Unplanned 30-day rehospitalization rates for acute MI (19.9 percent) and chronic heart failure (HF) (24.4 percent) represent a huge healthcare burden for patients and providers. Delays in follow-up and lack of adherence to standardized guidelines, by providers and patients, contribute to these findings. The hospital-to-home transition is one area with the potential to effect changes in this complex problem, according to the study by Sherry Bumpus, NP, and colleagues at the University of Michigan, Ann Arbor, in Michigan.
Patients who were seen in the transitional clinic, called the BRIDGE, had significantly lower 30-day readmission rates compared to those who were not seen in the BRIDGE—8.5 versus 21.2 percent, respectively. In addition, BRIDGE patients had significantly lower 30-day emergency department visits than those who did not attend: 13.9 versus 27.8 percent, respectively.
At the BRIDGE clinic, nurse practitioners, acting as an extension of the inpatient team, adjust treatments depending on patient status, educate patients and ensure adherence to lifestyle and therapeutic guidelines.
"We took open slots on a nurse practitioner schedule from a cardiology practice and filled them with patients who did not have follow-up within two weeks," Bumpus told Cardiovascular Business News.
Patients whose follow-up appointment after discharge is longer than two weeks are automatically referred to the BRIDGE clinic. Also, patients who cancel or miss their follow-up appointment generate a red flag on their discharge summary and are contacted and referred to the BRIDGE.
"We found that by using the nurse practitioners to assess patients' response to medications, make guideline-approved adjustments, provide further education, and forward communication to the receiving provider and retro-communication to the discharging team was that 30-day readmission rates went down substantially for those patients that had one visit to our clinic," Bumpus said.
Patients whose scheduled follow-up appointment with either their primary care provider or cardiologist was more than two weeks from discharge were automatically referred to the BRIDGE clinic. Patients who chose to go to the BRIDGE were seen on average within 19.5 days.
"The 19.5 days is too long. However this number represents all patients from start-up to the present. Initially, we only had one nurse practitioner; we now have five. We hope that as we continue to gather data for 2009, this number will be drastically lower," she said.
Patients who attended the BRIDGE saw their primary care provider on average within 19 days from their BRIDGE appointment (or 38 days from discharge), and then saw their cardiologist on average within 37 days of their visit to their primary care provider (or 75 days from discharge).
"For patients referred to the BRIDGE at discharge who did not go, they saw their primary care provider at about the same time as someone who did go to the BRIDGE (38 days), and were seen by cardiology on average within 53 days from discharge," Bumpus said.
"One of the reasons patients choose not to attend the BRIDGE is that they have their follow-up planned. Some patients may have chosen to wait 53 days for cardiology and did not feel the need to keep their BRIDGE appointment—despite instructions otherwise," she said.
Why does it take patients so long to be seen by their cardiologist? Bumpus has a few theories. "First, the wait time to be seen by cardiology is considerable. They are scheduling three to six months out and their schedules are full. Too much demand for them and not enough to go around. Second, there may be a disparity based on who their cardiologist is. Newer cardiologists are easier to get into than more well established cardiologists. Lastly, patients may not understand the importance of being seen and may change their appointments—though all receive written instructions related to timely follow-up."
She is "unclear at this time as to whether the problem is a system, provider or patient issue" and intends to study the phenomenon in the future.
To gather their data for the present study, Bumpus and colleagues conducted a retrospective study of all patients referred to the BRIDGE from June 2008 to February 2009.
Of the 359 total patients, 67 percent attended BRIDGE. They found that patients were more likely to attend the BRIDGE if they had greater than two comorbidities.
Primary cardiac diagnoses accounted for 217 BRIDGE referrals (acute coronary syndrome 21.2 percent, coronary artery disease 13.7 percent, chronic HF 13.4 percent, other cardiac 12.3 percent). Cardiac was a secondary diagnosis or complication for the remaining 39.4 percent.
BRIDGE attendees had significantly lower 30-day readmission rates compared to those who did not attend—8.5 veresus 21.2 percent. And BRIDGE patients had significantly lower 30-day emergency department rates than those who did not attend: 13.9 versus 27.8 percent.
Researchers concluded that these preliminary findings suggest that this strategy can improve efficiency of acute cardiac care in the U.S.
Bumpus and colleagues have begun a cost analysis of the program. "The emphasis of the cost-effectiveness analysis is to see if the cost savings from not having patients readmitted is offset by the cost of providing care in the BRIDGE clinic," she said.