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Heart Failure Hospitalist Can Reduce Length of Stay, Can Reduce Readmission, and Can Reduce Cost
The 23rd Annual Scientific Meeting HFSA underperformance and poor reimbursement related to improper documentation are increasing. Hence, transition to comprehensive clinical decision support systems (CDSS) will not just be inevitable but also rewarding. Purpose: Examine the level of correlation between the novel CDSS and health care providers’ clinical decisions. Methods: CDSS for diagnosis and treatment of HF (Cardiologist Evaluator) was developed using a USPO patented methodology with artificial intelligence to function as an assistant to health care provider. It serves as a search engine to select evidencebased diagnostic and therapeutic options for an individual patient. A total of 389 patients with suspected HF were available between 2017 and 2018 at a suburban tertiary care hospital. Both Cardiologist Evaluator and health care providers (mid-level practitioner or junior faculty) gave recommendations regarding diagnosis and treatment for each patient independently. Concordance rate between Cardiologist Evaluator recommendations and actual health care providers’ decisions was evaluated. Furthermore, ICD-10 coding provided by Cardiologist Evaluator was compared to ICD-10 coding of health care provider for immediate cost effectiveness evaluation. Recommendations given by Cardiologist Evaluator were later presented to board certified HF cardiologists who were then asked if they find them acceptable or unacceptable for care of each individual patient. New concordance rate, this time between Cardiologist Evaluator and HF specialist was evaluated. Results: Overall concordance rate between Cardiologist Evaluator recommendations and actual healthcare providers’ decisions was 69.7%. Most discrepancies were related to adoption of new therapies, dose advancements, workup for new onset heart failure, and/or referral for LVAD. HF specialists found recommendations given by Cardiologist Evaluator acceptable 99.3% of the time. Overall concordance rate between Cardiologist Evaluator and HF specialists was 98.9%. Cardiologist evaluator provided superior, automated ICD-10 coding in order of relevance. Conclusion: Cardiologist Evaluator shows high accuracy in evidence-based diagnosis and treatment of HF. It may be useful for consistent implementation of clinical guidelines and more reliable coding, especially in centers without HF specialists.
325 Improvement after Bariatric Surgery in Chronic Thromboembolic Pulmonary Hypertension: A Novel Treatment Target Anika Vaidy, Paul Forfia, Anjali Vaidya; Temple University Hospital, Philadelphia, PA Introduction: The complex interaction between obesity and pulmonary arterial hypertension (PAH) remains ill defined.There is a paucity of evidence that weight loss per se, can positively impact the hemodynamics of a patient with significant pulmonary hypertension. Herein, we present the first case of hemodynamic and functional improvement following bariatric surgery in a patient with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) and morbid obesity. Case: A 66 year old male with a medical history significant for multiple pulmonary embolism (PE) and morbid obesity was evaluated for chronic thromboembolic pulmonary hypertension (CTEPH). Echocardiogram and right heart catheterization were significant for severe pulmonary hypertension. Therefore, he was started on pulmonary hypertension medical therapy with riociguat and ambristentan, in addition to anticoagulation. He experienced a dramatic clinical response to medical therapy. Despite hemodynamic improvement, the patient remained symptomatic with significant fatigue, exertional dyspnea, and poor functional status as highlighted by a six minute walk distance of only 128 meters. Patient was referred for bariatric surgery with a gastric sleeve, after which he successfully lost 95 pounds in six months. Post operative right heart catheterization demonstrated normal PVR and cardiac output. His echocardiogram revealed normal RV size and function. His six minute walk distance also nearly quadrupled from 128 meters to 512 meters, consistent with WHO Functional Class I. Conclusion: We report the first case of hemodynamic improvement in pulmonary vascular disease following massive weight loss. This case illustrates the interplay of obesity and pulmonary hypertension while also highlighting the major cardiovascular benefits of bariatric surgery in this population. Weight loss accomplished through surgical means may augment the existing PH treatment paradigm.
326 A Survey of Family Medicine and Internal Medicine Faculty and House Officers’ Understanding and Experience with Left Ventricular Assist Devices Christopher R. Fagan, Abbas Bitar; University of Michigan, Ann Arbor, MI Introduction: The number of patients with stage D heart failure (HF) requiring a left ventricular assist device (LVAD) is on the rise. The aim herein is to examine family medicine (FM), internal medicine (IM) faculty and house officers (HO) understanding and experience about LVAD. Methods: A survey was distributed by email to FM, IM faculty and HO at the University of Michigan. The survey contained questions about LVAD survival and basic management of arresting LVAD patients. Results: 111 completed the survey (23.8%). Respondents self-identified as HO (59.5%) and the rest were FM and IM faculty. Only 30.9% reported receiving education on LVADs during their training and 66.6% reported being somewhat familiar with LVAD therapy. However, only half felt that LVAD therapy is a good option for improving quality of life and only 32% felt that LVADs improved survival. Only 6% of respondents estimated correct 1-year survival post pump implant. 77% correctly identified the anticoagulation of choice and 47% reported the appropriate way to measure blood pressure. No respondents received instruction on how to run a code on LVAD patients during ACLS certification, only 6.3% were aware of the recent AHA
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scientific statement regarding unresponsive LVAD patient management, and only 9% felt comfortable running a code blue on an LVAD patient. 49% and 35%, respectively, report that chest compressions and defibrillation can be performed if indicated. HO had better knowledge than IM and FM faculty regarding arresting LVAD patient management (p<0.05). Conclusions: Substantial knowledge gaps about LVAD and basic LVAD management were identified among IM, FM faculty and HO at a large teaching hospital. Similar knowledge gaps may exist among the larger internal and family medicine communities as a whole.
327 Heart Failure Hospitalist Can Reduce Length of Stay, Can Reduce Readmission, and Can Reduce Cost Jesus Vargas Jr, Ankit Goel, Tom Stoner, Kim Fowler; UPMC Pinnacle, Harrisburg, PA Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. By 2030, greater than 8 million Americans will be living with HF. The projected cost will increase to close to 70 billion with the majority of the cost attributed to hospitalization. Despite numerous evidence-based strategies in the literature to reduce HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Most HF admissions are co-managed with hospitalist resident teaching service and cardiologist. Although, prevention of readmissions is an overarching goal, readmissions do happen. With the current care hospital model, HF patients rarely have a consistent provider if readmitted. Lack of consistency reduced the ability to develop trusting relationships which are essential to facilitate goals of care discussions. In addition, even the best clinical documentation is challenged to record patient specific treatment plan successes and failures. To address this health care priority at UPMC Pinnacle with approximately 1,200 HF patients annually, an interdisciplinary HF team created a HF Hospitalist service to support an environment of patient centered care across the continuum by providing continuity of care for HF admission and HF patients admitted for non-HF admissions. The HF Hospitalists provide quality care with frequent daily rounding, optimization of HF medications, patient and family education to improve treatment plan adherence and early discussion of palliative and hospice transition. Furthermore, the HF hospitalist team coordinates care with the HF outpatient center. The goal is early post-hospital provider follow-up to aggressively monitor HF patients. The HF Hospitalist team meets daily with HF Nurse Navigators to support the system’s outpatient self-management program which uses an 8-visit template to review action plans, goals of care, medication reconciliation and education. The team also implemented innovative techniques such as Community Paramedicine outpatient visits to carry out intravenous diuretic protocols in the home, virtual/telemedicine visits, and ReDSVEST technology to monitor for signs of early exacerbation and prevent readmissions. At this community-based health care system, impressive HF Hospitalist outcomes include decreased length of stay by almost 1 day; decreased 30 day all-cause readmission to an impressive 9% (48.5% absolute reduction when compared to nonHF Hospitalist HF admissions as well as national averages), reduced 30 day HF readmissions to 3.13%, as well as transitioning 13% patient to hospice care; all while reducing costs during the first 12 months of the HF Hospitalist service.
328 The Intersection of Quality and Clinical Care: Approach to Improve Ventricular Assist Device Patient Care Erin Breen, Danielle Hinchey, Gurusher Panjrath; The George Washington University Hospital, Washington, DC Background: Improving outcomes in the Ventricular Assist Device (VAD) patient population is an on-going challenge. Incorporating comprehensive quality into a VAD program ensures not only meeting accreditation standards, but helps improve patient care. We used performance measure data to identify deficiencies and garner stakeholder buy-in with the intended goal of improving care. Methods: The quality specialist worked closely with the VAD team to identify the performance measures for the program as well as establish benchmarks using evidenced based best practices. Each performance measure was distinctly tied to a data point that would subsequently be abstracted from the chart for each patient. The quality specialist and VAD Coordinator then incorporated the quality measures and performance goals into a QAPI Plan and encouraged stakeholders to review and provide feedback. By engaging stakeholders to review and revise, we promoted buy-in to the QAPI elements of the VAD program. Performance measures were tracked monthly. Variance on the scorecard was presented to the VAD multidisciplinary team as well as Hospital Quality Council. If variance occurred, performance improvement activities were developed. Results: A unique color-coded QAPI scorecard was created in which different colors represented different levels of compliance. The metrics were tracked using the Scorecard and presented at the monthly meetings. At baseline, driveline dressing change compliance was 63%. After implementation of our improvement measures, compliance increased to 81%. Similarly, performance of Daily Weights increased from 36% to 96%. Documentation of Nursing VAD Education increased from 57% to 97% and documentation of Pain Assessment increased from 64% to 97%. We maintained a zero percent rate of driveline infection. Conclusion: Creating stakeholder awareness of gaps in performance increased commitment to performance improvement plans. Use of a unique color coded QAPI scorecard can be useful in improving quality metrics and
325 Improvement after Bariatric Surgery in Chronic Thromboembolic Pulmonary Hypertension: A Novel Treatment Target Anika Vaidy, Paul Forfia, Anjali Vaidya; Temple University Hospital, Philadelphia, PA Introduction: The complex interaction between obesity and pulmonary arterial hypertension (PAH) remains ill defined.There is a paucity of evidence that weight loss per se, can positively impact the hemodynamics of a patient with significant pulmonary hypertension. Herein, we present the first case of hemodynamic and functional improvement following bariatric surgery in a patient with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) and morbid obesity. Case: A 66 year old male with a medical history significant for multiple pulmonary embolism (PE) and morbid obesity was evaluated for chronic thromboembolic pulmonary hypertension (CTEPH). Echocardiogram and right heart catheterization were significant for severe pulmonary hypertension. Therefore, he was started on pulmonary hypertension medical therapy with riociguat and ambristentan, in addition to anticoagulation. He experienced a dramatic clinical response to medical therapy. Despite hemodynamic improvement, the patient remained symptomatic with significant fatigue, exertional dyspnea, and poor functional status as highlighted by a six minute walk distance of only 128 meters. Patient was referred for bariatric surgery with a gastric sleeve, after which he successfully lost 95 pounds in six months. Post operative right heart catheterization demonstrated normal PVR and cardiac output. His echocardiogram revealed normal RV size and function. His six minute walk distance also nearly quadrupled from 128 meters to 512 meters, consistent with WHO Functional Class I. Conclusion: We report the first case of hemodynamic improvement in pulmonary vascular disease following massive weight loss. This case illustrates the interplay of obesity and pulmonary hypertension while also highlighting the major cardiovascular benefits of bariatric surgery in this population. Weight loss accomplished through surgical means may augment the existing PH treatment paradigm.
326 A Survey of Family Medicine and Internal Medicine Faculty and House Officers’ Understanding and Experience with Left Ventricular Assist Devices Christopher R. Fagan, Abbas Bitar; University of Michigan, Ann Arbor, MI Introduction: The number of patients with stage D heart failure (HF) requiring a left ventricular assist device (LVAD) is on the rise. The aim herein is to examine family medicine (FM), internal medicine (IM) faculty and house officers (HO) understanding and experience about LVAD. Methods: A survey was distributed by email to FM, IM faculty and HO at the University of Michigan. The survey contained questions about LVAD survival and basic management of arresting LVAD patients. Results: 111 completed the survey (23.8%). Respondents self-identified as HO (59.5%) and the rest were FM and IM faculty. Only 30.9% reported receiving education on LVADs during their training and 66.6% reported being somewhat familiar with LVAD therapy. However, only half felt that LVAD therapy is a good option for improving quality of life and only 32% felt that LVADs improved survival. Only 6% of respondents estimated correct 1-year survival post pump implant. 77% correctly identified the anticoagulation of choice and 47% reported the appropriate way to measure blood pressure. No respondents received instruction on how to run a code on LVAD patients during ACLS certification, only 6.3% were aware of the recent AHA
S121
scientific statement regarding unresponsive LVAD patient management, and only 9% felt comfortable running a code blue on an LVAD patient. 49% and 35%, respectively, report that chest compressions and defibrillation can be performed if indicated. HO had better knowledge than IM and FM faculty regarding arresting LVAD patient management (p<0.05). Conclusions: Substantial knowledge gaps about LVAD and basic LVAD management were identified among IM, FM faculty and HO at a large teaching hospital. Similar knowledge gaps may exist among the larger internal and family medicine communities as a whole.
327 Heart Failure Hospitalist Can Reduce Length of Stay, Can Reduce Readmission, and Can Reduce Cost Jesus Vargas Jr, Ankit Goel, Tom Stoner, Kim Fowler; UPMC Pinnacle, Harrisburg, PA Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. By 2030, greater than 8 million Americans will be living with HF. The projected cost will increase to close to 70 billion with the majority of the cost attributed to hospitalization. Despite numerous evidence-based strategies in the literature to reduce HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Most HF admissions are co-managed with hospitalist resident teaching service and cardiologist. Although, prevention of readmissions is an overarching goal, readmissions do happen. With the current care hospital model, HF patients rarely have a consistent provider if readmitted. Lack of consistency reduced the ability to develop trusting relationships which are essential to facilitate goals of care discussions. In addition, even the best clinical documentation is challenged to record patient specific treatment plan successes and failures. To address this health care priority at UPMC Pinnacle with approximately 1,200 HF patients annually, an interdisciplinary HF team created a HF Hospitalist service to support an environment of patient centered care across the continuum by providing continuity of care for HF admission and HF patients admitted for non-HF admissions. The HF Hospitalists provide quality care with frequent daily rounding, optimization of HF medications, patient and family education to improve treatment plan adherence and early discussion of palliative and hospice transition. Furthermore, the HF hospitalist team coordinates care with the HF outpatient center. The goal is early post-hospital provider follow-up to aggressively monitor HF patients. The HF Hospitalist team meets daily with HF Nurse Navigators to support the system’s outpatient self-management program which uses an 8-visit template to review action plans, goals of care, medication reconciliation and education. The team also implemented innovative techniques such as Community Paramedicine outpatient visits to carry out intravenous diuretic protocols in the home, virtual/telemedicine visits, and ReDSVEST technology to monitor for signs of early exacerbation and prevent readmissions. At this community-based health care system, impressive HF Hospitalist outcomes include decreased length of stay by almost 1 day; decreased 30 day all-cause readmission to an impressive 9% (48.5% absolute reduction when compared to nonHF Hospitalist HF admissions as well as national averages), reduced 30 day HF readmissions to 3.13%, as well as transitioning 13% patient to hospice care; all while reducing costs during the first 12 months of the HF Hospitalist service.
328 The Intersection of Quality and Clinical Care: Approach to Improve Ventricular Assist Device Patient Care Erin Breen, Danielle Hinchey, Gurusher Panjrath; The George Washington University Hospital, Washington, DC Background: Improving outcomes in the Ventricular Assist Device (VAD) patient population is an on-going challenge. Incorporating comprehensive quality into a VAD program ensures not only meeting accreditation standards, but helps improve patient care. We used performance measure data to identify deficiencies and garner stakeholder buy-in with the intended goal of improving care. Methods: The quality specialist worked closely with the VAD team to identify the performance measures for the program as well as establish benchmarks using evidenced based best practices. Each performance measure was distinctly tied to a data point that would subsequently be abstracted from the chart for each patient. The quality specialist and VAD Coordinator then incorporated the quality measures and performance goals into a QAPI Plan and encouraged stakeholders to review and provide feedback. By engaging stakeholders to review and revise, we promoted buy-in to the QAPI elements of the VAD program. Performance measures were tracked monthly. Variance on the scorecard was presented to the VAD multidisciplinary team as well as Hospital Quality Council. If variance occurred, performance improvement activities were developed. Results: A unique color-coded QAPI scorecard was created in which different colors represented different levels of compliance. The metrics were tracked using the Scorecard and presented at the monthly meetings. At baseline, driveline dressing change compliance was 63%. After implementation of our improvement measures, compliance increased to 81%. Similarly, performance of Daily Weights increased from 36% to 96%. Documentation of Nursing VAD Education increased from 57% to 97% and documentation of Pain Assessment increased from 64% to 97%. We maintained a zero percent rate of driveline infection. Conclusion: Creating stakeholder awareness of gaps in performance increased commitment to performance improvement plans. Use of a unique color coded QAPI scorecard can be useful in improving quality metrics and