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Strategies to reduce hospitalizations in patients with heart failure

Authors
Leora Horwitz, MD, MHS
Harlan Krumholz, MD
Section Editor
Sharon A Hunt, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Heart failure (HF) is one of the most common causes of hospitalization and readmission. Approximately six million Americans and 15 million Europeans are living with HF [1,2]. In 2011, the HF hospitalization rate in the United States was 18 per 1000 for those over age 64 [3], making HF among the leading causes of hospitalization in this age group [4]. Furthermore, about a quarter of those who are hospitalized with HF are readmitted within 30 days [4] and 30 percent within 60 to 90 days post-discharge [5]. A marked decrease in admission rates between 1999 and 2011 (30.5 percent reduction, 95% CI, 29.3-31.6) has not been matched by a comparable reduction in readmission rates, which declined 9.7 percent (95% CI, 8.5-10.8) over the same period [6,7]. Data for Medicare patients show that risk-standardized rehospitalization rates and mortality rates were correlated only weakly [8]. A majority of readmissions after HF hospitalization are not for HF, as shown in a separate study of Medicare patients [9].

Strategies to reduce hospitalizations in patients with HF include optimization of evidence-based drug and device therapies, addressing causes of HF, treating comorbidities, and improved management of care [10]. It has been suggested that reducing disruption during the hospitalization might lower readmission risk as well [11]. Evidence from randomized controlled trials has established the efficacy of certain drug and device therapies in reducing hospitalizations as well as mortality in patients with systolic HF, but treatment in patients with diastolic HF remains empiric since trial data are limited. (See "Overview of the therapy of heart failure with reduced ejection fraction", section on 'General management' and "Treatment and prognosis of heart failure with preserved ejection fraction".)

Patients with HF are typically older adults with complex drug regimens for HF, multiple concurrent diagnoses, and resulting polypharmacy [12]. They are often cared for by many clinicians. Because of these complexities, the care of HF involves more than straightforward medical management of a solitary disease. Moreover, HF patients may have trouble with balance, eyesight, hearing, and/or executive function that makes self-management difficult. Decreased cognitive function has been associated with readmission risk [13]. The clinician, working with others in a care team, must provide appropriate coordination of care, manage the patient between office visits, ensure adequate patient education to support the acquisition of self-care skills, and create safe transitions of care between settings.

This topic will review outpatient- and inpatient-based management strategies aimed at reducing the risk of hospitalization and rehospitalization for patients with HF. Patient self-management of HF is discussed separately. (See "Heart failure self management".) The medical management of heart failure and treatment of acute decompensation are also discussed separately. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction" and "Treatment of acute decompensated heart failure in acute coronary syndromes" and "Treatment of acute decompensated heart failure: Components of therapy".)

OUTPATIENT STRATEGIES

Disease management — Disease management programs are designed to provide a multidisciplinary, integrated approach to care for patients with a chronic condition. Disease management programs facilitate the development of an individualized care plan, provide patient education and support, and coordinate care among healthcare providers, patients and patients’ support systems. A clinician acting as a solo caregiver typically has neither the expertise nor time to address all these components of a patient’s healthcare needs.

                          

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Literature review current through: Nov 2016. | This topic last updated: Tue Jul 19 00:00:00 GMT+00:00 2016.
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