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Archives of cardiovascular diseases
Volume 110, n° 1
pages 42-50 (janvier 2017)
Doi : 10.1016/j.acvd.2016.05.009
Received : 29 Mars 2016 ;  accepted : 18 May 2016
Patient journey in decompensated heart failure: An analysis in departments of cardiology and geriatrics in the Greater Paris University Hospitals
Analyse du parcours de soins du patient en insuffisance cardiaque aiguë dans les départements de cardiologie et gériatrie de l’Assistance publique–Hôpitaux de Paris
 

Florent Laveau a, , Nadjib Hammoudi a, Emmanuelle Berthelot b, Joël Belmin c, Patrick Assayag b, Ariel Cohen d, Thibaud Damy e, Denis Duboc f, Olivier Dubourg g, Albert Hagege h, Olivier Hanon i, Richard Isnard a, Guillaume Jondeau j, Florian Labouree c, Damien Logeart k, Nicolas Mansencal g, Christophe Meune l, Eric Pautas c, Yves Wolmark m, Michel Komajda a
a Université Paris 6, institut de cardiologie (AP–HP), centre hospitalier universitaire Pitié-Salpêtrière, institute of Cardiometabolism and Nutrition (ICAN), Inserm UMRS 1166, 75013 Paris, France 
b Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France 
c Charles-Foix Hospital, 94200 Ivry-sur-Seine, France 
d Saint-Antoine Hospital, 75012 Paris, France 
e Henri-Mondor Teaching Hospital, UPEC, 94010 Créteil, France 
f Cochin Hospital, 75014 Paris, France 
g Ambroise-Paré Hospital, 92100 Boulogne-Billancourt, France 
h Georges-Pompidou European Hospital, 75015 Paris, France 
i Broca Hospital, 75013 Paris, France 
j Bichat-Claude-Bernard Hospital, 75018 Paris, France 
k Lariboisière Hospital, 75475 Paris, France 
l Avicenne Hospital, 93000 Bobigny, France 
m Bretonneau Hospital, 75018 Paris, France 

Corresponding author. Institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, Assistance publique–Hôpitaux de Paris, 47–83, boulevard de l’Hôpital, 75651 Paris cedex 13, France.
Summary
Background

Hospitalization for worsening/acute heart failure is increasing in France, and limited data are available on referral/discharge modalities.

Aim

To evaluate patients’ journeys before and after hospitalization for this condition.

Methods

On 1 day per week, between October 2014 and February 2015, this observational study enrolled 260 consecutive patients with acute/worsening heart failure in all 10 departments of cardiology and four of the departments of geriatrics in the Greater Paris University Hospitals.

Results

First medical contact was an emergency unit in 45% of cases, a general practitioner in 16% of cases, an emergency medical ambulance in 13% of cases and a cardiologist in 13% of cases; 78% of patients were admitted directly after first medical contact. In-hospital stay was 13.2±11.3 days; intensive care unit stay (38% of the population) was 6.4±5 days. In-hospital mortality was 2.7%. Overall, 63% of patients were discharged home, whereas 21% were transferred to rehabilitation units. A post-discharge outpatient visit was made by only 72% of patients within 3 months (after a mean of 45±28 days). Only 53% of outpatient appointments were with a cardiologist.

Conclusion

Emergency departments, ambulances and general practitioners are the main points of entry before hospitalization for acute/worsening heart failure. Home discharge occurs in two of three cases. Time to first patient post-discharge visit is delayed. Therefore, actions to improve the patient journey should target primary care physicians and emergency structures, and efforts should be made to reduce the time to the first visit after discharge.

The full text of this article is available in PDF format.
Résumé
Objectif

Le nombre d’hospitalisations pour un épisode d’insuffisance cardiaque aigu en France est en augmentation et les données concernant les modalités d’entrée/de sortie d’hospitalisation sont insuffisantes. L’objectif était de décrire les caractéristiques du parcours de soins de ces patients avant et après l’hospitalisation.

Méthodes et résultats

Cette étude observationnelle a inclut, un jour par semaine, 260 patients consécutifs en insuffisance cardiaque aiguë d’octobre 2014 à février 2015 dans tous les départements de cardiologie (10) et 4 départements de gériatrie de l’Assistance publique–Hôpitaux de Paris. Le premier contact médical était un service d’urgence (45 %), un médecin généraliste (16 %), le SAMU (13 %) ou un cardiologue dans 13 % des cas. Au total, 78 % des patients étaient admis directement après le premier contact médical. La durée de séjour était de 13,2±11,3jours et 6,4±5jours en soins intensifs (38 % de la cohorte). La mortalité hospitalière était de 2,7 %. Au total, 63 % des patients sont sortis directement à domicile, 21 % en centre de convalescence. Une consultation de suivi dans les trois mois a été réalisée dans seulement 72 % des cas (à 45±28jours). Au total, 53 % de ces consultations ont été réalisées par un cardiologue.

Conclusion

Les services d’urgence, le SAMU et les médecins généralistes sont les premiers intervenants des patients en insuffisance cardiaque aiguë avant leur hospitalisation. Le retour à domicile à la sortie est observé dans deux-tiers des cas. L’intervalle entre la sortie et la première consultation de suivi est tardif. Les actions envisagées devront cibler principalement les médecins généralistes et les structures d’urgences. L’initiation du suivi à la sortie doit être plus précoce.

The full text of this article is available in PDF format.

Keywords : Patient, Journey, Heart failure, Hospitalization, Outcomes

Mots clés : Patient, Parcours de soins, Insuffisance cardiaque, Hospitalisation, Pronostic

Abbreviations : ACE, HF


Background

Heart failure (HF) is a highly prevalent condition associated with poor outcomes [1]. Although mortality has decreased during the past 20 years because of the broad dissemination of evidence-based therapies in HF with depressed left ventricular function [2], hospitalizations for acute/worsening HF are lengthy and recurrent, and induce considerable costs for the healthcare systems [3, 4, 5].

Among the many factors put forward to explain the burden of HF (re)hospitalizations, inappropriate cooperation between professionals in/out of hospital has been discussed during the pre- and post-discharge periods, leading to a fragmented patient journey, with delays in referral and in the introduction/titration of life-saving medications [6]. The French healthcare system is characterized by a huge number of private cardiologists and an absence of HF nurses, and data concerning the HF patient journey in France are scarce.

The aim of this study was to provide an analysis of the modalities of referral and discharge of patients hospitalized for acute/worsening acute HF in the Greater Paris University Hospitals.

Methods
Patients

Fourteen departments of the Assistance publique–Hôpitaux de Paris (all 10 departments of cardiology and four of the departments of geriatrics) participated in this prospective observational study from October 2014 to February 2015. Each center was asked to enroll 20 consecutive patients (on 1 day per week) aged>18 years and hospitalized for de novo or worsening acute HF using the criteria of the European Society of Cardiology guidelines [2]. Data on referral/discharge modalities, baseline demographic characteristics, therapies and procedures were collected. Each surviving patient was contacted by telephone 3 months after discharge to collect the time of the first post-discharge visit and the type of physician consulted. Outcomes, including all-cause rehospitalizations and all-cause deaths, were recorded.

Data collection

A structured paper case-report form was completed for each patient. For audit purposes, all case-report form data were compared with the discharge summary forms.

Written informed consent was obtained from all participating patients. This study is a substudy of the FRESH registry of the French Society of Cardiology, which was approved by the Institutional Committee on Human Research [7].

Statistical analysis

All quantitative data are expressed as means±standard deviations; qualitative data are expressed as percentages. Comparisons between continuous data were made using the unpaired t -test. The χ2 test or Fisher's exact test were used to compare categorical data, as appropriate.

MedCalc Statistical Software, version 12.7.7 (MedCalc Software, Ostend, Belgium) was used for calculations. A P -value<0.05 indicated statistical significance.

Results

From 1 October 2014 to 28 February 2015, 260 patients (cardiology, n =197; geriatrics, n =63) were enrolled.

Patient characteristics

The main patient characteristics before admission are presented in Table 1. Mean age was 77±15 years and 44% were women. Overall, 60% of the patients lived at home in a family environment, but a sizable proportion were isolated at home, and 5% lived in nursing homes. The proportions of female patients and patients isolated at home were higher in the geriatric subgroup. Main comorbidities were similar in geriatric and cardiology patients, except for cognitive disorders, which were more frequent in geriatric patients. A previous hospitalization for HF was common (58%). The most frequent causes of HF were ischemic heart disease (41%), hypertension (21%) and valvular disorders (20%), whereas non-ischemic cardiomyopathy was reported in 18%. The most common precipitating factors were supraventricular arrhythmias (38%), infections (28%) and treatment non-compliance (17%). Infection was much more frequent in patients from departments of geriatrics.

In-hospital data are summarized in Table 2. Mean left ventricular ejection fraction was 43%, and was higher in the geriatric subgroup. The majority of patients had a preserved ejection fraction, defined by a threshold of ≥45%, and the proportion of patients with a preserved ejection fraction was higher in the geriatrics subgroup. Use of intravenous nitrates, dobutamine and non-invasive ventilation was higher in patients hospitalized in cardiology departments.

Medical therapy at discharge is described in Table 3, Table 4. The rate of prescription of beta-blockers was 73%, whereas <50% of patients were receiving angiotensin-converting enzyme (ACE) inhibitors. There was a trend towards a lower use of life-saving HF medications in departments of geriatrics (Table 3). Loop diuretics were more commonly prescribed in cardiology departments.

As more patients hospitalized in departments of geriatrics had a preserved ejection fraction, the rate of prescription of HF medications was analyzed according to ejection fraction (Table 4). Patients with preserved ejection fraction were less likely to be receiving beta-blockers, ACE inhibitors and mineralocorticoid receptor antagonists, and were more likely to be taking angiotensin II receptor blockers or calcium channel blockers.

During hospitalization, 65% of patients had a dietician appointment and 16% were included in an educational programme. Calculation of the Mini-Mental State Examination was reported in only 20% of patients, and was performed only in departments of geriatrics.

Patient journey

The mode of referral is shown in Figure 1; it involved one professional before hospitalization in the majority of cases (78%), two in 19% of cases and three different professionals in 3% of cases. Direct admission through emergency departments was predominant, and occurred in 45% of cases, while 16% of patients were referred by a general practitioner, and only 13% by a cardiologist. Almost half of the patients referred to cardiology departments were admitted to intensive care units, at admission or during the index hospitalization.



Figure 1


Figure 1. 

Patient journey from referral to discharge. ICCU: intensive cardiology care unit.

Zoom

In-hospital stay was 13.2±11.3 days, and was longer in departments of geriatrics (15.5±9.3 days) than in cardiology departments (12.5±11.8; P =0.046), whereas intensive cardiology care unit stays were of similar duration in both groups (Table 2).

Overall, 63% of patients were discharged home, with home support in 21% of cases, whereas 21% were transferred to rehabilitation care units and 7.4% to other medical departments. Home support was much more common for patients hospitalized in departments of geriatrics. In-hospital mortality was low (n =7; 2.7%).

A preliminary medical report was given to 61% of patients before discharge. The name of a referral general practitioner or cardiologist was recorded in the medical report in 90% and 74% of cases, respectively. The final discharge summary was mailed 16.5±25 days after discharge.

Post-discharge data are summarized in Table 5 and Figure 2. In total, 253 patients were discharged alive and 16 (6%) were lost to follow-up. No follow-up occurred in 54 patients (21%); this was related to death or rehospitalization before the planned outpatient visit in 22 cases (9%). However, no visit was recorded in 32 patients (13%). An outpatient visit was made by 183 patients; the average time from discharge was 45 days, and was identical regardless of the physician concerned (general practitioner, geriatrician or cardiologist). Only 53% of the patients had an outpatient visit with a cardiologist.



Figure 2


Figure 2. 

Follow-up after discharge.

Zoom

At 3 months, rates of all-cause death, all-cause rehospitalization and the composite of all-cause death or rehospitalization were 11%, 24% and 29%, respectively. Mean time to first rehospitalization was 40.4±27.7 days and was similar between the two subgroups, whereas the 3-month mortality rate was higher in geriatric patients (18% vs 8%; P =0.015). The rate of 3-month rehospitalization was high, and was not different between the two groups.

Discussion

To the best of our knowledge, this is the first observational study of the patient journey from referral to 3 months after discharge in a large network of university hospitals in France. This analysis provides a detailed overview on how HF patients are referred to/discharged from the Greater Paris University Hospitals, and how they are managed in hospital and after discharge.

Patient characteristics and in-hospital management

Overall, the baseline characteristics of the patients enrolled in this study are in line with previous observational studies [6, 8, 9]: the population was elderly with multiple important comorbidities, and the majority of patients had previously been hospitalized for HF. There were important differences between patients hospitalized in departments of geriatrics and those referred to departments of cardiology: apart from age, higher proportions of female patients, cognitive disorders, repeated falls and hypertensive etiology were observed in the former group [10]. Regarding precipitating factors, infection and, to some extent, supraventricular arrhythmias were more common in the elderly subgroup [11].

Ejection fraction was also more often preserved in geriatric patients, suggesting that the prevalence of HF with preserved ejection fraction is very high, as previously published [12, 13]. Finally, the proportion of patients living without family support or staying in institutions was higher in the geriatric subgroup. Geriatric patients were also less likely to receive nitrate infusion, inotropic support or non-invasive ventilation than patients hospitalized in cardiology departments. Finally, there was a trend towards a lower rate of prescription of beta-blockers or mineralocorticoid receptor antagonists at discharge, and significantly lower rates of use of loop diuretics, beta-blockers and ACE inhibitors in the elderly population.

These findings can reflect the frailty of the geriatric population, with multiple comorbidities, (such as renal impairment), which may limit the use of life-saving medication, or tolerability (including hypotension), or the lack of evidence in elderly patients with preserved ejection fraction. The findings may also reflect the reluctance of physicians to use recommended HF medications, because of potential side effects, and/or to focus on symptom relief rather than outcomes [10, 14].

In-hospital stay was lengthy, and was in the range of previous European surveys [15], with a trend for longer stays in departments of geriatrics. Approximately half of the cardiology patients were referred to intensive care units, compared with a minority of those in departments of geriatrics. This difference may simply reflect the differential severity of the patients or the lack of intensive care units next to some departments of geriatrics.

Patient journey

The French healthcare system is characterized by a large number of private cardiologists, and by the absence of HF nurses. It was therefore anticipated that cardiologists would play a major role in the referral of HF patients to departments of cardiology or geriatrics.

Admission to the centers involved in this survey was made in four of five cases by only one healthcare professional. A noteworthy observation is the fact that direct admission through emergency departments occurred in nearly half of the population, and that admissions by cardiologists were made in only 13% of cases, which was less than the rate of admissions made by general practitioners [9]. This finding may reflect difficulties in contacting the referral physician or cardiologist, or the fact that patients preferred to contact an emergency unit or a medical ambulance directly because of the existence of severe symptoms. Whatever the explanation, this observation should lead to actions targeting general practitioners, such as patient education, to improve coordination between healthcare providers upstream of the admission and to prevent hospitalizations by having better knowledge of alert signs and symptoms.

Most patients were discharged home, and only a minority were referred to rehabilitation centers or to other medical structures. This emphasizes the need for measures, including a discharge checklist, planned follow-up visits and patient education, as most of the patients discharged home were without any medical support. Patient education has been shown to improve outcomes in HF in the early post-admission period, termed “the vulnerable phase” because of the high readmission rate [16, 17]. In the current study, however, we observed that only a minority of patients were included in an educational programme or received dietician advice. After discharge, the time to the first outpatient visit after discharge was, on average, 45 days, and was similar in departments of cardiology and geriatrics. This timing is not in line with current recommendations, and may lead to an increase in readmissions for HF, caused, in particular, by the absence of up-titration of recommended medications. In addition, an appointment with a cardiologist was made in only 53% of the cases, so dose adaptation was less likely to occur.

The lengthy delay between discharge and the first outpatient visit can result from several factors: improper in-hospital planning, patient negligence or difficulties in getting an appointment. Our study does not allow us to determine which of these factors was the most important limitation to early follow-up.

Whatever the explanation, this observation points to a need for corrective measures in order to improve the coordination of in-hospital/out-of-hospital professionals downstream of an HF hospitalization. The average time to rehospitalization (40 days) suggests that the lack of any early medical contact plays a role in this event. The creation of HF nurses trained to modulate HF medications or coordinators to liaise with patients and healthcare providers might improve this suboptimal situation. Indeed, the French National Social Security system is currently implementing a programme named PRADO [18], which aims to establish a network between healthcare professionals (general practitioners, cardiologists and nurses) via a coordinator who will facilitate contacts promptly after discharge.

Strengths and limitations

Our study has strengths: it included consecutive patients hospitalized for HF in all departments of cardiology and in the four main departments of geriatrics of the Assistance publique–Hôpitaux de Paris, the largest French network of university public hospitals; it is therefore representative of the situation in the Greater Paris area. We also used the HF diagnostic criteria recommended by the European Society of Cardiology. Finally, we analyzed factors related to healthcare organization, including timing of mailing of discharge summaries, inclusion in an educational programme and time to post-discharge outpatient visits.

This study also has limitations. Our study focused on university cardiology departments and some university departments of geriatrics. We therefore did not evaluate the patient journey for patients transferred to internal medicine departments. Only a limited number of consecutive patients were included in each of the 14 participating centers, and the overall sample size was limited. It was therefore not possible to analyze predictors of rehospitalizations because of the lack of power. The inclusion of departments of geriatrics is justified by the high prevalence of HF in the very elderly. This, however, introduced some heterogeneity in patient characteristics and in the patients’ journeys. In addition, only volunteer departments of geriatrics participated in this study. As a result, the number of patients enrolled by these centers was limited. The duration of follow-up was short (3 months) as we wanted to limit it to the vulnerable post-discharge phase. No information was collected in 16 patients lost to follow-up. Our study did not enable us to identify the reasons why undue delays occurred between discharge and the first outpatient visit. Finally, only all-cause and not HF-related hospitalization and death were collected after discharge.

Conclusions

This analysis of the HF patient journey in a large network of the Greater Paris University Hospitals suggests that the mode of admission mainly involves emergency units and general practitioners, and scarcely involves private cardiologists. Home discharge is the predominant mode of discharge. The timing of the first post-discharge visit is not in line with international recommendations, and may contribute to the high rate of early rehospitalizations. Therefore, actions should be taken to improve cooperation between in-hospital and out-of-hospital professionals.

Authors’ contribution

Florent Laveau and Michel Komajda take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation; the other authors revised the article and provided final approval of the version to be published.

Sources of funding

None.

Disclosure of interest

The authors declare that they have no competing interest.


Acknowledgements

We thank Genevieve Mulak (French Society of Cardiology) and the FRESH coordinators, research nurses and technicians for their contribution to the study.

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