Testing the Effect of and Intervention in Preventing Re-hospitalization - Research Paper Example

Contents Contents 2 Introduction 3 Studied Outcomes 4 Study Limitations 4 Performance Measures related to Discharge Education to Patients with Heart Failure 5 Factors Influencing Outcomes 5 Summary of Findings 6 Table of Evidence: Research Grid 7 Conclusion 9 References 10 Testing the Effect of and Intervention in Preventing Re-hospitalization Introduction As the expenditure in the United States leads with $2.3 trillion in 2008, attention has been focused on the rise of chronic disease among Americans as the major source of costs. The result is, in fact, higher, leaving the sole and biggest footprint on the healthcare system. While the figure on the exact number of citizens suffering from chronic illness change at any given time, the trends and magnitude conform to a consistent pattern showing a substantial and mushrooming problem (Turner, Paul, Stone, et al.2008). The only solution is improving chronic disease management which yields savings on a predictable basis. Though there has been much advancement in the curing of chronic diseases and in this case heart failure (HF), it still remains the core cause of hospitalizations in many nations and is linked with high mortality and morbidity, high medical care costs, and particularly in impaired quality of life. The different new approaches to heart failure care that have been investigated in clinical trials have raised the complexity of the treatment (Stromberg, 2002). The latest meta analyses indicates that, in addition to optimal pharmacological treatment or curing, the care of heart failure patients by a multidisciplinary team lowers rehospitalization and mortality rates and improves the quality of life of patients.(Van der Wal & Van Veldhuisen, 2005). A North-American survey of an intervention that involved telephoned contact and home visits by an HF specialized nurse after hospital discharge revealed that the intervention effectively reduced mortality and morbidity rates (The Lewin Group, 2008). During all visits, care givers of the patients were invited to listen to the instructions. After being discharged, patients were randomized to receive, systematic telephone contact for a three month investigational time or to receive the common care that comprised of the follow-up of the patient at the return appointment at the outpatient clinic without any telephone contact (GESICA, 2005). A single telephone contact per week was done in the first month, accompanied by one every 15 days in the second month and a single every 15 days in third month summing up to eight calls per patient. Telephone calls had to begin seven days after the release from the hospital, aiming and reinforcing and emphasizing instructions that were received during hospitalization and monitoring symptoms and signs of de-compensation and investigating probable visits to rehospitilizations and the emergency unit. Studied Outcomes The scores for the levels of heart failure knowledge and awareness of self-care were considered as primary results. The frequency of visits to the emergency care unit, deaths at the end of the three month duration and re-hospitalizations were considered as secondary results (Whellan, & Hasselblad, 2005). Study Limitations Some of the study limitations were: some of the patients could not be located at the start of the intervention and after the three month duration due to blocked telephone numbers or wrong telephone numbers. Another limitation of the study was the patient's economic and social statuses and cultural norms. On the other hand, the three-month duration of the study was perhaps too short for the patients to change the health behaviors and habits to the extent that could lower the rate of visits to the emergency care unit, death and re-hospitalizations (Folz, Friedenzohn , DeFrancesco et al., 2003). Performance Measures related to Discharge Education to Patients with Heart Failure Performance measures are used to determine whether a firm or an organization is meeting its patient focused goals and fulfilling its vision (Daniels & Roob, 2008). The performance measures are standardized to evaluate health systems and hospitals, despite of location in order to boost positive results in patient care. They may reflect medical management of patient, nevertheless, the may also assess aspects of patient care, like education of patients and their families at discharge. Patients should receive educational materials as part of the patient's complete discharge instructions. These materials should address the recommended activity level, discharge medications, diet, follow-up appointment, level, weight checking and what to do if signs worsen (Dunagan et al., 2005). Factors Influencing Outcomes Based on the evaluation results, various factors may have influenced the outcome of the demonstrations. (1) It seems that unintended selection bias emerged in all the programs in the demonstration. (2) The intervention group was not adequately differentiated from the control group. (3) The fees paid to the providers and contractors were a very high percentage of the total costs, making the savings above outlays a very high figure to clear. (4) There were wide disparities in spending amongst the beneficiaries while sample sizes of other plans were relatively small, making the averages a misleading picture of the real experiences of individual patient for savings across a larger population (Riegel et al, 2002). (5)The interventions were moderately heavy on telephone contacts in relation to face-to-face contact with patients and had no financial incentives for physicians (Bocchi et al., 2008). Summary of Findings While studies require one to be cautious about generalization, some consistent trends do arise. Where patients are being targeted according to the predictors of continued high utilization like recent hospitalization, and clinical indicators predictable savings emerge. The most obvious sources of savings are decreased in hospital readmissions or admissions and cost per stay, in spite of the length of stay. In patients with asthma, decrease in ER visit is also the main metric of savings (Geyman, 2007). Studies in addition quantified utilization according to hospital length of stay, outpatient costs, total hospital costs and pharmaceutical costs. In majority of those studies that quantified pharmaceuticals, total costs reduced even as pharmaceutical costs rose. Highly individualized hospital pre-discharge counseling and planning by multi- disciplinary teams yield considerable savings, even when there are no other interventions. Education interventions tend to be less effective, in adult or older patients, as this has low-intensity telephone contact that is the foremost way of intervention rather than follow-up from higher intensity interventions that are winding down to a level of patient self-management (Folz Friedenzohn , DeFrancesco et al., 2003). Table of Evidence: Research Grid Topic: The effect of telephone reinforcement versus home visits in preventing re hospitalization patients with chronic diseases. Author(s), Title, Year, Source (Journal) Purpose, Design, Level of Evidence Sample characteristics, size, setting Variables: List ¬e type: research, dependent, independent, extraneous Measurements: Describe tools &Reliability/Validity of each Key Findings Limitations Adams et al. A systematic review of the chronic model..(2007) journal of Archives of Internal Medicine These study focuses on chronic illness and evidence has been given on heart failure Meta-analysis of hospitalized patients age 55+ Some of the variables that were noted during the study were the genetics and intelligence, age and the test score for the group being studied. HF and self-care information questionnaires The questionnaires were based on instruments that were available in the literature and validated by the study groups and also based on recommendations for assessing and instructing patients. These instruments gave a result of in scores (range 0-10 points) . Where patients are being targeted according to the predictors of continued high utilization like recent hospitalization, and clinical indicators predictable savings emerge. some of the patients could not be located at the beginning of the interventions and after the three month duration due to blocked telephone numbers or wrong telephone number Dunagan, et al. …, telephone-based disease management program for patients with heart failure. (2005) Journal of Card Fail. These study focuses on chronic illness and evidence has been given on heart failure 180 day post-hospital discharge evaluation of CHF patients Some of the variables that were noted during the study were language, time of the day, HF and self-care information questionnaires The questionnaires were based on instruments that were available in the literature and validated by the study groups and also based on recommendations for assessing and instructing patients. These Instruments gave a result of in scores (range 0-10 points). Highly individualized hospital pr-discharge counseling and planning by multi- disciplinary teams yield substantial savings, even when there are no other intervention the three-month duration of the study was perhaps too short for the patients change the health behaviors and habits to the extent that could lower the rate of visits to the emergency care unit, death and re-hospitalizations Krumholz, et al.the Randomized trial of education and support interventions to prevent readmission of patients with heart failure. (2002)Journal of Am Coll Cardiol. These study focuses on chronic illness and evidence has been given on heart failure 1 year assessment of intervention with diagnosed asthma patients of ages 2-9. Some of the variables that were noted during the study were statistical regression and social class. HF and self-care information questionnaires The questionnaires were based on instruments that were available in the literature and validated by the study groups and also based on recommendations for assessing and instructing patients. These Instruments gave a result of in scores (range 0-10 points). Education intervention tends to be less effective older patients some of the patients could not be located at the start of the intervention Conclusion The conclusion of these study points out that the instructive or educational nursing intervention done during the hospitalization duration brought about improved understanding of heart failure and self care in all patients regardless of any telephone contact after their release from the hospital. Moreover, education of patients during discharge improves self-care, reduces readmission and assists patients to identify problems early; this increases the chances for intervention and improved results (Dove & Duncan 2004). What comes up from the existing research is a way to hopeful models of chronic care management that can decrease overall healthcare costs. This does not imply that every intervention that is labeled disease management works. On the other hand, not all patients with a diagnosis are candidates or among those for disease management. It is open, although, that while some conditions like, depression demands substantial investment, many interventions require only small expenditures to achieve large outcome for example, counseling and pre-discharge planning. Designing care around the requirements of the individual patient is as much a clinical and fiscal necessity as it is a health policy ideal (Brown, et al. (2007). References Adams S. G, and Smith, P. K et al. (2007). A Systematic Review of the Chronic Care Model…, Archives of Internal Medicine, Vol 167(6): 551-561. Bachler, R, and Duncan, I. (2005). A Comparative Analysis of non chronic and Chronic Insured Commercial Member Cost Trends. Bocchi, E. A, et al. (2008). Long-term prospective, randomized, controlled studies by use of repetitive education at a six-month intervals and monitoring for the adherence in heart failure outpatients. Circ Heart Fail. 1 (2): 115-24. Brown, R, Chen A, Peikes D, et al. (2007). The Evaluation of Medicare Coordinated Care Demonstrations: Finding for the First 2 Years. Policy Research CHCS, Inc. Daniels M. E, & Roob E.M (2008). Indiana Care Select Community Meeting. Indiana Care Select. Dove, H.G & Duncan, I. (2004). An Introduction to Care Management Intervention and their Implications for Actuaries.” Society of Actuaries. Dunagan, W., et al. (2005). Randomized trial of nurse-administered, telephone-based disease management program for patients with heart failure. Journal of Card Fail, 11 (5): 358-65 Folz, C, DeFrancesco L, Friedenzohn I, et al. (2003). Bridging the Health Coverage Gap. State Coverage Initiatives January 2003. http://www.statecoverage.net GESICA. (2005).Randomized trial of telephone intervention in chronic heart Failure, 331 (7514): 425. Geyman J. P. (2007).Disease Management: Panacea. Journal of Annals of Family Medicine, 5(3). Grady, K.L, Dracup, K, Stevenson, L.W, et al. (2000). Team management of patients with heart failure. 102 (19): 2443-56. Holtz-Eakin D. (2004). An Analysis of the Literature on the Disease Management Programs. Congressional Budget Office. The Lewin Group, (2008). Implementing and Designing Care Management Programs and Medicaid Disease. 07(08)-0063. Krumholz, H. M, et al. (2002). Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. Journal of Am Coll Cardiol. 39 (1): 83-9. Riegel B, et al. (2002). Effects of standardized nurse case-management and telephone Interventions on resource use in patients with heart failures. 162 (6): 705-12. Stromberg, A. (2002). Educating nurses and patients to manage heart failure. Eur J Cardiovasc Nurs. 1 (1): 33-40. Turner, D. A, Stone M, Paul S, et al.(2008). The Cost-effectiveness of Disease Management Programmes for Secondary Prevention of Heart Failure in Primary Care and Coronary Heart Disease. Van der Wal, M. H, Van Veldhuisen, D. J. (2005). Non-compliance in patients with Heart failure. Eur Journal of Heart Fail. 7 (1): 5-17. Whellan, D. J, Hasselblad V. (2005). Metaanalysis and review of the heart failure disease management randomized controlled clinical trials. Journal of Am Heart. 149 (4): 722-9. Read More