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The American Journal of Accountable Care March 2016
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Cognitive Impairment and Reduced Early Readmissions in Congestive Heart Failure?
Mark W. Ketterer, PhD; Jennifer Peltzer, PsyD; Usamah Mossallam, MD; Cathy Draus, RN; John Schairer, DO; Bobak Rabbani, MD; Khaled Nour, MD; Gayathri Iyer, MD; Michael Hudson, MD; and James McCord, MD
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Cognitive Impairment and Reduced Early Readmissions in Congestive Heart Failure?

Mark W. Ketterer, PhD; Jennifer Peltzer, PsyD; Usamah Mossallam, MD; Cathy Draus, RN; John Schairer, DO; Bobak Rabbani, MD; Khaled Nour, MD; Gayathri Iyer, MD; Michael Hudson, MD; and James McCord, MD
Proactive identification of cognitive impairment and compensatory destigmatized patient/familial psychoeducation regarding “forgetfulness” in hospitalized patients with congestive heart failure may reduce readmission rates substantially.
For I5, the average monthly 30-day readmission rate was 16%. For H5 it was 21.5%, and for the remainder of the hospital, it was 22.8%. Nationally reported figures from CMS average about 23%. A 1-tailed Student's t test (N = 12) comparing average monthly 30-day rates for I5 versus non-I5H5 yielded P = .007. For I5 versus H5, P = .052 (see Figure).

DISCUSSION

Present results suggest a significant reduction in early (30-day) readmissions among hospitalized CHF patients on an inpatient service where patients were proactively identified and evaluated, and subsequently underwent intervention for cognitive impairment, relative to national averages reported by CMS and hospital averages. Present results are congruent with other studies documenting CI as a prospective predictor of readmissions and nonadherence. In addition, these results complement several dozen published studies that found spontaneously reduced medical utilization (eg, hospital stays, length-of-stay, overall costs), as well as our own finding of reduced early readmissions in patients with acute myocardial infarction who screened positive for anxiety/depression and were receiving a psychiatric consult versus those not receiving one.52

We believe the present analyses represent a weak test of our hypothesis. Because we only intervened with about 20% of all CHF patients admitted to I5, when 50% or more were known to have CI, 4,5,18 the present results may be a conservative test of the effect. Might a greater reduction have been observed if we saw 30%, 40%, or 50% of the CHF sample?

Cultural Contamination?

On the other hand, is there a plateauing of this effect by the “cultural change” caused by the presence of a behavioral clinician on the care provided by the team to other patients, sometimes referred to as a “cultural change,” “paradigm shift,” “contamination,” or “transfer effect.”53 The presence of a behavioral clinician likely changes the care of not just the patients seen, but of the patients seen by collaborating clinicians whose interest and understanding is altered by cases shared with the behavioral clinician.

Proactive Identification

We believe it is likely that the apparent success of our intervention resulted, in part, because we were proactive about early case-finding of patients with various characteristics that made the presence of CI likely. These included early readmission, comorbid conditions, and clinical characteristics (eg, being a “poor historian,” unexplained metabolic derangements). Because spontaneous identification of CI is extremely poor4,21,22 such proactive identification of at-risk patients is almost certainly a necessity for timely recognition, evaluation, and intervention. Early identification enables time to evaluate the patient, educate the patient and family, and plan efforts to avoid another medical crisis.

Return on Investment

The professional time required for our proposal is currently reimbursable under all insurance programs, including Medicare and Medicaid. If the intervention reduces readmissions on 100 patients from about 23% to 9% in the first month, we project savings of $151,200 (14 admissions avoided × 4.5 days/admission × $2400/day) in the first month alone (not to mention a significant improvement in quality of life, reduced medical crises and, perhaps, deaths), for a net expenditure of $33,500 (100 patients × $335/patient for in-patient psychiatric care and first month’s costs). Net savings in the first month then would be $117,700 to the payer. The net savings over longer periods can only be guessed at currently, but may prove substantial. Regardless of the net cost/savings, this intervention improves clinical outcomes for patients by decreasing potentially fatal medical crises. For the hospital, the cost of the system of care being provided is covered by billing for the psychological services rendered.

Thus, the introduction of a health psychology service to a treatment team caring for CHF patients produces a higher “value” of care—better outcomes with reduced costs. We do not yet know whether other populations with high early readmission rates (eg, end-stage renal disease, chronic obstructive pulmonary disease) would display a similar increase in value. We suspect the prevalence rates of various behavioral factors affecting readmission may vary across medical populations.

Limitations

We must note that the present study was not a randomly assigned, controlled clinical trial. Therefore, we cannot be certain that all known or unknown potential selection/historical confounds (eg, average age, active smokers, exercisers, psychiatric history, number and kind of comorbidities, substance abuse, sex ratios, educational level) were not different across our groupings in a manner that biased the results in favor (or against) our results. For funding agencies, such a trial should have the highest priority.

CONCLUSIONS

If evidence-based care of CHF patients that maximizes effectiveness, safety, and efficiency is the goal, enhanced recognition of cognitive impairment and more proactive management of adherence is a necessity.

Author Affiliations: Henry Ford Hospital (MWK, JS, JPJ, BR, MH, CD, JM), Henry Ford Health System (GI, UM, KN), Detroit, MI.

Source of Funding: Partial support from the Blue Cross/Blue Shield of Michigan Foundation, and Health Resources & Services Administration Grant 1-D40HP25715-01-00.

Author Disclosures: Dr Peltzer Jones received an HRSA grant, which funded the clinical time. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MWK, MH, UM, CD); acquisition of data (MWK, JPJ, MH, CD); analysis and interpretation of data (MWK, JPJ, MH); drafting of the manuscript (MWK, JPJ); critical revision of the manuscript for important intellectual content (MWK, JPJ, MH, UM, CD); statistical analysis (MWK); provision of study materials or patients (MWK, JPJ, MH, BR, CD, JS, GI, KN, JM); obtaining funding (JPJ); administrative, technical, or logistic support (MWK, UM); and supervision (MWK, BR, GI, UM, JM).

Send correspondence to: Mark W. Ketterer, PhD, Henry Ford Hospital/PP=T117, 2799 West Grand Blvd, Detroit MI 48202. E-mail: MKetter1@hfhs.org.
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