Posts Tagged ‘Heart failure’

Physician, Patient Must Share in Decision Making

Monday, March 12th, 2012

Heart devices save lives, but too often make the patient miserable.  That unpleasant possibility is why physicians are being urged to talk more honestly with people who have very weak hearts and are considering pumps, pacemakers, new valves or procedures to clear clogged arteries.  Patients with advanced heart failure often don’t realize what they are getting into when they agree to a treatment, and doctors assume they want everything possible done to keep them alive, according to the American Heart Association. The directive recommends shared decision making when patients face chronic conditions that frequently prove fatal; they need to decide what they really want for their remaining days.  If they also have dementia or kidney failure, the answer may not be a heart device.

“Patients may feel that the treatment was worse than the disease,” said Dr. Larry Allen of the University of Colorado Anschutz Medical Center, who helped draft the new advice. One of Dr. Allen’s former patients was a 74-year-old man too weak to shop or take walks.  He was so despondent that physicians thought he would feel better with a “mini artificial heart” — a $100,000 left ventricular assist device to improve his heart’s ability to pump blood.  “Even if it goes well, people are left with an electrical cord coming out of their belly” and a higher risk of stroke and bleeding from the nose or throat, Allen said.

More than five million Americans suffer heart failure, and the number is increasing as the population ages.  More and more high-tech treatments treat advanced disease, but they usually don’t slow its progression, they just keep people alive.  And that means living longer with symptoms that do nothing but worsen.  Patients typically don’t understand the repercussions when they agree to gadgets like a $30,000 to $50,000 implanted defibrillator, which shocks a quivering heart back into normal rhythm.  “Defibrillators don’t actually make people feel better — it doesn’t treat the underlying heart failure.  All it does is abort sudden death,” Allen said.

Allen and other physicians involved in the study stressed the importance of building a patient-doctor consensus with respect to questions of survival, symptom relief and quality of life issues.  Depending on their personal situation, not all patients want to “do everything” at all costs.  One way to facilitate such a discussion, according to the authors, is to reserve one day a year to review the patient’s situation, focusing on prognosis and possible treatments alongside an appreciation for the patient’s values and goals.  This annual review is not intended to replace appropriate discussions about the patient’s ongoing care, such as when a turn for the worse or hospitalization occurs.  “The process of checking in with patients on a regular basis is extremely important because heart failure and general health change over time,” Allen said.

Shared decision making goes beyond informed consent, requiring that healthcare providers and patients consider information together and work toward consensus.  This process should focus on the outcomes that are most important to the patients, including not only survival but also relief of symptoms, quality of life and living at home.  “For patients with advanced heart failure, the decision-making process should be proactive, anticipatory, and patient-centered. This involves talking about goals of care, expectations for the future, and the full range treatment options, including palliative care,” according to Dr. Allen.

Because the time required for shared decision making is tricky to fit into a regular clinic visit, the authors suggest a yearly review to discuss prognosis, consider realistic therapies, and spell out the patient’s values, goals and preferences.  This review is in addition to discussions triggered by events such as hospitalizations and other changes in the patient’s health.  “The process of checking in with patients on a regular basis is extremely important because heart failure and general health change over time,” Dr. Allen said.

Heart failure typically progresses with time.  During the early stages, it can often be managed with medicines and lifestyle changes in diet, stopping smoking and exercise.  Advanced heart failure requires additional treatments, including heart transplantation.  A focus of the decision making process is understanding that “doing everything” is not always the best thing.  For many patients with advanced disease, receiving symptom relief, comfort, and support and medical therapy are preferred.

Hospitals, CMS Butt Heads Over Too Many Readmissions

Tuesday, February 14th, 2012

Medicare has plans to penalize hospitals that frequently readmit patients who really don’t need hospitalization. According to one estimate, this practice costs the federal government $12 billion every year.  Medicare’s goal is to persuade hospitals to be certain that patients get the care they need following their discharge.  This new policy is likely to excessively impact hospitals, particularly those that treat low-income patients, according to a Kaiser Health News analysis of data provided by the Centers for Medicare & Medicaid Services.  Hospitals that admitted the most underprivileged Medicare patients were approximately 60 percent as likely to have significantly higher readmission rates for heart failure.  At these hospitals, lower-income people comprise a larger share of the patients than they do at 80 percent of hospitals.

“When some of our patients get home, their lights and gas are shut off,” said Roland Abellera, vice president of quality and corporate compliance at St. Bernard Hospital in Chicago’s blighted Englewood neighborhood.  “So what ends up happening is that the ambulance brings them back to us and we have to house them until our staff can help them get the utilities turned on.  We have a community in need.”

Within 30 days of discharge, 25 percent of Medicare patients with heart failure are readmitted to the hospital.  The Patient Protection and Affordable Care Act (ACA) has ruled that beginning next October, Medicare will fine hospitals whose patients who have had heart attacks, heart failure or pneumonia return to the hospital too soon.  By 2014, hospitals with high readmission rates can potentially lose up to three percent of their Medicare reimbursements.

Medicare has set aside funds so hospitals can more effectively plan patients’ post-discharge care.  According to Patrick Conway, Medicare’s chief medical officer, some funds will be targeted to hospitals that serve significant numbers of poorer people.  “We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities,” he said.  At the same time, his agency is committed to the readmission penalties, in part because it is the law and because it believes the penalties will persuade hospitals to be certain that patients get the follow-up care they need.

Some hospital administrators are concerned that the new policy is too harsh.  “In essence, they are penalizing those hospitals and areas that need the most help and the most money to address these issues because we have the sickest, most noncompliant and vulnerable patient population,” said Guy Alton, chief financial officer at St. Bernard.  According to Abellera, St. Bernard’s heart failure patients usually have more than one serious conditions, such as kidney failure, hypertension and diabetes.  “A patient does not come here for heart failure alone,” he said.  “They have no less than six or seven diagnoses — we’ve had many with more than that.”

Dr. Ashish Jha, in the latest New England Journal of Medicine, makes the case that readmissions aren’t the best gauge of unnecessary care — even though they’re a natural target for budget-cutters.  The Harvard University professor points out that many hospitals with the highest readmission rates serve the poorest areas with the biggest health problems.  “Readmissions are caused by what hospitals do, who the patients are, and what’s happening in the community,” he says. “You want hospitals to fix the things they can, but you don’t want to punish them for taking care of poor people, and you don’t want to punish them for being located in a poor area.”

Two of the most frequent reasons for hospital readmissions are medication errors and failure to see a physician – both of which could be reduced if patients were supervised through home care visits following discharge.

Commonwealth Fund Tackling Better Care for Uninsured, Minorities

Tuesday, October 18th, 2011

A new strategy report issued by the Commonwealth Fund Commission on a High Performance Health System  has the goal of creating a road map to improve healthcare for the uninsured, minorities and low-income Americans.

The commission, which looks for opportunities to enhance the delivery and financing of healthcare, recommends three broad strategies for achieving that improved care in the report, Ensuring Equity:  A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations.  The recommendations seek to assure the safety net’s stability and stimulate higher performance; strengthen delivery systems for susceptible populations; and coordinate healthcare delivery systems with public health services and community resources.

“Our current economic situation has increased the number and proportion of people who are vulnerable, leaving even more families at risk of suffering from our healthcare system’s inequities,” said Dr. David Blumenthal, chairman of the commission, and Samuel Their, professor of medicine and professor of health care policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School, Boston.

According to the report, there is a significant divide between vulnerable populations and their more secure counterparts in rates of receiving recommended screening and preventive care, control of chronic diseases, and hospital admissions for conditions that may be preventable with good primary care and community health outreach.  By way of example, only four of 10 low-income adults receive all recommended screenings and preventive care, compared with six of 10 higher-income adults.  Approximately three of 10 (29 percent) uninsured adults diagnosed with diabetes do not have it under control, twice the rate of the insured (15 percent).  Black adults are hospitalized for heart failure at rates (959 per 100,000) that are more than twice the rate for Hispanic adults (466 per 100,000); that’s nearly three times the rate for white adults (349 per 100,000).

“This policy framework builds on the great strides we expect to be made for vulnerable populations once the Affordable Care Act takes full effect in 2014,” said Commonwealth Fund Executive Vice President for Programs Anthony Shih, M.D. “By addressing crucial issues like access to care, affordability, quality improvement, and better coordinated care, these recommendations seek to assure that the uninsured, those with low incomes, and racial and ethnic minorities see the full promise of health reform and experience a truly equitable healthcare system.” 

“The Affordable Care Act is a big step forward in terms of addressing the significant needs of vulnerable groups and the healthcare providers who serve them,” said Commonwealth Fund President Karen Davis. “However, the inequity in our healthcare system is significant and” as defined in the Commission’s report, “more work must be done to close that gap and assure that we have a healthcare system that provides all of us with access to high quality healthcare.”