Novel paradigms for managing hospital transitions in heart failureHarriette Van Spall MD MPH FRCPC (Cardiology)Associate Professor of MedicineDepartment of MedicineDepartment of Health Research Methods, Evidence, and ImpactScientist, Population Health Research InstituteMcMaster UniversityTwitter: @hvanspall

Novel paradigms for managing hospital transitions in heart failureHarriette Van Spall MD MPH FRCPC (Cardiology)Associate Professor of MedicineDepartment of MedicineDepartment of Health Research Methods, Evidence, and ImpactScientist, Population Health Research InstituteMcMaster UniversityTwitter: @hvanspall April 17, 2020 Funding •Canadian Institutes of Health Research•Ontario’s Ministry of Health and Long-Term Care•Heart and Stroke Foundation•Hamilton Health Sciences Foundation Objectives•Review evidence-informed transitional care services in HF•Discuss the use of patient-centered care models that may facilitate avoidance of emergency department use Hospitalization for HF is high-risk 10-1 No. ofdeaths63 6386941301501233Time after discharge from hospital (months)1-33-66-1212-2424+ 67 4 23 5 8Hazard ratio No HF hospitalization Solomon et al. Circulation 2007;116:1482-87. 3-phase lifetime readmission risk after HF hospitalization Desai, Stevenson. Circulation. 2012;126:501-506. Redindicates period of highest risk for readmission 1) Immediately after discharge 2) Just before death Improving outcomes following hospitalization 1.Address the underlying cause2.Optimize GDMT 3.Ensure adequate treatment response 4.Refer for transitional care services5.Assess the patient’s careneeds / preferences•Telemedicine•Palliative care Transitional care services in HF (n=54 RCTs): all-cause mortality Van Spall et al, EurJ Heart Fail 2017; 19(11): 1427-1443. Van Spall et al. EurJ HF 2017; 19(11):1427-43. Transitional care services in HF (n=54 RCTs): all-cause readmissions Stepped Wedge Cluster RCT Van Spall et al. Am Heart J 2018; 199:75-82Van Spall et al. JAMA 2019; 321(8):753-761 . Study protocol PACT-HF nurse includes patients with most responsible diagnosis of HF - Confirms diagnosis using Boston clinical criteria and NT-proBNP PACT-HF nurse provides 1)Comprehensive assessment of patient and multidisciplinary linkages/referrals 2)Patient and informal caregiver self-care education 3)Patient-centred discharge summary, including action plan, to patient and family physician (FP) 4)Follow-up appointment with FP within 7 days High-risk criteria for 30-day readmission? Yes Patients are seen in HFC within 2-4 weeks and receive home care transition nurse visits and telephone calls from home -care agency nurses within 1 week for a period of 4-6 weeks Excludes patients who -Do not have diagnosis of HF -Are transferred to another hospital -Died d uring h ospitalization No Outcome Assessment Primary Clinical Outcome Time-to-first event of composite: (1) All-cause readmissions, emergency department (ED) visits, or death (2) All-cause readmissions or ED visits Van Spall et al. JAMA 2019; 321(8):753-761. Baseline Characteristics of PatientsPACT-HF (N=1104)Usual Care (N=1390)P-valueDemographicsAge,mean (SD)77.8 (12.4)77.6 (11.9)0.71Female, n (%) 544 (49.3%)714 (51.4%)0.30Resides in long-term care, n (%)164 (14.9%)222 (16.0%)0.44Self-reportedQuality of LifeEQ-Visual Acuity Score (1-100), mean (SD)52.6 (22.7)53.7 (22.2)0.20ComorbiditiesHypertension,n (%) 844 (76.5%)1,084 (78.0%)0.66Atrial Fibrillation, n (%)583 (52.8%)684 (49.2%)0.07MyocardialInfarction, n (%)240 (21.7%)295 (21.2%)0.76Diabeteswith complications, n (%)524 (47.5%)704 (50.6%)0.11Chronic Kidney Disease,n (%)242 (21.9%)316 (22.7%)0.63Chronic PulmonaryDisease, n (%)235 (21.3%)334 (24.0%)0.11Cerebrovascular Disease, n (%)101 (9.1%)129 (9.3%)0.91Dementia, n (%)98 (8.9%)123 (8.8%)0.98 Primary outcome (N=2494): Composite all-causedeath, readmission, ED visit at 3 months Van Spall et al. JAMA 2019; 321(8): 753-761. Co-primary outcome: Composite all-cause readmission or ED visit at 30 days Van Spall et al. JAMA 2019; 321(8): 753-761. Clinical outcomesPACT-HF (N=1104)Usual Care (N=1390)Hazards Ratio(95% CI)P-value3-month composite all-causedeath, readmission, or ED visit545 (49.5%)698 (50.3%)0.99 (0.83, 1.19)0.93Death <3 months111 (10.1%)136 (9.8%)1.18 (0.83, 1.68)0.36Readmission <3 months400 (36.2%)500 (36.0%)1.10 (0.91, 1.34)0.32ED visit* <3 months248 (22.4%)334 (24.0%)0.88 (0.68, 1.15)0.3630-day composite all-cause readmissionor ED visit304 (27.5%)409 (29.4%)0.93 (0.73, 1.18)0.54Readmission<30 days225 (20.4%)265 (19.1%)1.23 (0.95, 1.59)0.12ED visit* <30 days113 (10.2%)190 (13.7%)0.65 (0.45, 0.95)0.03*without hospitalization Van Spall et al. JAMA 2019; 321(8): 753-761. Sex-specific composite all-cause death, readmission or ED visit at 6 months P-value for sex interaction: 0.043 HR (95%CI): 1.05 (0.87-1.26)HR (95%CI): 0.85 (0.71-1.03) Van Spall et al. AHA 2019. Sex-specific composite all-cause readmission or ED visit at 6 months HR(95%CI): 1.03 (0.86-1.25) HR(95%CI): 0.83 (0.69-1.00) P-value for sex interaction : 0.034Van Spall et al. AHA 2019. Patient reported outcomesPACT-HFLS Mean(95%CI) (N=606)Usual Care LS Mean(95%CI) (N=380)Mean Difference(95% CI)P-Value B-PREPARED Score (0-22)16.52 (15.47, 17.57)13.96 (12.92, 15.00)2.64 (1.37, 3.92)˂0.01CTM-3 score(0-100)76.49 (72.00, 80.98)70.99 (66.53, 75.46)6.10 (0.83, 11.36)0.02EQ-5D-5Lscore (0-1)At discharge0.73 (0.70,0.76)0.55 (0.52, 0.58)0.18 (0.14, 0.23)˂0.016 weeks0.73 (0.70,0.76)0.67 (0.64, 0.70)0.06 (0.01, 0.11)0.026 months0.71 (0.67, 0.74)0.64 (0.61, 0.68)0.06 (0.01, 0.12)0.02Quality Adjusted Life Years (6 months)0.34 (0.33, 0.36)0.34 (0.33, 0.35)0.00 (-0.02,0.02)0.98 Van Spall et al. JAMA 2019; 321(8): 753-761. #AHA19 Clinical outcomes•PACT-HF did not improve: –Composite all-cause death, readmission, or ED visit–Composite all-cause readmission or ED visit •Efficacy in explanatory RCTs ≠ Effectiveness in real-world settings •Pitfalls in titrating services to risk •Floor effect Sex-specific outcomes•PACT-HF was more effective in improving 6 month clinical outcomes in females than in males•? self-care, self-efficacy, adherence Remote monitoring / telemedicine Brahmbhattand Cowie. Card Fail Rev 2019;5(2):86-92. Clinical course of HF: progression to advanced HF Larry A. Allen et al. Circulation. 2012;125:1928-1952 Hospital-at-homemodel of care Qaddoura, Van Spall. PLoSONE 2015; 10(6): e0129282 1.Admission avoidance schemes that offer hospital ward-level care•in the patient’s home•in an ambulatory day hospital1.Early discharge schemes that facilitate early discharge from the hospital with ward-level treatment in the patient’s home Meta-analysis: Hospital-at-home does not improve readmission or death Qaddoura, Van Spall. PLoSONE 2015; 10(6): e0129282 Meta-analysis: Hospital-at-home improves health-related quality of life Qaddoura, Van Spall PLoSONE 2015; 10(6): e0129282 Health care utilization among HF decedents in Ontario in last month of life (N=396,024) Van Spall et al. 2018, Unpublished Van Spall et al ESC Congress 2019 VariableTotalFemalesMalesAbsolute Difference(95% CI)ED visits (%) 61.158.763.64.9 (4.6, 5.2) Hospital admission (%)57.254.959.74.8(4.5,5.1)ICU admission (%)18.015.520.65.1 (4.8, 5.3Mechanical ventilation (%)15.112.917.44.5 (4.3, 4.8) Cardiac catheterization (%)1.61.22.10.8 (0.7,0.9) Coronary revascularization (%)1.00.81.30.5(0.5,0.6)Dialysis (%)5.74.47.12.7 (2.6, 2.8) Communitypalliative care (%)26.026.626.30.6 (0.3,0.8)10 ≥different physicians (%)21.828.124.96.3 (6.0,6.6)Hospitaldays (Mean [SD]) 5.3(7.3)4.9(7.0)5.7(7.6)0.8(0.7, 0.9)ED:emergency department; ICU: intensive care unit; AD: absolute difference; CI: confidence interval; SD: standard deviation Healthcare system costs at end of life in HF: death in hospital vshome (N=396,024) 0 10 000 20 000 30 000 40 000 50 000 60 000 6-months1-month6-months1-monthDied in hospitalDied out of hospital Mean Total Cost , CA$ 2004200520062007200820092010201120122013 Van Spall et al. 2018, Unpublished Van Spall et al ESC Congress 2019 Predictors of death in hospital vshome (N=396,024)Variable(comparator group)OR (95% CI)ED visit within 15 days of death (reference: No)9.69 (7.96, 11.79)Age per 10 year increase 0.74 (0.73, 0.74)Femalesex 0.88 (0.86, 0.89)Charlson score (0)1 3.28 (3.15, 3.42)2 4.38 (4.21, 4.56)≥3 6.95 (6.70, 7.20)Income quintile (lowest quintile)2 1.09 (1.06, 1.12)3 0.95 (0.93, 0.98)4 0.96 (0.93, 0.99)5 (Highest) 0.91 (0.89, 0.94)Outpatient Palliative care:6-months (none)0.69 (0.67, 0.70)More recent year of death (per year)0.98 (0.98, 0.98)Van Spall et al. 2018, Unpublished Van Spall et al ESC Congress 2019 Non-cardiac causes of readmission following HF hospitalization (N=10,978,900) Kwok et al, 2019; Am J Cardiology 124(5): 736-45 Summary: hospital to home transitions1.Address the underlying cause2.Optimize medical therapies3.Refer for transitional in select patients•Nurse home visits•Case management•Heart function clinics4.Consider patient centered models of care•Remote monitoring / telemedicine•Hospital at home•Palliative care