A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

Abstract

Objective: Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.

Design: Cluster-randomized controlled trial.

Participants: The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).

Methods: The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.

Results: Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.

Conclusions and implications: The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

Keywords: Heart failure disease management; older adults; skilled nursing facilities.

Figure 1:. Overview of SNF Connect Intervention

This figure provides an overview of the study including the HF-DMP, follow up and collection of outcomes. *The 7-day time frame allowed the best chance for successful informed consent. † Medication titration was tailored to HF with reduced ejection fraction or HF with preserved ejection fraction according to the HF Guidelines. Loop diuretics were titrated throughout the SNF stay based on weight. Medication titration recommendations according to pre-established protocols for ACE-I, ARBs and beta blockers for those with HF with reduced ejection fraction and a loop diuretic protocol for weight gain (a gain of 3 pounds in 3 days or 5 pounds in a week) and blood pressure protocol regardless of ejection fraction. The clinician was prompted by the nurse but made their own clinical decision if they would like to initiate a medication protocol. ‡ HF self-management education for five sessions using the teach-back method: a) recognizing signs and symptoms of HF, b) daily weight monitoring and documenting it on a calendar and how to compare weight trends, c) recognizing and understanding HF medication, d) following a low sodium diet, and e) when to call the doctor.^,. Abbreviations: SNF – Skilled nursing facility; NYHA – New York Heart Association; PCP – Primary Care Physician; Colorado Regional Health Information Organization

Figure 2:. Study Outcomes

Outcomes from Heart Failure Disease Management Program vs. Usual Care in Skilled Nursing Facilities The left side of the figure shows the primary composite outcome (rehospitalization, emergency department visit and mortality) at 30- and 60-days post SNF admission. The right side of the figure shows exploratory analysis of the rates of emergency department visits and rehospitalizations at 60 days. Footnote: none