Telemonitoring: Catching Heart Failure Problems Early

Fewer Hospitalizations

Telemonitoring puts technology to work improving the lives of Pathways’ heart failure patients.  By catching problems earlier, it reduces hospitalizations.

Home Health nurses don’t visit daily, so telemonitoring gives Pathways a way to assess the patient 7 days a week, from our office.
 
The easy-to-use unit can give us the patient’s:

• Weight
• Blood pressure
• Heart rate
• Oxygen saturation

When a patient touches any button on the small unit, a friendly voice talks them through each step of the health check.  Patients also receive the data, giving feedback.

The information is sent automatically to a nurse via telephone: there is no phone charge to the patient.

Nurses monitor the health information daily, call the patient if necessary, and make home visits when indicated.

Pathways Telemonitoring Program Criteria

• Patient has heart failure
• Patient or caregiver can understand and follow instructions, and are physically able to use the unit 
• Patient or caregiver are open to telemonitoring technology
• Patient does not have an infectious disease (i.e. TB,  MRSA, varicella zoster, herpes zoster)   

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Depression in Heart Patients

Two of every five patients who experience acute coronary syndrome (ACS) will have depression—a very important psychosocial predictor of poor cardiovascular prognosis.

“A growing body of evidence suggests that mental health problems complicate physical health conditions and that this relationship worsens clinical outcomes, increases hospitalization, and adversely affects quality of life,” Joseph A. Ladapo, MD, PhD, of New York University in New York City.

He and colleagues predicted that treatment of depression after ACS would be cost effective and improve patient outcomes.  They conducted a randomized, controlled study comparing enhanced depression care with usual care in patients with ACS and persistent depression 3 months after discharge.  Ladapo and colleagues defined enhanced depression care as problem-solving psychotherapy, antidepressant use or both.

Their conclusion at the close of the 6-month, prospective trial involving 157 patients was that treatment for depression reduced total per-patient healthcare costs by more than 40% and was cost effective for almost all patients.

An assessment of quality of life showed improved health utility in the intervention group.  Interviews 6 months after discharge showed that in the intervention group 51% were using antidepressants or anxiolytics and 75% had visited a mental health specialist at least once for a total cost of $1,083.  In the control group 30% were using antidepressants or anxiolytics and 35% had seen a mental health professional, for an average of $554.

The extra costs for the intervention group were more than offset by the significant reduction in hospitalization for ACS and heart failure (5% vs. 16%), with a mean cost savings of $1,782 for the intervention group and unmeasured improvement in quality of life.

Total healthcare costs averaged $1,857 in the intervention group and $2,797 for the usual-care arm, resulting in an adjusted difference of $1,229, which did not achieve statistical significance (P=0.09). Because the intervention was cost saving, the investigators could not calculate a cost-effectiveness ratio.

The research was reported in Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4448, and was supported by the National Heart, Lung, and Blood Institute; the Health Resources and Services Administration; and the American Heart Association.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Heart Failure & Hospice

Patients with congestive heart failure who elect hospice live longer than those who don’t.  These were the findings of a defining 2007 study published in the Journal of Pain and Symptom Management.  Other diagnoses also experience longer prognosis with hospice, but none longer than the 81 day extension of life in heart failure.

Many factors probably contribute to the increased longevity.  Hospice care increases monitoring in the home and gives psychological, emotional and spiritual support from friendly visitors.  This holistic attention may increase the desire to live and reduce the sense of being a burden to one’s family.

Skipping the ER

Heart failure is the diagnosis most commonly associated with hospitalization.  By some estimates, patients with heart failure are readmitted at a rate of nearly 50% within six months.  For some patients, knowing that they have 24-hour access to nursing advice and visits for management of symptoms gives them a welcome alternative to the emergency room. 

Who is Appropriate?

Medicare guidelines include:

• Patient is optimally treated with vasodilators or unable to tolerate them.
• Patients with conditions usually treated with surgery are either ineligible or decline it.
• Patient is Class IV on the New York Heart Association scale: unable to do any physical activity without discomfort and symptoms may be present at rest.
• If ejection fraction is available, 20% or less is appropriate for hospice.
• Co-morbidities play a large role in estimating prognosis.  The following co-morbidities support a prognosis of 6 months or less in conjunction with the conditions listed above:
• Symptomatic arrhythmias resistant to treatment
• History of cardiac arrest, resuscitation or unexplained syncope
• Brain embolism of cardiac origin
• Concomitant HIV disease

The extra time that hospice can give patients may be especially important to patients and families trying to find resolution and peace at the end of life.  

Questions to Ask Patients

• Do you have discomfort when physically active? or Does physical activity give you more discomfort?
• Do you get short of breath when you are lying down?
• Do you ever wake up at night feeling short of breath?
• When you are resting in a chair do you ever feel short of breath, perspire or have chest pain?
• Do you have any swelling?
• Do you need help with activities like dressing, bathing, walking or eating?

Supporting Documentation

• Cyanosis
• Rales
• Dusky nail beds
• Tachycardia or bradycardia
• Hyper- or hypotension
• Jugular venous distension
• Liver enlargement
• Cachexia
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Decreased ejection fraction
• Weight gain due to fluid retention

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Meds That Cause ER Visits

Four Culprits

Just four drugs and drug classes cause two thirds of the 100,000 annual emergency room visits for drug reactions in the elderly, according to recent research.  At the top of the list is warfarin (also known as Coumadin); it alone accounted for one third of the visits.  The other categories are insulins, oral hypoglycemic agents and oral antiplatelet medications.

With antiplatelet or blood thinning drugs, bleeding was the main problem. For insulin and other diabetes medications, about two-thirds of cases involved changes in mental status such as confusion, loss of consciousness or seizures.

Some of the common denominators in these drugs are that: they are commonly prescribed; there is a fine line between the therapeutic dose and a dangerous one; and they can all be difficult to use.  The researchers made note that none of the medications that were culprits were drugs that were labeled “high risk” for older adults, although some over-the-counter drugs like Benedryl are.

“Of the thousands of medications available to older patients, a small group of blood thinners and diabetes medications caused a high proportion of emergency hospitalizations for adverse drug events among elderly Americans,” said lead study author Dr. Daniel Budnitz of the Centers for Disease Control and Prevention (CDC). 

“We weren’t so surprised at the particular drugs that were involved,” Budnitz said. “But we were surprised how many of the emergency hospitalizations were due to such a relatively small number of these drugs.”

It is estimated that hospitalizations for accidental overdoses and adverse side effects are likely to increase as Americans live longer and the senior population grows.  Currently 40% of people older than 65 take five to nine medications; 18% take 10 or more.

Researchers at CDC published the study in the Nov. 24, 2011 New England Journal of Medicine.

Care at Home vs. Hospitalization

Home Fares Better for Heart Failure Patients

Hospitalization, the standard venue for short-term medical care, may be hazardous for the elderly according to a study reported in the Archives of Internal Medicine in September, 2009.*  The study evaluated the feasibility and effectiveness of physician-managed home care for selected patients with acute decompensation of chronic heart failure.  The prospective, single-blind, randomized trial followed patients 75 years or older who had been hospitalized.  They were randomly assigned to a Geriatric Home Hospitalization Service or a general medical ward.

Overall Improved Status

Findings demonstrated no significant difference in the number of deaths or subsequent hospitalizations, but the mean time until the first additional admission was longer for the patients cared for in their own homes.  Only the home patients experienced improvements in depression, nutritional status and quality-of-life scores.

The research concluded that home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF.
  
*Arch Intern Med. 2009 Sep 28;169(17):1569-75.

For more information about Pathways Home Health services for patients with chronic heart failure, please visit www.pathwayshealth.org/home-health.