It shouldn't have taken the threat of monetary loss, a president, or malpractice to get our attention—yet it's very satisfying that, following the advent of that headline-producing, government-driven, reverse money-back guarantee, nearly every single driver of heart-failure readmission is being picked apart.

The satisfaction one receives from witnessing the stampede of hospital-based initiatives driving hard to block the emergency-department door is indeed impressive. All over the US, we can hear the cries of newly born palliative-care programs freshly birthed and swaddled, now nurtured in the loving arms of their CEOs.

At least it's getting done, and I'm happy for all of those dedicated heart-failure specialists who not only have a larger audience to whom they can say "I told you so" but also have a much larger platform for instruction. CHF specialists have always been dedicated to their cause. Good for them, because we are all now listening!

I met Dr Eiran Gorodeski a few years back when he was a mere fellow at the Cleveland Clinic. We were all down in the lounge following a long day in Orlando at yet another heart meeting. He's now faculty there, and just as I knew he was destined for great things then and even greater things to come, he presented an interesting study today regarding cognitive impairment in heart-failure patients. It provided welcome proof there is beauty and clarity in simplicity. Although we all know that patients who cannot think cannot comply, we don't often acknowledge that fact with any type of systems adjustment.

In this study of heart-failure patients, average age 77, the subjects were told three words: penny; apple; table. Then they were asked to draw a clock whose hands were positioned at 8:20.


This three-minute examination administered by transitional-care nurses found that one-quarter of heart-failure patients at discharge either could not remember all three words and/or could not draw the clock appropriately. Those who exhibited significant levels of cognitive impairment when compared with their better-scoring cohorts demonstrated a much higher 30% readmit rate at 30 days than those who performed well.

These findings speak volumes about our patients' ability to remember to take meds, avoid the saltshaker, weigh themselves, and recognize progressive symptoms. It also hinted that using home health systems, engaging a family member or nurse call-back programs, or referring them to a long-term care might be the only effective solutions to their inherent boomerang effect that produces the all-too-common frequent-flier status in our emergency departments. More important, it should speak volumes to us as healthcare providers who desire to improve the quality of life of these patients and their families who are suffering.

We really shouldn't have needed to put a price tag on that, but third-party payers have tried and succeeded. Hospitals have been brought to their knees at the mere thought of the financial implication, and so we are finally moving forward. Who would have thought that the inability to draw a clock could rock the financial stability of an institution? Now we get it. This recent affirmation of the impact of cognition really won't work very well if we don't also create our own healthcare-provider "mini-cog." Just a simple three-minute examination administered by the same transitional-care nurses would go a long way. Physicians, nurse practitioners, PAs, and nurses who do the discharge planning for heart-failure patients should be asked to remember three words: salt; ACEI; weight. Then we should be instructed to draw an image: our best rendering of a 1700-cc fluid restriction. After we finish our drawing, we should be asked to repeat those words and then draw a happy face and a dollar sign.


Other studies of equal impact today included one from the University of Alabama at Birmingham that demonstrated that patients discharged on ACE inhibitors demonstrated a nearly 50% reduction in readmission rates. A Western Michigan School of Medicine study found that researchers need more information on why younger patients are readmitted with heart failure as a primary diagnosis vs older patients in whom heart failure was a secondary diagnosis. Information from Providence Health Services described a vulnerability index that assigned points for variables such as number of admits in the past 90 days, substance abuse, and psychiatric disorders both psychotic and nonpsychotic. The patients were scored, and emails were sent to the healthcare providers informing them of their very low to very high readmit rates in the hopes of implementing early intervention. An Emory University study emphasized the impact of timely follow-up and specifically the impressive reduction in readmission rates when implemented. Finally, a Mayo Clinic study employed a smart-phone app that serves as a personal health assistant. When utilized, it reduced weight, improved fasting glucose levels, and improved readmission rates as well.

Although improvements in both quality and quantity of life should trump any concerns regarding the cost of 30-day readmits, it was a great day for heart failure here at American College of Cardiology 2014 Scientific Sessions . Only when we muster the same penchant for clarity in our own systems adjustments that we demand in the daily lives of our heart-failure patients will we meet with the ultimate success in the reduction of heart-failure bounce-backs. We can do this. Seriously.


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