Medical device companies, payors and hospitals are all looking at ways to reduce hospital readmission rates for heart failure patients. Here's an approach taken by Cedars-Sinai hospital that worked.
In a bid to curtail healthcare costs, the Centers for Medicare and Medicaid Services has been reducing payments to hospitals when heart failure patients are readmitted into the hospital within 30 days of discharge.
The provision went into effect in October 2012 and since then hospitals nationwide have been scrambling to find a solution to this expensive problem. Managing CHF patients has become a priority not just for hospitals but device makers too. Medtech companies are seeing their roles shift from caring for patients who need expensive implantable devices in a hospital setting, to helping patients manage disease across the continuum of health. Companies like Medtronic have teamed up with payors like Aetna to see how they can bend the cost curve of patients living with chronic diseases such as congestive heart failure and diabetes.
At Cedars-Sinai Medical Center in Los Angeles, doctors have hit upon a successful formula for managing congestive heart failure patients that combine a handheld ultrasound device, biomarker analysis and clinical protocols. For a small cohort of 52 patients who were in the program for at least one year, there was a greater than 50% reduction in readmission, explained Dr. Raj Khandwalla, a Cedars-Sina cardiologist and co-director of the heart failure program. The program began in August 2012.
The device that Cedars-Sinai doctors have begun to use instead of the humble stethoscope is GE Healthcare’s Vscan portable ultrasound.
“Physical exam is really a blunt instrument and not really that accurate in a patient who is just becoming more and more decompensated from a cardiac perspective,” Khandwalla said in a phone interview. “To be able, instead of a stethoscope,to use a handheld ultrasound to actually visualize the heart, to be able to estimate volume pressures is really helpful as a tool to intervene on people early to keep them out of the hospital.”
But it’s not just the Vscan alone that has contributed to keeping heart failure at bay. At Cedars-Sinai, doctors are also looking at a certain biomarker - BNP or brain natriuretic peptide - that is released by the he atrium of the heart, which functions as an early indicator system that shows patients are retaining fluid because of a weak heart, Khandwalla said. He noted that the BNP is not a perfect tool to judge whether a patient is headed to heart failure, but used in conjunction with the Vscan, provides a pretty good system of his or heart health.
There's still more that makes up the clinical protocol to manage CHF patients. If a cardiologist isn’t available when a patient shows worsening signs of heart failure, a clinical pharmacist can intervene.
“The clinical pharmacist works with the medication using the biomarkers and works with us to be able to devise an action plan for these patients and prevent hospital admission,” Khandwalla said.
The clinical pharmacist and cardiologists draw on data collected on heart failure patients at the hospital over the years to determine optimal medical therapy. The heart failure protocol also includes nurses who have the ability to see patients at home. So, it’s a combination of tools that Cedars-Sinai has at its disposal to manage these patients that has worked, he said.
Not surprisingly, there are more precise devices to tell whether CHF patients are deteriorating - implantable left atrial pressure sensors or CardioMEMS' wireless pulmonary artery pressure sensor that was recently approved by the FDA, for instance - but in the end Cedars-Sinai has chosen a combination of device, biomarker and clinical protocols to manage CHF patients.
“What we found is that using the ultrasound and using the biomarkers is really the kind of low-cost alternative to these expensive devices," he said,
And yet the end result was convincing.
"We compared the number of admissions one year before and after enrollment into the program. Each patient, therefore, acted as their own control." he said. "We found that we had a more than 50% reduction in our hospitalization readmission rate after the initiation of this program. It’s really exciting stuff.”
Now the hospital is planning to significantly expand the program.
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