique Modifications

Implementing standard care management lowered average heart failure length of stay (LOS) in a single center retrospective observational study from 7.60 days to 6.56 days, reported Maekal Elyasi of New York University Winthrop Hospital in Mineola, New York, and colleagues.

Other improvements from 2016 before implementation of the standardized care protocol at the center to after implementation, in February through June 2017, included:

• The utilization of higher-dosage diuretics like furosemide (Lasix) in quantities of 60 mg or more increased from 36% to 86%.
• Heart failure order set use increased from 32% to 81%.
• Cardiology consultations for acute decompensated heart failure rose from 75% to 95% in the first month and 99% by month 6.
• As the study progressed, initiation of diuretics at a high dose increased to 93%.
• Heart failure order set use went up to 80%.
• Early cardiology consultation rose to 98%.

Standardized management in the study called for:

• Modifying the initial dose of diuretics administered in the emergency department from less than or equal to 40 mg of furosemide (Lasix) to greater than or equal to 60 mg.
• Monitoring urine output on furosemide and alerting the HF team of inadequate output.
• Early implementation of the heart failure guideline-directed medical therapy (GDMT).
• Early heart failure-specific consultation.
• Implementation of multidisciplinary rounds on a day-to-day basis.
• Close attention from nursing staff and heart failure nurse coordinators.

The study was impressive and probably required a very big investment, especially considering the involvement of a heart failure coordinator nurse, commented Eiran Gorodeski, MD, of the Cleveland Clinic.

While no surprise, the investigators of this study "really demonstrated that nicely when they reduced variability of care, they got better outcomes," Gorodeski told 番茄社区.

As to the key components, he noted: "It was more that they were able to standardize the type of consults patients got and care coordination was tighter and patients got physical therapy and palliative medicine was involved, so that's to me probably what led to the improved reduced length of stay."

This study calls for more research addressing how patients fared after being discharged from the hospital, Gorodeski pointed out. "We are reducing length of stay, so how does this impact both readmission risk after the patient is discharged from the hospital and also did it impact mortality?"

Lung Impedance-Guided Treatment

Lung impedance (LI)-oriented care significantly reduced heart failure-associated death, all-cause death, and heart failure readmissions, a randomized, single-blind two-center trial found.

The research results showed 52% fewer heart failure hospitalizations for the LI-guided group, 33% fewer deaths from any cause, and 47% fewer HF-related deaths, Michael Kleiner Shochat, MD, BSc, PhD, of Hillel Yaffe Medical Center in Haifa, Israel, and colleagues reported.

"Using new technology we can define if patient is 'ready' or not to discharge from HF hospitalization on the basis of the degree of his pulmonary congestion. If [the] patient is well decongested he is 'ready' to go home," said Shochat in an interview with 番茄社区.

"If not, [the] patient is in danger of emergent readmission during 30 day[s] and has a high risk to die," Shochat continued.

The study is "of great practical value," explained T. Sloane Guy, MD, of Weill Cornell Medicine in New York City in an interview with 番茄社区.

"If we are able to measure lung impedance and we are able to say okay, your lung impedance is not adequate for you to be discharged for another day or 2 and then we discharge you in a couple of days and you stay out and don't get readmitted, that's a huge win," Guy continued.

The researchers evaluated 290 patients (average age 67, 80% men). The researchers evaluated the participants LI at each monthly outpatient hospital visit and at both admission as well as discharge for each heart failure hospitalization.

Within 30 days, the LI-guided group had 89 readmissions out of 270 discharges, compared with 179 readmissions in the control group out of 467 discharges.

The 90-day mortality rate after heart failure readmissions was 48.5% in the LI-guided group versus 61% among controls.

Death from any cause occurred by day 30 in 22 of the LI-guided group and 41 of the controls and by day 90 in 25 and 46, respectively.

Heart failure-related deaths in the LI-guided and control groups at 30 days were 19 and 40 cases, respectively, and at 90 days 20 and 43 cases.

While there are a number of ways to measure heart failure and good clinicians are capable of determining if more diuretics are needed, Guy noted, clinicians are "are scrutinized for length of stay."

However, he added, "for most practitioners this is probably going to be a good tool and also it allows us to push back. If an insurance company is pushing us to discharge a patient, we can say, 'Well, wait a minute their lung impedance is not adequate, and studies show that if we wait until their lung impedance is better than the chance of readmission is less.' And most insurance companies would say at that point, 'Okay, yeah forget that.'"

Studies should be aimed at reducing readmissions in a scientific way, and both of these studies do that, noted Guy. "This is a very fruitful area of research, where we can and need to examine every possible way to treat heart failure such that the patient stays home and they don't have to keep going back to the hospital."